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Assessing the Determinants of Compliance with National Health Insurance Contributions among Unemployed Workers in Indonesia†
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Author: TrisnasariTrisnasari SciProfiles Scilit Preprints.org Google Scholar 1, 2, Orapin LaoseeOrapin Laosee SciProfiles Scilit Preprints.org Google Scholar 1, Cheerawit RattanapanCheerawit Rattanapan SciProfiles Scilit Preprints.org Google Scholar Preprints.org Janmaimool Sciprofiles Google Scholar 1, *
This is a longer version of a paper presented at the 14th International Postgraduate Conference on Population and Public Health Sciences (IGSCPP), Bangkok, Thailand, 7 July 2023.
Date of Submission: October 10, 2023 / Date of Revision: November 21, 2023 / Date of Approval: November 28, 2023 / Date of Publication: November 30, 2023
(This article is excerpted from the Special Issue on Universal Health Coverage: Universal Health Coverage.)
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This study aimed to investigate the determinants of National Health Insurance (NHI) contribution implementation among unemployed workers in Bogor region, West Java, Indonesia. The survey of 418 unemployed people in Bogor regency was conducted from April to May 2023. Multivariate logistic regression analysis was performed to assess the factors associated with non-payment of NHI premiums by workers. As a result, it was found that they were female, had primary education or less, had good family health, had negative thoughts and knowledge about national health insurance, had financial problems, were willing to attend public medical institutions, and were willing to use outpatient services. . Unemployment services are closely linked to NHI contribution rates. It was concluded that not only the economic factors that cause non-adherence to occupational accident benefits, but also the motivational factors (knowledge, attitude towards the insurance system, health status) that encourage donation compliance can have an impact. Improving public awareness, especially the shared concept of national health insurance, should be achieved through large-scale health insurance education using methods appropriate to people’s characteristics.
Low- and middle-income countries (LMIC) face various challenges in their efforts to achieve universal health coverage (UHC). The ability of health systems to provide access to quality health care is hampered by a lack of early intervention methods and tools and resources to address the problem. As a result, health systems in LMICs rely heavily on out-of-pocket (OOP) costs to pay for health care, accounting for 30–85% of total health care expenditures [ 2 , 3 ]. These countries suffer from dangerous diseases due to high rates of OOP [4]. As of 2010, the number of people in need of health care was reported to be approximately 808 million [5] and this number continued to increase from 2000 to 2017 [6].
Health insurance (SHI), including subsidized and unsubsidized programs, is the most common strategy used to increase income and save money on health care services. This model has been confirmed in many countries that have successfully implemented UHC [7]. Positive outcomes such as increased health care [8, 9, 10], improved health quality [11, 12], reduced OOP costs [13], and SHI medical cost coverage [14] have been observed after the implementation of SHI. . However, several problems related to the design of the SHI study emerged, including low enrollment among unemployed workers [ 15 , 16 ], adverse selection [ 17 , 18 ], and participant attrition [ 19 , 20 ].
Indonesia has been working to achieve UHC since 2002 and has taken further steps since 2014 by implementing a family-based SHI subsidy program called the National Health Insurance (NHI) (Jaminan Kesehatan Nasional) (JKN)[19], which is the largest single payer. . It is designed globally and administered by the Social Security Administration (SSAH). In this system, health care needs are divided into three levels of membership: Level 1 (per capita contribution USD 9.92), including the formal and informal sectors paying more than USD 264.6; Stage 2 for the formal and informal sectors paying wages below USD 264.6 (gross USD 6.61 per capita) and Stage 3 for the poor and vulnerable or the informal sector (gross USD 2.77 per capita). In the public sector, employees share 1% and employers 4%, the poor and vulnerable are borne by the government, and in the information industry members do not directly bear the burden. For those, excluding those in class 3 or below, the government will support approximately 16.6% of the allowance [21]. Details are given in Table 1. All family studies were considered equal.
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After the implementation of the NHI, coverage increased rapidly from 66.5% in 2016 to 91.7% in December 2022. Total investment also increased from $5 billion in 2016 to $8.2 billion. Accordingly, medical expenditures increased from $5 billion in 2016 to $7.3 billion in December 2022 [22, 23]. Despite the positive results of the program, financial sustainability became a serious issue in 2016–2019 as the number of non-eligible PBPU participants (unemployed workers) increased and the NHI maintenance status improved [14]. From 2016 to 2019, there was a gap between total revenue and total healthcare expenditure of NHIs, as shown in Figure 1. This problem appears to have decreased in 2020-2022 due to reduced access to healthcare facilities. Of the 12.3% unemployed registered with the NHI as PBPU members (unemployed), 51% were recorded as having stopped paying contributions as of December 2022 (non-compliance with NHI regulations for paid members). Note that the unemployment rate in Indonesia is 59.97% of the working population [24]. The ratio of average medical expenses to average premiums is reported to have ranged from 115% in 2015 to 124% in 2019, mainly due to unemployed workers not paying regular premiums. This ratio does not exceed 100% [25].
Banerjee et al. [26] stated that imposing fines on subsidy program members to force them to pay would be brute force and would only lead to lower enrollment in the program and adverse selection, and suggested suspending payments to members of NHI, especially those who are unemployed [19]. 20]. Lack of money to pay for training [19, 27], inadequate training [20], lack of need for reinsurance after a period of common illness (usually among young people) [28], perception of poor quality of services [29], forgot . Payments [20] and negative feelings from providers [28] are reasons why members make decisions not to participate. Meanwhile, Dartanto et al. [19] revealed that income is more important than monthly household income when it comes to the economic opportunities of unemployed workers. Although the unemployed can earn more money at once, the guarantee of receiving the same amount each month makes it difficult to pay their NHI premiums, which requires them to work on time each month. Although income volatility is the most important economic characteristic identifying the unemployed, it is poorly studied. Therefore, this study aims to examine the income of unemployed workers.
For many years, SSAH has had financial problems and has struggled to provide health services due to imbalances in resource collection and increased medical care from the NHI [30]. The government has implemented various regulations to help the unemployed get an education and pay off their debts, but no significant results have been achieved and the number of non-participants is increasing. This does not include informal workers who have registered as NHI members (also known as PBPU members) but have not paid their premiums.
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