Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces.

Abstract

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance. Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants. The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less). Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.