Impact of Indonesia’s national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis

摘要

BackgroundReducing inequality in maternal, neonatal and infant mortality are key targets in the Sustainable Development Goals. This study is the first to evaluate the impact of Indonesia’s national health insurance scheme, Jaminan Kesehatan Nasional (JKN), on access to maternal health services by sociodemographic status.MethodsUsing data from the 2017 Indonesia Demographic and Health Survey (IDHS) on women with live births in 2016-2017, we conducted propensity score matching (PSM) analysis to evaluate the association of JKN enrollment on the following maternal health care utilisation outcomes: (1) at least four antenatal care (ANC4+) visits; (2) ANC4+ visits and received essential components of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the national level and by economic subgroup and region of residence. Additionally, we investigated the potential negative impact of JKN on access to maternal health services among the uninsured population by looking at trends over time using data from the 2012 and 2017 IDHS.ResultsOf the 5429 women who had recently given birth, 61% were insured by JKN in 2017. After matching treated and untreated women on key sociodemographic characteristics, enrollment in JKN was associated with a higher prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI)?=?4.8-9.39); ANC4+ visits and received essential components of ANC (5.6%, 95% CI?=?3.3-7.9); skilled birth attendance (3.0%, 95% CI?=?1.5-4.5; facility-based delivery (10.2%, 95% CI?=?7.5-12.7); PNC (4.0%, 95% CI?=?2.2-5.7); PNC with skilled provider (4.5%, 95% CI?=?2.6-6.5). Effect sizes were larger among the poor and those living in less-developed areas, such as Eastern Indonesia and Sulawesi, except for at least ANC4+ and received clinical components.ConclusionsExpansion of health insurance coverage was associated with reductions in sociodemographic inequalities in access to maternal health services in Indonesia. However, large differences in utilisation persist across regions and by economic subgroup. Accelerating progress toward universal health coverage may reduce health inequalities in other low and middle-income countries.Despite declines in maternal, newborn, and child mortality since implementation of the Millennium Development Goals in 1990, these burdens remain disproportionately high among disadvantaged groups in low- and middle-income countries (LMICs) [1,2]. Achieving equitable access to high quality essential maternal health service has been identified as an important instrument for countries to reduce maternal and neonatal mortality and attain Sustainable Development Goals (SDGs) 3.1 and 3.2 [3]. Indonesia, a lower-middle income country, has one of the highest maternal mortality ratios (MMRs) in the South-East Asia Region [4] at 305 maternal deaths per 100?000 live births, with a substantially higher MMR of 489 in Eastern Indonesia [3,5,6]. Aside from the direct loss of life, a maternal death can result in profound negative health consequences for neonates and other children in the household, can lead to household economic deprivation, and productivity losses to society [7,8].A high burden of maternal death is often linked to inequality in access to maternal health services [8-10]. Women from disadvantaged groups, including the poor and those living in rural and remote areas, often face increased financial barriers and limited access to high quality health services, resulting in lower coverage of essential maternal health care services [8-15]. These inequities also persist across regions. For example, health services are more concentrated in the more developed islands of Java-Bali, while lack of services and understaffing remains a problem in less developed regions of Sulawesi and Eastern Indonesia [14,16].In 2014, the Indonesian government rolled out the world’s largest single-payer health insurance programme [12], Jaminan Kesehatan Nasional (JKN), or National Health Insurance, to achieve universal health coverage (UHC) by 2019. The programme integrates and replaces all previous fragmented social health insurance schemes, including Jamkesmas, Jamkesda and Askeskin [12,17]. Not only covering the poor and near-poor, JKN scheme is compulsory for all people in Indonesia, with a differentiated timeline until it covers the entire population. Participants are categorized into four groups: 1) subsidised participants or Penerima Bantuan Iuran (PBI)/Premium assistance beneficiaries, for the poor and near-poor; 2) salary earners and formal workers, for employees in the public and private sectors; 3) informal workers, for the non-poor who work in the informal sector; and 4) non-salaried workers [12]. Data from Social Security Agency for Health show the incline of enrolment rates from 48% in January 2014 to 85%, or almost 225 million people by the end of 2019 with around 60% among those classified as subs