The health card insurance scheme in Burundi: a social asset or a non-viable venture?

La Carte d'Assurance Maladie (CAM) is a national health card insurance scheme implemented by the government of Burundi since 1984. Focus group discussions, a household survey, and a retrospective outpatient survey were used in 1992 to assess its financial and social performance in Muyinga Province. The study showed that although the revenue from premiums was insufficient to fund even the recurrent costs of outpatient drugs consumed by participating households (the current price of the CAM card would cover approx. 34% of the outpatient drug costs), the scheme performed a valuable social equity function. Women reported that they had little access to cash and that CAM, by eliminating cash payments at the point of use, empowered them to decide the need for, and timing of health care consumption by household members without consulting male household heads. Other findings suggested that the schemes financial performance was poor because current membership was low (23% of households) and, more importantly, households with relatively high risks dominated the scheme ('adverse household selection'), making risk-sharing sub-optimal. The author concludes that improvements in the quality of care, in particular increased drug availability and higher standards of prescribing by health workers, would encourage the participation of 'lower risk' households, many of whom did not have a valid CAM because they judged the quality of care provided under the scheme to be inadequate. A policy obliging communes (local governments) to use the greater part of the scheme's revenue, initially supplemented by external 'seed money', to fund services at the health centres would facilitate these improvements. It is evisaged that improved quality would also lead to increased revenue and therefore, greater financial viability, by paving the way for moderate increases in the price of the card.