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All Journal International Journal of Health and Pharmaceutical (IJHP)
Christine, Grace
Unknown Affiliation
Nursing Public Health

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The Moral Hazard Phenomenon in Health Insurance: A Review of Driving Factors and Control Strategies Christine, Grace; Anindhita Sekarsari, Ayu; Irawan, Budy; Puspitaloka Mahadewi, Erlina
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025 ( Indonesia - Iraq - Malaysia)
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.348

Abstract

Moral hazard in health insurance is a significant institutional issue that concerns the efficiency, sustainability, and equity of health funding systems. This study intends to comprehensively assess the different types of moral hazard, discern the root causes that contribute to it, and examine the regulatory strategies implemented at both national and international levels. This study employed a methodology characterized by a descriptive literature review, which involved a comprehensive analysis of 25 meticulously chosen peer-reviewed articles. The articles in question were published between the years 2014 and 2025, and they were obtained from reputable databases such as Scopus, PubMed, and Google Scholar. The results indicate that moral hazard presents itself in two main forms. Initially, this phenomenon arises among beneficiaries who may engage in excessive consumption and use of healthcare services lacking adequate medical justification. Secondly, it is apparent that healthcare providers may participate in administrative and clinical manipulation, which includes practices such as upcoding, unnecessary hospitalizations, and fraudulent claims. Several contributing factors to moral hazard can be identified, including deficiencies in the design of the INA-CBGs payment system, a lack of health insurance literacy among participants, and insufficient oversight and auditing mechanisms.The findings presented have considerable implications for policymakers, outlining the necessity to improve the national health insurance system. Structural reforms and the implementation of sustainable, multidisciplinary approaches.
Evaluation of Capitation Scheme as a Financing Instrument for Primary Services in the National Health Insurance (NHI): A Review of Health Economics Literature Christine, Grace; Anindhita Sekarsari, Ayu; Irawan, Budy; Hartono, Budi; Ghutsa Daud, Alfani
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025 (Indonesia - Malaysia)
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.380

Abstract

The study discuss about the capitation scheme is the main financing mechanism for primary healthcare services in the National Health Insurance (NHI), aimed at expanding access, promoting cost efficiency and strengthening promotive and preventive services at First Level Health Facilities (FLHF). This study aims to evaluate performance and effectiveness of capitation schemes as a strategic financing instrument in NHI’s system. Through a narrative- thematic literature review of 20 relevant publications from 2021–2025, this study examines four key aspects: the capitation policy structure, its impact on service quality and coverage, financing efficiency and administrative barriers. The results indicate that while capitation supports financial stability and increases visitation volume, its impact on clinical service quality and promotive-preventive service coverage remains limited. Key barriers include fragmented digital systems (P-Care, SIKDA, e-Kinerja), inadequate managerial capacity and a mismatch between performance indicators and clinical outcomes. This study recommends governance reforms based on output indicators, integration of digital reporting systems, as well as the implementation of a hybrid financing model. Strengthening capitation as a contextual, adaptive and performance-based strategic purchasing instrument is key to sustainable primary service financing within NHI’s framework.  
Co-Authors Anindhita Sekarsari, Ayu Budi Hartono Ghutsa Daud, Alfani Irawan, Budy Puspitaloka Mahadewi, Erlina