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

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.

Factors affecting access to healthcare for young people in the informal sector in developing countries: a systematic review

Background

Young people are increasingly seeking employment in the informal sector due to increasing global unemployment. However, the precarious nature of work in the informal sectors, coupled with the high risk of occupational hazards, calls for a greater need for effective healthcare for informal sector workers, particularly young people. In addressing the health vulnerabilities of informal workers, systematic data on the determinants of health is a persistent challenge. Therefore, the objective of this systematic review was to identify and summarise the existing factors that affect access to healthcare among young people from the informal sector.

Methods

We searched six data databases (PubMed, Web of Science, Scopus, ProQuest, Crossref, and Google Scholar), which was followed by hand searching. Then we screened the identified literature using review-specific inclusion/exclusion criteria, extracted data from the included studies and assessed study quality. Then we presented the results in narrative form, though meta-analysis was not possible due to heterogeneity in the study design.

Results

After the screening, we retrieved 14 studies. The majority were cross-sectional surveys and were conducted in Asia (n = 9); four were conducted in Africa, and one in South America. Samples ranged in size from 120 to 2,726. The synthesised results demonstrate that problems of affordability, availability, accessibility, and acceptability of healthcare were barriers to young informal workers seeking healthcare. We found social networks and health insurance as facilitators of access for this group of people.

Conclusion

To date, this is the most comprehensive review of the evidence on access to healthcare for young people in the informal sector. Our study finding highlights the key gaps in knowledge where future research could further illuminate the mechanisms through which social networks and the determinants of access to healthcare could influence the health and well-being of young people and thus inform policy development.

Health insurance ownership among female workers in Indonesia: does socioeconomic status matter?

BACKGROUND

Female workers are vulnerable groups in the Indonesian context, and female workers must be responsible for domestic problems and earn a living. The study aimed to analyze the role of socioeconomic on health insurance ownership among female workers in Indonesia.

METHODS

The study population was all female workers in Indonesia. This cross-sectional study involved 7,943 respondents. The study analyzed health insurance ownership as an outcome variable and socioeconomic status as an exposure variable. The study also involved five control variables: residence, age, marital, education, and occupation. The research used multinomial logistic regression in the final step.

RESULTS

The results show the poorest female workers have a possibility of 0.735 times more than the richest to have NHI (AOR 0.733; 95% CI 0.733-0.737). The poorer female workers have 0.939 times less likely than the richest to have NHI (AOR 0.939; 95% CI 0.937-0.942). Female workers with middle socioeconomic status are possibly 0.833 times less than the richest to have NHI (AOR 0.833; 95% 0.831-0.835). Moreover, the richer female workers have 1.028 times more likely than the richest to have NHI (AOR 1.028; 95% CI 1.025-1.030). Moreover, all socioeconomic statuses have a lower possibility than the richest of having other health insurance.

CONCLUSIONS

The study concluded that socioeconomic has a role in health insurance ownership among female workers in Indonesia.

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.

Socioeconomic Disparities in Hospital Utilization Among Female Workers in Indonesia: A Cross-Sectional Study

BACKGROUND

The study aims to analyze the relationship between socioeconomic and hospital utilization among female workers in Indonesia.

METHODS

The study analyzed secondary data from the 2018 Indonesian Basic Health Survey. The study gathered 161 186 female workers through stratification and multistage random sampling. As control factors, the study looked at age, marital status, education, occupation, and health insurance, in addition to the categories of socioeconomic and hospital utilization. The study used binary logistic regression to evaluate the data in the final step.

RESULTS

The result shows female workers with poorer wealth status are 1.142 times more likely than the most impoverished female workers to utilize the hospital (AOR 1.142; 95% CI 1.135-1.148). Female workers with median wealth status are 1.509 times more likely than the poorest female workers to take advantage of the hospital (AOR 1.509; 95% CI 1.501-1.517). Female workers with wealthier wealth status are 1.808 times more likely than the poorest female workers to use the hospital (AOR 1.808; 95% CI 1.799-1.817). The wealthiest female workers are 2.399 times more likely than the poorest female workers to utilize the hospital (2.399; 95% CI 2.387-2.411).

CONCLUSION

The study concluded a relationship between socioeconomic status and hospital utilization among female workers in Indonesia. The better the socioeconomic, the better the hospital utilization.

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.

Can National Health Insurance Pave the Way to Universal Health Coverage in Sub-Saharan Africa?

Countries of sub-Saharan Africa are increasingly turning to public contributory health insurance as a mechanism to advance UHC goals. Eight countries in sub-Saharan Africa have introduced national health insurance (NHI) systems, and at least seven more have plans or have passed legislation to establish NHI. Examining the experience of countries that have taken this path, some lessons emerge about whether and how contributory national health insurance may or may not be a viable path toward UHC in sub-Saharan Africa. Only Gabon, Ghana and Rwanda have been able to extend NHI coverage to a significant share of the population. None of the countries with NHI have peformed better on other UHC indicators-resource mobilization, service coverage and financial protection-than higher performing countries of Africa that did not introduce NHI. The experience of Gabon, Ghana and Rwanda provide lessons for what may be required to make NHI a viable path to UHC-there need to be explicit objectives and an understanding of why NHI can meet those objectives in the country's particular context; it must include key pro-equity design elements; and NHI needs to be supported by widespread political commitment and ongoing learning and adaptation. For many governments, achieving this kind of enabling environment for NHI may be particularly challenging for various political, economic, or social reasons. In these contexts, health sector leaders may consider looking inward to their existing health financing systems for ways to improve and be more effective.