Abstract

BackgroundThe growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia’s aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization.MethodsWe used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers.ResultsIn 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03–1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01–1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents’ village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation.ConclusionsPoor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.

Highlights

  • The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement

  • In order to better understand the effects of UHC interventions on the use of maternal health services in Indonesia, we evaluated the potential role of the Jamkesmas health insurance scheme in increasing health facility and skilled birth delivery among poor women in Indonesia, and explored the reasons behind any observed changes

  • Perceived barriers to health insurance membership and maternal health services Results from the indepth interviews (IDI) found key barriers associated with health insurance access and maternal health services among poor women (Table 3)

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Summary

Introduction

The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. The result of Indonesia’s UHC initiative is the roll-out and implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jaminan Kesehatan Masyarakat (Jamkesmas) [health insurance for the population] program. The Askeskin program was designed to increase access and quality of health services for the poor through operational funds provided to puskesmas [community health center] in the form of capitation payments and a fee-for-service health insurance scheme reimbursed through a quasi-governmental agency. Jamkesmas beneficiaries were entitled to comprehensive maternity benefits, including antenatal care, institutional delivery, and postnatal care [23, 36]

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