An insurance scheme covering hospital care in the rural district of Bwamanda in the North-west of the Democratic Republic of Congo, which locally is called the mutuelle, was conceived and developed in 1986 on the initiative of Belgian doctors working in the district under the arrangements for bilateral Belgian aid. After more than 10 years of operation the Bwamanda scheme has achieved a high rate of coverage, contributed to a significant improvement in access to hospital-based in-patient care, and constitutes a stable source of revenue for the operation of the hospital. We present an investigation conducted through focus groups in 1996 of the population's social perceptions of this risk-sharing scheme to identify ways to improve it. The findings pertain to the reasons for people to subscribe to the scheme; to the perception of its redistribution effects; to people's frustrations and questions; and finally to the relationships between the insurance scheme and traditional mutual aid arrangements. The difference between a hospital insurance scheme (a logic of contract) and the traditional systems of mutual aid (a logic of alliance) is highlighted, and the impact of the hospital insurance scheme on social inequalities is discussed. The implications of this study on the management of the Bwamanda health insurance scheme are reviewed, and this study may be useful to health managers working in similar contexts.