Payment compliance of informal sector workers in Indonesia National Health Insurance: a study on ability and willingness to pay

BackgroundMany sub-Saharan African countries are increasingly adopting national health insurance policies to improve access to essential services. Informal sector workers, however, often lack coverage because their earnings are typically not low enough to qualify for government subsidies but insufficient to cover insurance premiums, resulting in a phenomenon known as "missing middle". This paper examined socioeconomic inequalities in national health insurance enrolment and determinants of participation among informal sector workers in Kenya.MethodsWe used nationally representative cross-sectional household survey data (n = 5168) collected from informal sector workers in Kenya in December 2020. First, we examined levels of national health insurance enrolment among informal sector workers. Second, we examined socioeconomic inequalities in national health insurance enrolment using concentration curves and the Wagstaff index. Third, we employed a three-level mixed effects logistic regression model to assess the determinants of national health insurance enrolment.ResultsOverall, 21.75% (95% Confidence Interval 20.63–22.89) of informal sector workers in Kenya were enrolled in the national health insurance scheme. We observed pro-rich inequalities in national health insurance enrolment, with a concentration index of 0.35 (95% CI 0.30–0.41). Older age (adjusted odds ratio (AOR) = 1.66, 95% CI 1.31–2.10), employment in the non-agricultural sector (AOR = 1.96, 95% CI 1.60–2.39), microfinance institutional membership (AOR = 1.44, 95% CI 1.23–1.69), higher education level (AOR = 2.49, 95% CI 1.99–3.11), household’s prior positive experience with healthcare (AOR = 1.45, 95% CI 1.22–1.72), and higher socioeconomic status based on the wealth asset index (AOR = 3.87, 95% CI 2.97–5.05) were all significantly positively associated with national health insurance enrolment. Larger households had lower odds of enrollment (AOR = 0.76, 95% CI 0.60–0.96).ConclusionsOur findings suggest that enrollment rates among informal sector workers remain low, and important pro-rich inequalities prevail. Economic factors, education, and prior experience with healthcare services were key drivers of national health insurance enrollment. Further policies are needed to increase enrollment among informal sector workers, including differential premium levels, reliance on expanded targeted subsidies, and enhanced awareness campaigns. Our findings are also applicable to other low-resource settings experiencing conditions similar to those in Kenya as they transition toward national health insurance policies, with the goal of achieving universal health coverage.

Indonesia faces a growing informal sector in the wake of implementing a national social health insurance system—Jaminan Kesehatan Nasional (JKN)—that supersedes the vertical programmes historically tied to informal employment. Sustainably financing coverage for informal workers requires incentivising enrolment for those never insured and recovering enrolment among those who once paid but no longer do so. This study aims to assess the ability- and willingness-to-pay of informal sector workers who have stopped paying the JKN premium for at least six months, across districts of different fiscal capacity, and explore which factors shaped their willingness and ability to pay using qualitative interviews. Surveys were conducted for 1,709 respondents in 2016, and found that informal workers’ average ability and willingness to pay fell below the national health insurance scheme’s premium amount, even as many currently spend more than this on healthcare costs. There were large groups for whom the costs of the premium were prohibitive (38%) or, alternatively, they were both technically willing and able to pay (25%). As all individuals in the sample had once paid for insurance, their main reasons for lapsing were based on the uncertain income of informal workers and their changing needs. The study recommends a combination of strategies of targeting of subsidies, progressive premium setting, facilitating payment collection, incentivising insurance package upgrades and socialising the benefits of health insurance in informal worker communities.

Indonesia faces a growing informal sector in the wake of implementing a national social health insurance system-Jaminan Kesehatan Nasional (JKN)-that supersedes the vertical programmes historically tied to informal employment. Sustainably financing coverage for informal workers requires incentivising enrolment for those never insured and recovering enrolment among those who once paid but no longer do so. This study aims to assess the ability- and willingness-to-pay of informal sector workers who have stopped paying the JKN premium for at least six months, across districts of different fiscal capacity, and explore which factors shaped their willingness and ability to pay using qualitative interviews. Surveys were conducted for 1,709 respondents in 2016, and found that informal workers' average ability and willingness to pay fell below the national health insurance scheme's premium amount, even as many currently spend more than this on healthcare costs. There were large groups for whom the costs of the premium were prohibitive (38%) or, alternatively, they were both technically willing and able to pay (25%). As all individuals in the sample had once paid for insurance, their main reasons for lapsing were based on the uncertain income of informal workers and their changing needs. The study recommends a combination of strategies of targeting of subsidies, progressive premium setting, facilitating payment collection, incentivising insurance package upgrades and socialising the benefits of health insurance in informal worker communities.

BackgroundMost low-income countries have prioritised implementing national health insurance schemes (NHIs) as a solution to reducing the high out-of-pocket expenditures on health and enhancing access to healthcare, especially among informal...

PurposeThe purpose of this paper is to establish the main factors influencing willingness to pay for health insurance and pension schemes among informal workers in low- and middle-income countries (LMICs). Historically, informal economy workers have been excluded from social protection coverage. There is a growing need, interest and policy discourse in LMICs to extend social security to informal economy workers. However, little is known about informal workers' willingness to pay (WTP) for social security services in different LMIC settings.Design/methodology/approachThe authors conducted a systematic review and searched five databases from 1987 to 2017. Included papers focused on “social security”, “social insurance”, “pension”, “informal economy”, “informal sector” and “informal workers” in LMICs. Authors conducted independent data appraisal and data extraction. A total of 1790 papers were identified. After exclusion, 34 papers were included in the analysis. Given the heterogeneous results, the authors performed a narrative synthesis to consolidate the findings of the different studies.FindingsIn total, 34 studies from 17 countries were included in the review, out of which 23 studies focused on health insurance, 7 studies on pension schemes and 4 studies on social security in general. The study showed that income and trust were associated with WTP for both health insurance and pension schemes. In addition, family size, age, education and residential area were common factors for both forms of social security. For health insurance, experience of sickness, attitude and presence of medical doctors as well as distance from the healthcare facility all played a role in determining WTP. For pension schemes, low and flexible contribution rates, benefit package, government subsidies and quality of administration of the schemes influenced enrolment and contributions.Research limitations/implicationsMore evidence is needed for WTP for pensions among informal workers.Practical implicationsThe findings show that socio-economic differences, scheme-type (health or pension) and level of trust influence WTP for health insurance or pension among informal sector workers. The review results suggest that the factors influencing WTP for health insurance and pensions interplay in a complex web of relations. More evidence is needed on WTP for pensions among informal workers.Social implicationsFurther studies are particularly needed on the interrelationship of the influences to WTP, including gender issues, access barriers and socioeconomic factors, among program design issues for social security.Originality/valueThis paper is based on a systematic review methodology and contributes to the discourse on extending social security to informal economy workers based on evidence from various countries.

Extending health insurance coverage to informal sector populations remains a major challenge toward achieving universal health coverage. This study aimed to fill the gap in the literature by examining barriers to enrollment in National Health Insurance Scheme (NHIS) among informal sector workers in Nigeria. Data were drawn from the 2018 Nigeria Demographic and Health Survey. The study population comprised of men (n = 10,163) and women (n = 22,216) working in the informal sector. Bivariate and multivariate logistic regression were used to examine barriers to enrollment in NHIS. Results show that the majority of men (98.9%) and women (98.6%) were not enrolled in NHIS. Age, gender of household head, educational level, socioeconomic status, geopolitical zone, distance to a health facility, frequency of reading newspapers or magazines, and watching television were significantly associated with non‐enrollment in NHIS. Findings suggest that enrollment in NHIS in Nigeria is very low. Additionally, there are significant barriers to enrollment. There is a need for governments and policymakers to address these barriers. The use of voluntary prepayments from informal sector workers as a strategy to extend health insurance coverage has not been effective.

This research addresses considerations when designing and implementing social protection programs and systems for informal sector workers in the extractive industry in Bojonegoro Regency. Policy and program considerations relating to social protection, the quality of day-to-day administration of social protection programs greatly influence the extent to which these programs generate the expected impact. This paper outlines best practices at each level of social protection program design and implementation as a way to provide guidance on how such programs can best meet the needs of informal sector workers. As such, it also includes examples of social protection programs and systems that address the vulnerabilities faced by informal sector workers in extractive industries in other countries and regions. The aim is to explore the level of access and understanding of informal workers to social protection programs in the extractive industry sector in Bojonegoro. The research methods used include surveys and interviews with a representative sample of informal workers in the sector. The main findings of this study show that the level of access to social protection, such as health insurance and social security, is still low among informal workers. In addition, their understanding of social rights and the availability of social protection programs is also limited. These results highlight the need for greater efforts from the government and other stakeholders to improve informal workers' awareness and access to social protection. Policy implications of this study include expanding the coverage of social protection programs, improving accessibility and understanding of these programs, and developing more inclusive policies to improve the welfare of informal workers in the extractive industry sector in Bojonegoro.

Background Most of the about 140 million informal sector workers in urban China do not have health insurance. A 1998 central government policy leaves it to the discretion of municipal governments to offer informal sector workers in cities voluntary participation in a social health insurance for formal sector workers, the so-called 'basic health insurance' (BHI).MethodsWe used the contingent valuation method to assess the maximum willingness to pay (WTP) for BHI among informal sector workers, including unregistered rural-to-urban migrants, in Wuhan City, China. We selected respondents in a two-stage self-weighted cluster sampling scheme. ResultsOn average, informal sector workers were willing to pay substantial amounts for BHI (30 Renminbi (RMB), 95% confidence interval (CI) 27-33) as well as substantial proportions of their incomes (4.6%, 95% CI 4.1-5.1%). Average WTP increased significantly when any one of the copayments of the BHI was removed in the valuation: to 51 RMB (95% CI 46-56) without reimbursement ceiling; to 43 RMB (95% CI 37-49) without deductible; and to 47 RMB (95% CI 40-54) without coinsurance. WTP was higher than estimates of the cost of BHI based on past health expenditure or on premium contributions of formal sector workers. Predicted coverage with BHI declined steeply with the premium contribution at low contribution levels. When we applied equity weighting in the aggregation of individual WTP values in order to adjust for inequity in the distribution of income, mean WTP for BHI increased with inequality aversion over a plausible range of the aversion parameter. Holding other factors constant in multiple regression analysis, for a 1% increase in income WTP for BHI with different copayments increased by 0.434-0.499% (all p < 0.0001), and for a 1% increase in past health care expenditure WTP increased by 0.076-0.148% (all p < 0.0004). Being male, a migrant, or without permanent employment significantly decreased WTP for BHI. Education was not a significant determinant of WTP for BHI. ConclusionOur results suggest that Chinese municipal governments should allow informal sector workers to participate in the BHI. From a normative perspective, BHI for informal sector workers is likely to increase social welfare because average WTP for BHI is significantly higher than estimates of the average cost of BHI. We further find that informal sector workers do not value the BHI as a mechanism to recover the relatively frequent but small financial losses associated with common illnesses, but because it protects against the rare but large financial losses associated with catastrophic care. From a behavioural perspective, our results predict that at a price equal to the average premium contribution of formal sector workers 35% of informal sector workers will enrol in the BHI. Subsidies and changes in insurance attributes (e.g. including catastrophic care and portability) should be effective in increasing BHI coverage. In addition, coverage should expand with rising incomes among informal sector workers in China. Finally, adverse selection will be unlikely to be a large problem, if the BHI is offered to informal sector workers.

ObjectiveInformal sector workers are exposed to occupational hazards which could escalate their healthcare expenditures. Thus, enrollment in a health protection scheme among informal sector workers is useful for reducing their catastrophic healthcare expenditures. However, there is scant information on factors predicting their enrollment in the National Health Insurance Scheme (NHIS) in Ghana, a gap this quantitative study aims to fill. A sample of 350 informal sector workers was involved in a cross-sectional survey.ResultsApproximately 17% of the participants were enrolled in NHIS. Respondents who had worked between 5 and 7 years were significantly more likely to enroll in NHIS compared with those who had worked below 2 years (AOR = 13.159, CI 1.135–152.596, p = 0.039). The study further found that apprentices (AOR = 0.72, CI 0.353–1.056, p = 0.005) were less likely to enroll in NHIS compared with their masters. Participants who were exposed to electrical hazards (AOR = 2.93, CI 1.56–5.10, p = 0.013) and suffered from occupational diseases (AOR = 2.75, CI 1.743–5.17, p = 0.001) were significantly more likely to enroll in NHIS. Also, respondents who were non-Christians were significantly less likely to enroll in NHIS compared with their respective counterparts (AOR = 0.726, CI 0.067–2.503, p = 0.011). The findings are useful for increasing the NHIS enrollment rate among informal sector workers in Ghana.

Background: Universal Health Coverage is the mandate of the Pancasila and 1945 Constitution. UHC's target on January 1 st , 2019 is that all Indonesians are covered by the National Health In­su­ran­ce (JKN). Meanwhile, the participation of informal workers as of May 1, 2019 only reached 57%. The cross subsidy system is not optimal and the budget deficit will continue to be experienced because the­re are still many citizens who have not joined JKN. This study aimed to analyze the de­ter­mi­nants of the participation of informal workers in the national health insurance program in Kudus using the Health Belief Model. Subjects and Method: This was case control study,conducted in 5 sub-districts in Kudus Re­gen­cy, Cen­tral Java from September to October 2019. Total of 200 informal workers were selected by pur­posive sampling, it were devided into two groups including 100 in case group and a 100 in con­trol group. The dependent variable was the participation of informal workers in the JKN program. The independent variables were perception of vulnerability, perception of seriousness, perspective of be­nefits, family support, self-efficacy, and social environment. The data collection was per­for­med using a questionnaire and data analysis with logistic regression using stata 13. Results: The participation of informal workers in the JKN program increased with knowledge of ≥Senior high school (b = 5.09; 95% CI = 0.32 to 9.87; p = 0.036), high perception of vulnerability (b = 3.01; 95% CI = 0.26 to 5.75; p = 0.031), high perceived seriousness (b= 5.38; 95% CI = 2.14 to 8.61; p= 0.001), high perceived benefit (b= 3.86; 95% CI= 0.39 to 7.34; p= 0.029), strong family support (b= 7.26; 95% CI= 2.69 to 11.82; p= 0.002), strong self-efficacy (b = 3.98; 95% CI = 0.98 to 6.98; p= 0.009) and a supportive social environment (b = 4.51; 95% CI= 1.61 to 7.40; p= 0.002). Conclusion: Knowledge, perception of vulnerability, perception of seriousness, perceived use­ful­ness, family support and social environment influence the participation of informal workers in the JKN program. Keywords: universal health coverage, national health insurance, health belief model Correspondence: Anom Dwi Prakoso, Masters Program in Public Health, Universitas Sebelas Maret, Jl. Ir. Sutami 36A, Surakarta 57126, Central Java, Indonesia. Email: anomdwiprakoso@gmail.com. Mobile: +62­895363­054­393. Journal of Health Policy and Management (2020), 5(1): 61-73 https://doi.org/10.26911/thejhpm.2020.05.01.06

The study examines the impact of the COVID-19 pandemic lockdown policy on the welfare of workers in the formal and informal sectors in Gwagwalada Area Council, Abuja, Nigeria, during the COVID-19 period using health and education services as case study. The study was motivated by the fact that the outbreak had a negative influence on both formal and informal workers’ well-being; nonetheless, concluding that the lockdown had an equivalent impact on both formal and informal sector workers in Gwagwalada Area Council without an empirical investigation may not have been reasonable enough. Thus, the need for this study to make a comparative analysis between formal and informal sector workers. For empirical purpose, independent two-sample t-test were used to compare perceptions of the two sectors regarding the effects of daily COVID-19 cases and the attendant lockdown stringency measures on health and education services uptake of workers in the two sectors understudy. A survey of 363 respondents was undertaken between the formal and informal workers in Gwagwalada Area Council of Abuja, Nigeria, to examine the effects of the pandemic lockdown policy measures on the uptake of education and health services. The study found that the informal sector workers were more severely affected than the formal sector during the lockdown. To address these challenges, the study recommends, among others, massive loans and grants for business owners with little or no interest rate to cushion the effects of the COVID-19.

The study examines the impact of the COVID-19 pandemic lockdown policy on the welfare of workers in the formal and informal sectors in Gwagwalada Area Council, Abuja, Nigeria, during the COVID-19 period using health and education services as case study. The study was motivated by the fact that the outbreak had a negative influence on both formal and informal workers’ well-being; nonetheless, concluding that the lockdown had an equivalent impact on both formal and informal sector workers in Gwagwalada Area Council without an empirical investigation may not have been reasonable enough. Thus, the need for this study to make a comparative analysis between formal and informal sector workers. For empirical purpose, independent two-sample t-test were used to compare perceptions of the two sectors regarding the effects of daily COVID-19 cases and the attendant lockdown stringency measures on health and education services uptake of workers in the two sectors understudy. A survey of 363 respondents was undertaken between the formal and informal workers in Gwagwalada Area Council of Abuja, Nigeria, to examine the effects of the pandemic lockdown policy measures on the uptake of education and health services. The study found that the informal sector workers were more severely affected than the formal sector during the lockdown. To address these challenges, the study recommends, among others, massive loans and grants for business owners with little or no interest rate to cushion the effects of the COVID-19.

Health insurance receives a great deal of attention in the SDG’s, where one of its main targets is to guarantee a healthy life and to encourage welfare for all people of all ages or later to be called Universal Health Coverage (UHC). In Indonesia there are more informal workers than formal sector workers, but almost half of informal sector workers work without health insurance protection. This study aims to determine the achievement of UHC in terms of ownership of health insurance for informal sector workers. The database used in this study was sourced from SUSENAS 2018. Data processing and analysis techniques were carried out in a quantitative descriptive form of a single frequency table and a cross table. The results showed that based on socio-economic and demographic characteristics, Indonesian informal sector workers were dominated by men, living in rural areas, being married, being heads of households (KRT) and their partners, aged 18-44 years, having a population registration number (NIK) ), only completed the highest level of basic education, worked in industrial businesses, had no health complaints, was in households with the lowest 40 percent economic status, and did not self-medicate when ill. The study also found that there was still considerable variation in the achievement of UHC between provinces in Indonesia. When viewed by province, Aceh is the province with the highest percentage of health insurance ownership or UHC reaching 94.77 percent. Meanwhile West Kalimantan is the province with the lowest percentage of health insurance ownership, which is only 40.73 percent.

The implementation of Indonesia’s national health insurance programme in 2014 highlights the “missing middle” problem in which non-poor workers in the informal sector remain uncovered from the health care due to self-enrolment. This study aims at examining why informal workers are reluctant to join the national health insurance even though the benefits of the programme are very generous. Observing 400 households working in the informal sector and applying the Triple Bounded Dichotomies Choice Contingent Valuation Method to observe the Willingness to Pay, this study found that 70 per cent of respondents were willing to pay a premium that is lower than the current rate. Yet, only 18.7 per cent of households had registered for national health insurance. Our econometric estimations provide evidence that the availability of hospitals, insurance literacy, experiences of being an inpatient or outpatient, the number of family members, the sex of the head of the household, access to the Internet, and household income are highly correlated to the likelihood of workers in the informal sector joining the national health insurance programme. In contrast to other studies, we found that the insurance premium was not the primary impediment. Rather, the two main obstacles were: availability of health services; and a lack of insurance literacy. Hence, this study calls for increased investment on healthcare facilitates as well as campaigns to educate the public about the importance of health insurance.

IntroductionFor the last two decades, promoted by many governments and international number in sub-Saharan Africa. In 2005 in Cameroon, there were only 60 Community-based health insurance (CBHI) schemes nationwide, covering less than 1% of the population. In 2006, the Cameroon government adopted a national strategy aimed at creating at least one CBHI scheme in each health district and covering at least 40% of the population with CBHI schemes by 2015. Unfortunately, there is almost no published data on the awareness and the implementation of CBHI schemes in Cameroon.MethodsStructured interviews were conducted in January 2010 with 160 informal sectors workers in the Bonassama health district (BHD) of Douala, aiming at evaluating their knowledge, concern and preferences on CBHI schemes and their financial plan to cover health costs.ResultsThe awareness on the existence of CHBI schemes was poor awareness schemes among these informal workers. Awareness of CBHI schemes was significantly associated with a high level of education (p = 0.0001). Only 4.4% of respondents had health insurance, and specifically 1.2% were involved in a CBHI scheme. However, 128 (86.2%) respondents thought that belonging to a CBHI scheme could facilitate their access to adequate health care, and were thus willing to be involved in CBHI schemes. Our respondents would have preferred CBHI schemes run by missionaries to CBHI schemes run by the government or people of the same ethnic group (p).ConclusionThere is a very low participation in CBHI schemes among the informal sector workers of the BHD. This is mainly due to the lack of awareness and limited knowledge on the basic concepts of a CBHI by this target population. Solidarity based community associations to which the vast majority of this target population belong are prime areas for sensitization on CBHI schemes. Hence these associations could possibly federalize to create CBHI schemes.