While Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out-of-pocket (OOP) for their healthcare–over 30% of current health expenditure (CHE). This study aims to better understand how JKN is influencing OOP payments, especially among the poor and rural, at the range of health facilities. This study uses data from the National Socio-Economic Survey (SUSENAS) in 2018 and 2019, as these surveys started including a question on how much OOP spending a household incurs on health. The results show that households with JKN membership are far less likely than the uninsured to pay OOP for healthcare, and that if they do incur a cost, the magnitude of this cost is much lower among JKN households than uninsured ones. The results also show that JKN households in the two poorest quintiles have a higher probability to not incur any OOP (37% and 35%, respectively) compared to those in the wealthier quintiles 4 (32%) and 5 (30%). Poorer JKN households living in the eastern part of Indonesia–the less urbanized and developed regions–experienced the most cost-savings, though largely due to supply-side constraints. In fact, JKN members save more at public primary health care facilities vs. private ones (who often do not contract with JKN) and also save significantly more (over 50%) than uninsured households at both public and private hospitals. The study demonstrates the positive influence JKN has on OOP payments, especially among the poor and rural, but also highlights how the scheme needs to better engage with the growing private sector and invest in infrastructure in rural areas to help secure financial protection for its entire population.
Background: The Indonesian maternal and neonatal mortality rates remain some of the highest in Southeast Asia. Aims: This study aims to assess and compare district-level innovations that address maternal and neonatal mortality. Methods: This was a qualitative study conducted via four focus group discussions in eight selected districts in November 2021. Data obtained were analyzed using the WHO health system building blocks framework. Results: The study found high variation in districts’ innovations ranging from expansion of service for maternity waiting homes to periodical obstetrician visits at Puskesmas. A majority of districts use a local approach as the basis for innovation. Some innovations are modifications of the national program or initiated purely by District Health Offices, Puskesmas, and the community. Many interventions are based on multisectoral commitment, community participation, and targeting to strengthen health service delivery. Leadership and health financing also have an influence on the implementation of these innovations. Conclusion: The multitude of innovations reflects a high variation in barriers to reducing maternal and neonatal mortality that need to be addressed at the district level. A routine forum to share districts’ best practices is warranted. Additionally, family-based surveillance for neonatal danger signs, monitoring for pregnant women and neonates via WhatsApp, and zoning systems for referrals to healthcare facilities in larger districts are innovations identified in this study that have potential to be replicated in other districts or expanded nationally.
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