Factors Contributing to the Bankruptcy of Community-Based Health Insurance Schemes in Northwest Ethiopia

Abstract Background: The expansion of the community-based health insurance (CBHI) program in Ethiopia from 13 to 1,100 districts indicates a commitment to extending healthcare coverage to a larger population. A significant portion of the CBHI in the Amhara region is facing financial difficulties totaling 4 million dollars. This highlights the need for a more in-depth investigation of the underlying issues, such as financial audits, risk assessments, and governance and management practice evaluations. Objective: To explore the facilitators of the community-based health insurance scheme bankruptcy in the North Mecha district, Northwest Ethiopia. Method: A phenomenological study design was utilized. A purposive sampling technique was used to select participants for the study. Data were collected from 14 key informants using a detailed interview guide until information saturation was reached. To ensure consistency of data and avoid researcher bias, all interviews were transcribed verbatim from the audio files into Amharic transcripts and then translated into English. The transcribed data was coded and categorized. The data was then organized into related themes and sub-themes to conduct thematic analysis using Atlas ti 7. Results: The study found that the main facilitators of community-based health insurance bankruptcy were low enrolment rates, too many benefit packages, low contribution amounts, fraud and moral hazards on both the demand and supply sides, low availability of drugs and laboratory services, low subsidies, increased costs of medical supply and healthcare services, low community awareness, and increased health service utilization. Conclusions: This study's findings explored program, community, provider, and health insurance scheme-related factors that were identified as facilitating scheme bankruptcy. These facilitating factors would require policy shifts and program redesign. Therefore, all concerned bodies should focus on addressing these factors for the financial sustainability of the schemes and the capacity of members to contribute to membership. [Ethiop. J. Health Dev. 2024; 38(3): 00-00] Keywords: health insurance, adverse selection, capitation, contributions, target subsidy.