Introduction: Community-based health insurance made a significant contribution by lowering catastrophic health-care costs during illness. However, there is limited evidence in our country, particularly in this study area, that adverse selection and moral hazards are potential causes of bankruptcy in the insurance industry.

Objective To assess adverse selection, moral hazard, and scheme sustainability of community-based health insurance among clients attending at public health institutions in East Gojjam Zone, North West, Ethiopia, 2022

Methods and materials: A mixed (quantitative and qualitative) institutional-based comparative cross-sectional study was employed. among 1161 insured and 1162 uninsured participants and two-stage random sampling techniques. Both primary and secondary data were used. Adverse selection (risk pooling) enrollment status was determined by using odds ratios and logistic regression. Factors that affect the sustainability of community-based health insurance were explored through a qualitative study and analyzed through thematic analysis.

Result: A total of 2140 participants with a response rate of 92.1 percent were included in the study. The mean age of respondents was 40 years (SD +13.7 years). Female (AOR = 1.8; 95% CI: 1.393 2.207), age (AOR = 1.496; 95% CI: 1.15 1.945), married (AOR = 2.286; 95% CI: 1.694, 3.084), education (AOR = 2.117; 95% CI: 1.563, 2.866), frequent illness in family (AOR = 3.8; 95% CI: 2.938, 4.849), poor participants were 2 times (AOR =more likely to enroll in CBHI. Low-risk pooling, frequent and multiple facility visits, and medication sharing have all been identified as threats to sustainability. Community health insurances

Conclusion and recommendation: financial bankruptcy and health care costs over utilization of health care services were the major threats to the sustainability of health insurance, which is reported as a treat for CBHI sustainability. According to the study's findings, sex, age, marital status, education, family size, chronic disease, household wealth, family size, and history of frequent visits to health institutions had a significant association with CBHI enrollment. As a result, all concerned parties should work to strengthen the sustainability of CBHI by raising community awareness in order to reduce adverse selection, moral hazards, and other risks.

keyword: Adverse Selection, Moral Hazards and Community Based Health Insurance Scheme Sustainability