Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia

Collaborative governance of an integrated system for collecting contributions for social health insurance, pension, and taxes from the informal sector: a synthesis of stakeholder perspectives

BACKGROUND

Many low-and middle-income countries have adopted social health insurance schemes. However, the collection of contributions from the large informal sector of these economies poses a significant challenge. Employing an integrated system of contribution collection from all relevant institutions may be cost-effective. We used the integrative framework for collaborative governance, to explore and explain factors that may shape the governance of an integrated system for collecting contributions for social health insurance, pension, and taxes from the informal sector in Zambia.

METHODS

We undertook a qualitative case study involving 25 key informants drawn from government ministries and institutions, cooperating partners, non-governmental organizations, and association representatives in the informal sector. Data were analyzed thematically using Emerson's integrative framework for collaborative governance.

RESULTS

The main drivers of collaboration included a need for comprehensive policies and legislation to oversee the integrated system for contribution collection, prevent redundancy, reduce costs, and enhance organizational effectiveness. However, challenges such as leadership issues and coordination complexities were noted. Factors affecting principled engagement within the collaborative regime consisted of communication gaps, organizational structure disparities, and the adoption of appropriate strategies to engage the informal sector. Additionally, factors influencing shared motivation involved concerns about power dynamics, self-interests, trust issues, corruption, and a lack of common understanding of the informal sector.

CONCLUSION

This study sheds light on a multitude of factors that may shape collaborative governance of an integrated system for contribution collection for social health insurance, pension, and taxes from the informal sector, providing valuable insights for policymakers and implementers alike. Expanding social health insurance coverage to the large but often excluded informal sector will require leveraging factors identified in this study to enhance collaboration with pension and tax subsystems.

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method

BACKGROUND

Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana.

METHODS

Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses.

RESULTS

The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services.

CONCLUSION

Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BACKGROUND

Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.

METHODS

A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.

RESULTS

Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.

CONCLUSIONS

Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Assessing the Determinants of Compliance with Contribution Payments to the National Health Insurance Scheme among Informal Workers in Indonesia

This study aimed to investigate the determinants of compliance with contribution payments to the National Health Insurance (NHI) scheme among informal workers in Bogor Regency, West Java Province, Indonesia. Surveys of 418 informal workers in Bogor Regency from April to May 2023 were conducted. Multivariate logistic regression analyses were performed to assess the factors associated with informal workers' compliance with NHI contribution payments. The results revealed that being female, having lower secondary education or below, perceiving good health of family members, having negative attitudes toward and poor knowledge of the NHI, experiencing financial difficulties, preferring to visit health facilities other than public ones, and utilizing fewer outpatient services were significantly associated with the noncompliance of informal workers with NHI contribution payments. It was concluded that economic factors alone cannot contribute to informal workers' payment compliance and that motivational factors (knowledge, attitudes toward the insurance system, and self-related health status) also encourage them to comply with contribution payments. Improving people's knowledge, especially on the risk-sharing concept of the NHI, should be done through extensive health insurance education using methods that are appropriate for the population's characteristics.

The Experiences of Strategic Purchasing of Healthcare in Nine Middle-Income Countries: A Systematic Qualitative Review

BACKGROUND

Efforts to move towards universal health coverage (UHC) aim to rebalance health financing in ways that increase efficiency, equity, and quality. Resource constraints require a shift from passive to strategic purchasing (SP). In this paper, we report on the experiences of SP in public sector health insurance schemes in nine middle-income countries to understand what extent SP has been established, the challenges and facilitators, and how it is helping countries achieve their UHC goals.

METHODS

We conducted a systematic search to identify papers on SP. Nine countries were selected for case study analysis. We extracted data from 129 articles. We used a common framework to compare the purchasing arrangements and key features in the different schemes. The evidence was synthesised qualitatively.

RESULTS

Five countries had health technology assessment (HTA) units to research what services to buy. Most schemes had reimbursement mechanisms that enabled some degree of cost control. However, we found evidenced-based changes to the reimbursement mechanisms only in Thailand and China. All countries have some form of mechanism for accreditation of health facilities, although there was considerable variation in what is done. All countries had some strategy for monitoring claims, but they vary in complexity and the extent of implementation; three countries have implemented e-claim processing enabling a greater level of monitoring. Only four countries had independent governance structures to provide oversight. We found delayed reimbursement (six countries), failure to provide services in the benefits package (four countries), and high out-of-pocket (OOP) payments in all countries except Thailand and Indonesia, suggesting the schemes were failing their members.

CONCLUSION

We recommend investment in purchaser and research capacity and a focus on strong governance, including regular engagement between the purchaser, provider and citizens, to build trusting relationships to leverage the potential of SP more fully, and expand financial protection and progress towards UHC.

Health taxes in Indonesia: a review of policy debates on the tobacco, alcoholic beverages and sugar-sweetened beverage taxes in the media

INTRODUCTION

One of the WHO's 'best buys' in controlling non-communicable diseases and their risk factors is to impose health taxes. While the Indonesian political process inhibits the implementation of health tax policy, studies to discuss the issue remain limited.

METHODS

We employed media analysis to document health tax policy dynamics, for example, the changes in policy timeline and key actors' statements. We conducted an article search in the Open-Source Intelligence database using appropriate terminology on three commodities, for example, tobacco, alcoholic beverages and sugar-sweetened beverages (SSB).

RESULTS

Throughout the 15 years of implementation (2007-2022), tobacco has received the most policy attention compared with the other two commodities. This is mainly related to the increasing tariff and reforming the tax structure. As Indonesia is a Muslim-majority country, alcohol consumption is low, and a tax on alcoholic beverages was nearly unchanging and lacked media coverage. Ministry of Finance (MoF) officials are key opinion leaders often cited in the media for health taxes. MoF's support for health taxes is important to pass and implement health taxes. While SSB taxation is emerging, key opinion leaders' media statements imply policy contestation, leading to delayed implementation. The policy debates on tobacco taxation implied election years as a major challenge for health tax passages. During the political years, anti-health tax arguments emerged from politicians. While the political contestation on SSB concluded that accentuating the health tax arguments in favour of public health generates the strongest opposition against taxation from the industry.

CONCLUSIONS

Politics of tobacco tax implementation are complex-compared with the other two commodities. The political context drives the divided views among policy-makers. Policy recommendations include generating public allies with key religious opinion leaders, continuing capacity building for politicians and Ministry of Health, and generating evidence-based arguments in favour of public health for MoF.

Household satisfaction and associated factors with community-based health insurance scheme in Ethiopia: systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) schemes are crucial for households to avoid financial hardship, improve healthcare quality, and engage in health policies. Household satisfaction is a key indicator for assessing healthcare quality and identifying service gaps. However, research on household satisfaction with CBHI in Ethiopia is limited. Therefore, this study aimed to evaluate household satisfaction and associated factors with CBHI schemes in Ethiopia.

METHODS

A comprehensive search of relevant literature was conducted using multiple databases, including PubMed, Google Scholar, Africa Journal Online, and Ethiopian Universities' institutional open-access online repositories. The search was carried out between January 25, 2023, and February 28, 2023. Twelve primary studies, including eight published and four unpublished, were identified and included in the analysis with a total sample size of 5311 participants. A protocol with the registration number CRD20531345698 is recorded on the Prospero database. Two authors, DT and MK, independently extracted the required data using a standardized form. The extracted data were then analyzed using STATA version 17 software. Heterogeneity was assessed using the Cochrane Q-test and I2 tests. Finally, a random-effect model was employed to calculate the overall household satisfaction with CBHI and to determine the associated factors.

RESULTS

The meta-analysis showed that the overall household satisfaction with CBHI in Ethiopia was 62.26% (95% CI 53.25-71.21%). The study found regional variations in household satisfaction, with 63.40% in Oromia, 64.01% in Amhara, 49.58% in Addis Ababa, and 66.76% in SNNPs. The study identified several factors associated with household satisfaction and the CBHI scheme, including the availability of drugs (OR 2.13, 95% CI 1.47-2.78), friendly services (OR 3.85, 95% CI 1.60-6.10), affordability of premium (OR 2.80, 95% CI 1.97-3.63), and knowledge/awareness of CBHI (OR 2.52, 95% CI 1.73-3.33).

CONCLUSIONS

The study provides valuable insights into household satisfaction with CBHI in Ethiopia, with a considerable proportion of enrolees being satisfied. The finding highlights regional variations in household satisfaction and underscores the need for tailored interventions and monitoring to enhance CBHI sustainability and effectiveness. The results suggest that healthcare providers and policymakers should prioritize the availability of drugs, friendly services, affordable premiums, and education to improve household satisfaction with CBHI schemes.

Health financing challenges in Southeast Asian countries for universal health coverage: a systematic review

BACKGROUND

Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers.

METHODS

The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes.

RESULTS

The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people's needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours.

CONCLUSIONS

The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends.

REGISTRATION

This study is registered with PROSPERO, under registration number CRD42022336624.

Extending universal health coverage to informal workers: A systematic review of health financing schemes in low- and middle-income countries in Southeast Asia

Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments' commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.

Predictors of national health insurance membership among the poor with different education levels in Indonesia

BACKGROUND

Indonesia has made significant progress in expanding universal health coverage (UHC) through its National Health Insurance (NHI) mechanism. However, in the context of NHI implementation in Indonesia, socioeconomic disparities caused its subpopulations to have different literacy of NHI concepts and procedures, increasing the risk of healthcare access inequities. Hence, the study aimed to analyse the predictors of NHI membership among the poor with different education levels in Indonesia.

METHODS

This study used the secondary dataset of the nationwide survey "Abilities and Willingness to Pay, Fee, and Participant Satisfaction in implementing National Health Insurance in Indonesia in 2019" by The Ministry of Health of the Republic of Indonesia. The study population was the poor population in Indonesia and included a weighted sample of 18,514 poor people. The study used NHI membership as a dependent variable. Meanwhile, the study analysed seven independent variables: wealth, residence, age, gender, education, employment, and marital status. In the final step of the analysis, the study used binary logistic regression.

RESULTS

The results show that the NHI membership among the poor population tends to be higher among those who have higher education, live in urban areas, are older than 17 years old, are married and are wealthier. The poor population with higher education levels is more likely to become NHI members than those with lower education. Their residence, age, gender, employment, marital status, and wealth also predicted their NHI membership. Poor people with primary education are 1.454 times more likely to be NHI members than those without education (AOR 1.454; 95% CI 1.331-1.588). Meanwhile, those with secondary education are 1.478 times more likely to be NHI members than those with no education (AOR 1.478; 95% CI 1.309-1.668). Moreover, higher education is 1.724 times more likely to result in being an NHI member than no education (AOR 1.724; 95% CI 1.356-2.192).

CONCLUSION

Education level, residence, age, gender, employment, marital status, and wealth predict NHI membership among the poor population. Since significant differences exist in all of those predictors among the poor population with different education levels, our findings highlighted the importance of government investment in NHI, which must be supported with investment in the poor population's education.

The 2019 economic cost of smoking-attributable diseases in Indonesia

BACKGROUND

In 2019, ever-smoking prevalence among adults in Indonesia was 32.8%, which may correlate with a high burden on the economy. Therefore, there is an urgent need to estimate the economic costs of tobacco use, which are crucial for policymakers in planning healthcare provisions and other public expenditures.

METHODS

We follow the WHO standard approach, multiplying the sum of the direct and indirect costs with the smoking-attributable fraction. Direct costs include healthcare and non-healthcare costs. Indirect costs include the loss of productivity resulting from absence from work and premature death due to smoking-related illnesses.

FINDINGS

We found that the 2019 economic cost of smoking ranges from Rp 184.36 trillion to Rp 410.76 trillion (1.16%-2.59% of the gross domestic product). This research found a similar economic cost of smoking compared with a previous estimate conducted by Kosen et al of Rp 438.5 trillion. However, the estimated direct cost of smoking ranges from Rp 17.9 trillion to Rp 27.7 trillion, which is higher than the estimate of Rp 15.5 trillion by Kosen et al. Badan Penyelenggara Jaminan Sosial Kesehatan allocated between Rp 10.4 trillion and Rp 15.6 trillion to cover the healthcare costs attributable to smoking, representing between 61.2% and 91.8% of the 2019 deficit.

CONCLUSIONS

The vast economic cost of smoking is a waste of resources and a burden on Indonesia's National Health Insurance System. Therefore, the government must increase cigarette taxes to correct the negative externalities of smoking consumption.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Factors Affecting Payment Compliance of the Indonesia National Health Insurance Participants

Background

The study aims to explore factors that affect the compliance of Indonesia National Health Insurance (INHI) in paying the premiums.

Methods

The study design was qualitative with grounded theory research approach and constructivism paradigm. The study was conducted in 2018 and carried out for 3 months. We recruited 22 respondents from four different cities/districts. Triangulation was carried out through 26 informants from various stakeholders. Data were analyzed through coding, categorizing and pattern matching to obtain substantive theory.

Results

The resulting substantive theory consists of 6 constructs and 14 categories. Compliance with paying insurance premium depends on the intention to pay for contribution. Meanwhile, the intention to pay is related to internal and external factors of INHI participants. To improve payment contribution of independent participants, INHI program has to pay attention for factors originating internally from the participants themselves (understanding of INHI program, financial ability and self-attitude) and also externally such as operational system and the quality of health care.

Conclusion

Compliance of paying insurance premium is related to internal and external factors of participants. Thus, interventions to improve compliance to pay premium should take these factors into account, and not merely on increasing the knowledge of participants.

Costs of providing hospital-based psychotic disorder treatment in Indonesia

BACKGROUND

Mental illness prevalence is increasing globally and has caused a significant economic burden. However, information from developing countries regarding this issue is still limited.

AIMS

To estimate the cost of treating psychotic disorders in outpatient and inpatient wards in a provincial referral mental health hospital in West Java province, Indonesia.

METHODS

We collected data on the direct cost of treating psychotic disorders within 2014-2015. Billing data from 1565 patients were used to calculate inpatient cost, while micro-costing was used to estimate outpatient cost. One hundred and five patients visiting the hospital were interviewed to estimate indirect costs, for example, patients' and caretakers' travel, meal, and opportunity costs.

RESULTS

For inpatient care, the average direct and indirect cost/patient/episode are USD328.84 and USD213.22, respectively. For outpatient care, the direct and indirect costs are USD148,484.83/year (USD25.38/visit) and USD88,503.70/year (USD15.13/visit), respectively. The total societal cost of treating patients in the hospital is USD1,085,310.21/year (39% is an indirect cost, dominated by productivity loss).

CONCLUSION

The societal cost of treating psychotic disorders is large and potentially catastrophic to the patients. Early treatment for mental illness may avoid the high costs and lead to better productivity. Potential access barriers such as financial factors and stigma should be addressed.

Barriers to Expanding the National Health Insurance Membership in Indonesia: Who Should the Target?

Background:

The Indonesian government initiated National Health Insurance (NHI) to reduce health service barriers. The study aimed to analyze specific targets for expanding the NHI’s membership in Indonesia.

Methods:

The study population was all populations in Indonesia. Meanwhile, the study involved a 47 644 weighted sample. The analyzed variables included NHI’s membership, residence, age, gender, education, employment, marital status, and wealth. The study employed binary logistic regression in the final step.

Results:

The urban population was 0.608 times less likely than the rural population to become a non-member of NHI. Aging younger was one of the barriers to becoming an NHI member, and the male gender is one of the barriers to becoming an NHI member. Meanwhile, the lower the education level, the greater the obstacles to becoming an NHI member in Indonesia. Besides, the unemployed population was 1.002 more likely than the employed population to become a non-member of NHI. The result shows that never married or married have a higher chance of becoming a non-member of NHI. Finally, all wealth status categories are more likely to become barriers to the most prosperous population becoming an NHI member.

Conclusions:

The study concluded that 7 population characteristics become specific targets for expanding NHI membership in Indonesia. The 7 characteristics are the population who live in rural areas, are young, male, poor education, unemployed, never married or married, and poor.

Predictors of annual membership renewal to increase the sustainability of the Nepal National Health Insurance program: A cross-sectional survey

Expanding membership coverage and retention of the National Health Insurance (NHI) programs among informal sector workers (ISWs) continues to be a significant challenge in most low and lower-middle-income countries (LMICs). The Nepal NHI program is also facing a similar problem, but to date, there are no studies that focus on identifying key predictors of annual membership renewal and retention in Nepal. This study therefore aimed to determine the predictors of intention to renew annual subscription to the NHI program among enrolled members. This cross-sectional quantitative study was part of a larger mixed-methods study conducted in three districts in Nepal. A random sample of 182 current NHI members and 61 dropped out NHI members who met the inclusion criteria were interviewed. The study's dependent variable was the intention to renew annual membership and employed univariate regression to assess the bivariate associations with the independent variables. The multivariate logistic regression examined the net effect of the independent variables on the odds of intention to renew. Our results showed that the household (HH) with high monthly income had lower odds of renewing their annual NHI membership (adjusted OR: 0.14, 95% CI: 0.03-0.58). Similarly, households (HHs) with overall health service satisfaction (adjusted OR:3.59, 95%CI: 1.23-10.43) and increased frequency of visits after NHI membership (adjusted OR: 10.09, 95% CI: 1.39-73.28) had high odds of renewing their membership. The top three dropout reasons were health services underutilization (43.3%), poor health services (26.9%), and the inadequacy of the benefits package (14.9%). Almost 64% of the respondents were willing to renew their membership upon improved services. The study found that the Nepal NHI annual membership renewal key predictors are HH income, health service quality, and health service utilization. Among these three key predictors, health service quality and service utilization were among the top three dropout reasons. The study, however, did not differentiate between moral hazards or actual service utilization, demanding further studies on the health service utilization of the insured members.

Healthcare Cost Reduction and Health Insurance Policy Improvement

OBJECTIVES

Reducing healthcare costs is a constant endeavor of all healthcare organizations, governments, policy makers, and individuals. A comparative study of available healthcare policies from the patient's perspective is not available. Furthermore, an analysis of how the various components of these policies affect the healthcare cost of a patient is required.

METHODS

Data were collected from 150 hospitalized patients in India regarding their views on 7 healthcare cost categories covering 22 cost components. These are statistically analyzed under 4 commonly used health insurance policies (2 government insurance schemes: ex-servicemen contributory health scheme and employee state insurance; private insurance schemes; and self-financing-ie, no insurance) to assess which healthcare cost component is more important under which policy option.

RESULTS

Under 7 healthcare cost categories, 22 cost components were studied, and out of these 22, 16 were found statistically significant. Results revealed that the treatment of all 16 significant cost components under the 4 health insurance policy options was statistically different.

CONCLUSIONS

Patients covered under government sector health insurance policies were found to be less concerned about healthcare costs, whereas those covered under private health insurance policies were found to be more cost-conscious. Access to healthcare or transportation costs to the healthcare facility is a key concern area for self-financed patients.

The sustainability of premium payment of national health insurance's self-enrolled members in Jakarta Greater Area

Background: The sustainability of the National Health Insurance (NHI) program heavily relies on the premium of its member. The negligence of a large number of members at pay the premium lead to the failure of the Social Security Agency for Health (SSAH) to deliver its services. This study aims at analyzing important factors that influence the sustainability of premium payment of NHI’s self-enrolled members in the Jakarta Greater Area.

Design and methods: This study performed an econometric analysis from the panel and the same respondent’s data in 2015 and 2017. The population of the study was NHI’s self-enrolled members who lived in the City of Jakarta, Bogor, Depok, Tangerang, Bekasi, (Jakarta Greater Area) and it represents the urban area of Indonesia. The ordinal logistic regression model was used to determine the type of sustainability NHI premium payment.

Results: The survey shows that around 28.3% of self-enrolled members do not pay the NHI insurance premium regularly. Applying ordered logit this study statistically confirms that age of household head, income per month, never experience economic hardship, 1^st/2^nd class registration, and benefits of SSAH are positively correlated with compliance rate to pay NHI insurance premium. Whereas tobacco consumption, health-seeking behavior, and the 2016 increase of premium are negatively correlated with regular premium payment.

Conclusions: This study calls for policy intervention to improve compliance of premium payment such as i) massive promotion of insurance literacy and benefits of insurance through a health professional, internet, and government officer; ii) expanding auto-debit and installment premium payment; iii) incentive for paying premium regularly and not smoking; and iv) improving access and quality of health services.

Is Indonesia achieving universal health coverage? Secondary analysis of national data on insurance coverage, health spending and service availability

OBJECTIVES

To analyse the relationship between health need, insurance coverage, health service availability, service use, insurance claims and out-of-pocket spending on health across Indonesia.

DESIGN

Secondary analysis of nationally representative quantitative data. We merged four national data sets: the National Socioeconomic Survey 2018, National Census of Villages 2018, Population Health Development Index 2018 and National Insurance Records to end 2017. Descriptive analysis and linear regression were performed.

SETTING

Indonesia has one of the world's largest single-payer national health insurance schemes. Data are individual and district level; all are representative for each of the country's 514 districts.

PARTICIPANTS

Anonymised secondary data from 1 131 825 individual records in the National Socioeconomic Survey and 83 931 village records in the village census. Aggregate data for 220 million insured citizens.

PRIMARY OUTCOME MEASURES

Health service use and out-of-pocket payments, by health need, insurance status and service availability. Secondary outcome: insurance claims.

RESULTS

Self-reported national health insurance registration (60.6%) is about 10% lower compared with the insurer's report (71.1%). Insurance coverage is highest in poorer areas, where service provision, and thus service use and health spending, are lowest. Inpatient use is higher among the insured than the uninsured (OR 2.35, 95% CI 2.27 to 2.42), controlling for health need and access), and poorer patients are most likely to report free inpatient care (53% in wealth quintile 1 vs 41% in Q5). Insured patients spend US$ 3.14 more on hospitalisation than the uninsured (95% CI 1.98 to 4.31), but the difference disappears when controlled for wealth. Lack of services is a major constraint on service use, insurance claims and out-of-pocket spending.

CONCLUSIONS

The Indonesian public insurance system protects many inpatients, especially the poorest, from excessive spending. However, others, especially in Eastern Indonesia cannot benefit because few services are available. To achieve health equity, the Indonesian government needs to address supply side constraints and reduce structural underfunding.

Barriers and Facilitators of Community-Based Health Insurance Policy Renewal in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

A growing number of low- and middle-income countries are implementing small-scale community-based health insurance schemes to tackle the burdens posed by direct out-of-pocket payments. Apart from a few successful experiences, such schemes suffer from the problem of persistent low membership which could be attributed to either initial low enrollment or low renewal rate. However, there is a lack of comprehensive information on the factors that influence subscribers' policy renewal decisions. Hence, we systematically synthesize information to answer the review question "what are the barriers and facilitators of community-based health insurance policy renewal in low and middle-income countries?".

METHODS

We searched PubMed, Scopus, and Hinari electronic databases in line with the PRISMA guidelines. Our search was limited to studies published from January 2005 to February 2020 in the English language. Additional studies and grey literature were searched using Google Scholar. We included quantitative, qualitative, and mixed-method studies in the review. We assessed the methodological quality of the studies using standardized appraisal tools. The findings were synthesized inductively using a thematic analysis approach.

RESULTS

Our searches retrieved 2386 records among which 27 were included in the review. The thematic synthesis identified six major themes that influence the decision to renew scheme policy: socio-demographic factors; scheme-related awareness and understanding; participation in scheme and other voluntary groupings, need and benefit factors; health-care quality; and scheme operation and policy.

CONCLUSION

Lower socioeconomic status, poor quality of health care, lack of benefit from the scheme, lack of trust in scheme management, and dissatisfaction with scheme services are important barriers for community-based health insurance policy renewal. Better education, understanding the principles of the scheme, active participation in the scheme, and long-term illness experience of member households facilitate renewal decisions. These are important areas of intervention for governments and other relevant stakeholders to retain members and maintain the sustainability of the schemes.

REGISTRATION

The review protocol was registered in PROSPERO international prospective register of systematic reviews (ID = CRD42020168971).

Enrolment of informal sector workers in the National Health Insurance System in Indonesia: A qualitative study

One of the main challenges facing the expansion of universal health coverage (UHC) in developing countries like Indonesia is the high prevalence of those working in the informal sector who must voluntarily register in the National Health Insurance System (NHIS). This condition hinders some from being covered by the NHIS. Following Bourdieu's concepts of field, capital and habitus, this research aims to analyse some aspects that influence the decision of informal sector workers to join the NHIS in Indonesia. We conducted qualitative methods, including in-depth interviews of 29 informants and Focus Group Discussion (FGD) in the three selected regions of Deli Serdang (North Sumatera), Pandeglang (Banten) and Kupang (East Nusa Tenggara). Using thematic content analysis and several triangulation processes, this study found that three main factors influence the decisions of those working in the informal sector to join the NHIS: health conditions, family and peers, and existing knowledge and experience. The stories provided by the informants regarding their decision-making processes in joining NHIS also reveal the necessary and sufficient conditions that enable informal sector workers to join the NHIS, which are individual-specific and which may differ between people, depending on individual characteristics, regional socioeconomic and demographic characteristics and belief systems. These three factors are all necessary conditions to support the joining of informal sector workers into the NHIS. This study suggests that one possible route for expanding the UHC coverage of informal sector workers is through maximising the word-of-mouth effect by engaging local or influential leaders.

Primary health care policy and vision for community pharmacy and pharmacists in Indonesia

The practice of community pharmacy in low and middle-income countries, including in Indonesia, is often described as in the state of infancy with several intractable barriers that have been substantially and continuously hampering the practice. Such description might be valid in highlighting how pharmacy is practiced and the conditions within and beyond community pharmacy organizations. Therefore, it is not surprising that the concept of integrating community pharmacy into the primary care system may not be considered in the contemporary discourse despite the fact that community pharmacy has been operating within communities for years. However, in the case of Indonesia, we argue that changes in the health care system within the past decade particularly with the introduction of the universal health coverage (UHC) in 2014, may have significantly amplified the role of pharmacists. There is good evidence which highlights the contribution of pharmacist as a substantial health care element in primary care practice. The initiative for employing pharmacist, identified in this article as primary care pharmacist, in the setting of community health center [puskesmas] and the introduction of affiliated or contracted community pharmacy under the UHC have enabled pharmacist to work together with other primary care providers. Moreover, government agenda under the “Smart Use of Medicines” program [Gema Cermat] recognizes pharmacists as the agent of change for improving the rational use of medicines in the community. Community pharmacy is developing, albeit slowly, and is able to grasp a novel position to deliver pharmacy-related primary care services to the general public through new services, for example drug monitoring and home care. Nevertheless, integrating community pharmacy into primary care is relatively a new notion in the Indonesian setting, and is a challenging process given the presence of barriers in the macro, meso- and micro-level of practice.

Health insurance literacy: discussion and reaction of Facebook users' towards the National Health Insurance in Indonesia

Universal Health Coverage always persevered as a pro poor policy in many countries, characterized by a major impact on higher out-of-pocket healthcare costs, with low-cost alternative prescription drugs and capitation payments made to physicians, in order to reduce inequity. These concerns have been discussed widely on social media, including Facebook, but social media are consistently neglected as a source of scientific information. The purpose of this study, therefore, is to analyze the thought process or feelings of individuals about the policies, also focusing on the possible reactions. Hence, a systematic review in the form of discussion forums on the Facebook page of the National Health Insurance Agency, Indonesia was conducted from 2015 to 2016, with regards to the implementation of National Health Insurance, within a year and half after the policy was launched. In addition, the contents of 148 discussions were deductively analyzed, and the findings showed the pragmatic disposition of most Facebook users towards health care utilization, the costs of Insurance, and the possible benefits of payment. Furthermore, the debate conducted in social media related with the policy and its practice issues ought to be countered through appropriate modification.

Significance for public health

Social media has been incorporated for the communication of health strategies in Indonesia, through the discussions related to National Health Insurance policies. Social media can provide opportunities to better understand the concept of health insurance literacy and facilitate growth in social norms and skills, as participants of online forums. Until now, there is a deficiency in studies related to the use of social media as source of news where people pay attention to specific issues. This study analyzes the thought process and feelings of individuals, as well as the reaction towards the National Health Policies implemented.