|District-based Health Insurance in sub-Saharan Africa (Institut Tropical - Tropical Institute, Antwerp, Belgium, 1998)|
|1. The Bwamanda scheme: Rationale and results|
The relatively successful development of the Bwamanda scheme, as well as its viability, was possible because it took place in a specific environment. A proper understanding of this environment is necessary if the Bwamanda scheme is to be of help and guidance to health planners considering similar financing schemes. However, the various constitutive features of the Bwamanda environment in which the scheme was conceived, and in which it thrived, cannot, strictly speaking, be considered as conditions. The identification of conditions for a successful development would imply a more formal research perspective in which different conditions, or a set of conditions, were tested with the object of assessing whether, and to what extent, they were necessary for a satisfactory development. This was not done in Bwamanda. Hence caution is needed in the interpretation of the relative importance of each factor in the development of the Bwamanda scheme. The various features of the Bwamanda environment are tentatively classified in four categories:
ORGANISATIONAL/MANAGERIAL FACTORS: The insurance scheme was launched in a context in which the district health service system had reached a relatively high level of operational efficiency. The Bwamanda district in the mid-eighties was considered amongst the best functioning health districts in the country. A strong district management team composed of medical doctors, senior nursing staff and health service administrators, headed it. From the early seventies on, it had enjoyed continuous external support, especially from Belgian bilateral aid. On average, two expatriate Belgian doctors and two Dutch nurses (sisters of the Medical Mission) were working in the Bwamanda hospital in the period 1970-1990. In 1986, the district health system functioned as an integrated two-tier system, i.e. a system in which health centres and hospital fulfil their specific roles in a complementary way (Unger and Criel 1995). The use of resources was highly rationalised. The referral and counter-referral system functioned well and contributed to the effective and efficient functioning of the health services. Mechanisms of control to secure rational utilisation of the health services were in place The network of health centres covered the whole of the district area and direct hospital utilisation bypassing the first line was virtually non-existent. The hospital doctor decided on hospital admission after the patient's referral by the health centre nurse. In such circumstances it was a priori feasible to keep moral hazard within reasonable proportions.
The hospital offered relatively high standards of care and there were no major cultural barriers to its utilisation. Moreover, the Bwamanda hospital, the only one in the district occupied a virtual monopoly position for most people in the district. Hence people's willingness to subscribe to a hospital insurance scheme was high.
The scheme's design represented a direct pattern of insurance the insurers were also the health care providers. In an environment in which rational resource use was a strong tradition such a direct insurance system fostered efficiency.
The preparation of the scheme took more than a year and both health centre staff and community representatives were closely involved in the initial process of planning and in the implementation of the scheme There was a huge effort of communication and mobilisation every year during the weeks before the enrolment period. Staff from other sectors (for instance rural development and agriculture) also contributed to the effort.
ECONOMIC/FINANCIAL FACTORS: The district management team received substantial support from the CDI's general infrastructure and administration facilities. For example, value-maintaining mechanisms for the collected funds were developed in a context of high inflation. Initially, the premiums collected were deposited in a special fund at the CDI, which then paid interest rates of 3% per month. Later the collected premiums were invested in the purchase of drugs by the CDI supported inter-diocesan pharmacy. In the nineties, when inflation became very high, the revenue from the insurance plan was immediately introduced into the local and regional economic circuit via the CDI' s economic activities.
From the start of the scheme the CDI agreed to act as financial guarantor. This back up was of crucial importance in case the scheme turned out not to be financially viable. This financial viability was unpredictable at the time when the scheme was launched in 1986. The CDI committed itself, if necessary, to cover a financial deficit, which could, in the absence of such support, jeopardise the credibility of the insurance scheme. In the period 1990-1995, for instance, a deficit occurred on two occasions: on the first occasion the deficit was met by a gift from a donor, and on the second the CDI lent the necessary funds.
SOCIAL FACTORS: The CDI project initiated its economic and social activities in the economically much disadvantaged Bwamanda area around 1969-1970. Initially, the Catholic mission in Bwamanda was the structure around which the project's activities were organised and expanded Gradually, a certain number of social services were developed in a spirit of integrated development. The health infrastructure was upgraded and extended, the health care delivery system in the district was rationalised, the local primary and secondary education systems received support; activities in the field of rural development were launched, local communications and transport infrastructures were rehabilitated, etc. A relationship of trust grew between the CDI and the population in general and between the health services and the population in particular. This confidence certainly influenced the community representatives in their decision in 1985-1986 to join in a hospital insurance scheme, even though not all the issues involved were clearly understood at the time. There was also faith in the district management team's ability and trustworthiness to manage the financial aspects of the insurance scheme efficiently.
POLITICAL FACTORS: Under the Zairian decentralisation policy, health districts were to be largely self-financed. Consequently, the Bwamanda district management team had sufficient autonomy to allow them to experiment with innovative financing schemes. The overall environment in which the initiative took place was characterised by the virtually total absence of the state, both in terms of resource allocation and in terms of planning, regulation, control, etc. This de facto vacuum left district teams with almost total autonomy to manage (or not to manage) the health systems for which they were and are responsible.
IS THE BWAMANDA SCHEME REPLICABLE?
As argued above, the Bwamanda experiment was launched at a time when the overall performance of the district health services system had reached a high standard, and local managerial capacity was strong. These features were not, however, specific to the Bwamanda setting alone. During the seventies and eighties, many other districts in Zaire developed, often with substantial donor support, highly effective district health services. What was specific to Bwamanda was the existence of the CDI project and its financial, logistical, technical and institutional support. The CDI increasingly took over some of the basic responsibilities that would normally fall on the state. Indeed, the project's activities partly filled the vacuum created by the virtually complete withdrawal of the Zairian State from the public service arena. The reproducibility of the Bwamanda scheme in other parts of the country and perhaps in other parts of the region seems therefore largely dependent on the presence of support by a public-interest-oriented body or institution. In the Zaire of the early 90s, the state had completely collapsed and was not capable of performing this supportive role; it is probable, in the Congo of today, that such an enabling environment can be found only where there are effective and sustained NGO-supported development projects in operation.