This study examined the scheme's financial viability using key indicators, and explored its challenges from the perspectives of various stakeholders. Results from the quantitative data showed that both schemes experienced a higher claims ratio during the period under study. The scheme in both districts spent more than it received for claims settlement in almost all the period under the study, as a result, they experienced heavy losses in these periods. Even after subsidies, the scheme’s net income remained negative (for three and four fiscal years in Tehulederie and Kallu districts, respectively). A high claims ratio indicates how valuable the program is to the insured, but if it is higher than predicted, the scheme may be about to fail, leading to a decline in financial protection. Furthermore, persistently negative net income values may indicate that the program requires certain adjustments to become viable (11). Rising claims cost is a common issue in voluntary health insurance systems. Even greater claims ratios have been observed in Gana's national health insurance, ranging from 4.3 to 18.1 (38, 39).
As explored by the qualitative part of the study, adverse selection, moral hazard behaviors, and unavailability of medicines at contracted health facilities are all possible reasons for higher claims costs. The findings revealed that households with higher health care needs are showing more interest in enrolling and staying in the scheme, implying adverse selection. Patients also had a tendency to drop out of the program as soon as their illnesses were alleviated. Even people who have dropped out of the scheme opt to re-enroll if they require health care with a high treatment cost. To prevent adverse selection, membership units were set at the household level instead of at individual level. However, this was not adequately enforced in practice. As a result, partial enrollment of family members who need more health care is broadly practiced in the community. In line with our findings, another study revealed that adverse selection was quite common in a voluntary rural mutual health care scheme in China, particularly among partially enrolled households (18). Risk cross-subsidization (cross-subsidy from the healthier to the less healthy) is the underlying principle of voluntary community health insurance schemes (9). However, in the event of adverse selection where the healthy are left out, risk cross-subsidization would be diminished because most members would consume health care that costs more than their contribution, leading to higher claims costs for the scheme. Hence, strategies must be devised to attract more members in order to improve the scheme's risk redistribution ability. Adverse selection pertaining to partial enrollment can be prevented by firmly enforcing the obligation to enroll all household members. For households that re-enroll in the scheme after dropping out, a waiting period during which benefits are not available can be imposed. This would make it more likely for healthy people to keep their membership or enroll in the scheme in order to avoid unforeseeable future risks.
The study also identified a variety of moral hazard behaviors that are indicative of scheme abuse, which include repeated visits to a health facility for the same illness, storing medicines at home, seeking medical attention for every minor ailment, attempting to collect medicines for the uninsured, visiting different health centers for the same illness within the same period, and attending health care facilities ahead of time for follow-up appointments to reserve medicines. Our findings were corroborated by a study in Ghana, which documented most of these moral hazard behaviors (15). Although moral hazard has been argued to generate welfare and equity gains in health insurance (40), which may be true in some instances in this study, the majority of the behaviors observed are welfare losses. Most of the practices are undesirable to both individuals and the overall health insurance system. Unnecessary repeat visits, for example, lead to a shortage of medicines in health facilities, causing other members to pay out of pocket at the point of service. The scheme must also cover any excess claims costs incurred as a result of overconsumption, as well as high price markups at private pharmacies. To avert a rising claims cost due to patient moral hazards, the scheme should consider certain limits on the number of visits in a given period. It has been stated that some moral hazard practices are linked to a lack of community understanding of health insurance principles. Raising awareness of the concept of solidarity is also paramount for encouraging insured people to change behaviors that undermine the scheme. To limit visits to different health centers for the same illness and period, Kallu district has implemented cluster level treatment, in which patients are required to receive care only at one health center. Although this may fix the problem, it infringes on the rights of insurance cardholders to seek treatment at health centers where they believe the care is of better quality. When one health center runs out of medicines, for example, they would have to go to another health center.
The findings revealed that two or more households are covered under health insurance as if they are one, and those with higher health-care needs are only partially enrolled, an issue involving both adverse selection and moral hazard. To avoid this situation, scheme and Kebele administrators should strive to revise the family structure that has existed since the start of health insurance. The study also revealed some moral hazard behaviors among health care providers, such as ordering expensive medicines and laboratory or imaging services, over-prescribing, and writing prescriptions for uninsured patients in the name of insured patients. To overcome some of these practices, the scheme should consider replacing the existing fee-for-service payment mechanism with a capitation model. Capitation is an efficient method of provider payment for controlling over-servicing and operational costs, especially in primary care settings (41).
Unavailability of medicines at CBHI-affiliated health facilities is another issue that jeopardizes the scheme's financial viability. This is consistent with studies done elsewhere, which reported that a scarcity of medicines is a common source of concern among insured patients at contracted health facilities (19, 42–47). Due to the unavailability of medicines, insured patients were forced to buy from private pharmacies at higher price markups. The scheme must reimburse for out-of-pocket expenses paid at private pharmacies for services that might have been delivered at contracted health facilities for a much lower cost. As a result, claims reimbursement for insurance members has become a substantial cost driver, thereby endangering the scheme's financial stability. Moreover, medicines are an essential component of high-quality care, and their scarcity in health care facilities would result in greater dissatisfaction among insured patients, limiting the size of risk pools.
It is worth noting that the scheme's high pocket money replacement indicated that it fell short of its purpose of protecting members from having to pay for health care out of pocket at the point of care. People who cannot afford to pay for health care at private institutions would also have limited access, as the only other option would be to forego treatment. This is supported by the fact that a shortage of medicines at contracted health facilities is largely due to the scheme's inability to settle claims on time. Despite the fact that one of the aims of health insurance is to improve healthcare facilities financially, this is not the case in this study. Health centers have experienced a financial setback after the introduction of health insurance. Although health care facilities mainly rely on claims payments to acquire supplies, many have been unable to meet their obligations due to considerable reimbursement delays. It has been revealed elsewhere that, due to claims payment delays, service providers have been forced to stop attending to insurance cardholders and issue prescriptions to buy medicines outside contracted hospitals (46–50).
We have noticed that a delay in claims settlement has been linked to medicine stockouts at contracted health facilities as both a cause and a consequence. In order to break the vicious circle that links scheme budget deficits, claims settlement delays, and medicine shortages, improving the capacity of government pharmaceutical supply should also be a priority. The low rate of insurance premiums in relation to the cost of health care has been highlighted as one important factor in the scheme's financial deficiency. This is consistent with the results of earlier studies (48, 49). This is common in low-income countries like Ethiopia, where the bulk of the CBHI target population are subsistence farmers who cannot afford even small premium rates (9). While there will undoubtedly be concerns about the poor and most disadvantaged being left out, the health insurance premium should be managed to increase. To determine the base premium, however, more research on the community's willingness and ability to pay is required. This must, however, be done after efforts have been taken to improve the quality of health care, particularly in terms of medicine availability. Despite the study provides useful insights into voluntary health insurance schemes, it is not without limitations. First, due to a lack of records, we were unable to determine the promptness with which health care providers' claims were settled, which would have allowed us to contrast against the stipulated timeframe. Second, the use of secondary data might not accurately reflect real financial status.