Stakeholder perspectives on the financial sustainability of community-based health insurance schemes in North Shewa Zone, Ethiopia: a qualitative study.

Community-based health insurance (CBHI) schemes are widely implemented in low- and middle-income countries to improve access to health care and protect households from catastrophic health expenditures. Despite their potential benefits, many CBHI schemes face serious financial sustainability challenges, including scheme insolvency. While quantitative studies have identified structural and financial factors associated with scheme failure, limited qualitative evidence exists to explain the underlying mechanisms driving insolvency in Ethiopia. This study explored stakeholders' perspectives on the financial sustainability of CBHI schemes in North Shewa Zone, Oromia Region. A descriptive qualitative study design was conducted from March to April 2025 in North Shewa Zone, Ethiopia. Twenty key informant interviews (KIIs) were conducted with stakeholders involved in the implementation and management of CBHI schemes. A Purposive sampling technique was used to select participants for KIIs. Data were coded, categorized, and analysed manually by using inductive thematic analysis and the result was presented in narrative forms to stakeholders' perspectives on the financial sustainability of CBHI schemes. Four major themes emerged from the analysis: (1) rising health service utilization and escalating health-care costs, (2) premium inadequacy and revenue constraints, (3) inefficiencies in claims management and weak medical audit systems, and (4) governance and accountability challenges. The study highlights multiple structural, financial, and governance-related factors contributing to CBHI scheme insolvency in the study area. Addressing these challenges requires revising premium structures, strengthening claims management systems, improving medical audit capacity, and enhancing governance and accountability mechanisms within CBHI programs.