A health insurance scheme for hospital care in Bwamanda District, Zaire: lessons and questions after 10 years of functioning.

A voluntary insurance scheme for hospital care was launched in 1986 in the Bwamanda District in northwest Zaire. The paper briefly reviews the rationale, design and implementation of the scheme and discusses its results and performance over time. The scheme succeeded in generating stable revenue for the hospital in a context where government intervention was virtually absent and external subsidies were most uncertain. Hospital data indicate that hospital services were used by a significantly higher proportion of insured patients than uninsured people. The features of the environment in which the insurance scheme thrived are discussed and the conditions that facilitated its development reviewed. These conditions comprise organizational-managerial, economic-financial, social and political factors. The Bwamanda case study illustrates the feasibility of health insurance-at least for hospital-based inpatient care-at rural district level in sub-Saharan Africa, but also exemplifies the managerial and social complexity of such financing mechanisms.