Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study.
The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia's strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization.



We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers.



In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03-1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01-1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents' village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation.



Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.
Pathfinder International, 9 Galen St, Suite 217, Watertown, 02472, MA, USA. mib@bu.edu.|Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA. mib@bu.edu.
Mohamad I
MI
Brooks
Center for Health Economics and Policy Studies, University of Indonesia School of Public Health, Building G Room 311, Depok, 16424, West Java, Indonesia.
Hasbullah
H
Thabrany
Department of Epidemiology, Boston University School of Public Health, 715 Albany Street, Talbot T2C, Boston, 02118, MA, USA.|Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.
Matthew P
MP
Fox
Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.|Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.
Veronika J
VJ
Wirtz
Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.|Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.
Frank G
FG
Feeley
Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.|Center for Global Health and Development, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.
Lora L
LL
Sabin
D000293:Adolescent; D000328:Adult; D036861:Delivery, Obstetric / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D007214:Indonesia; D007348:Insurance, Health / Q000191:economics / Q000706:statistics & numerical data*; D008427:Maternal Health Services / Q000191:economics / Q000706:statistics & numerical data*; D008428:Maternal Mortality; D008875:Middle Aged; D008880:Midwifery / Q000706:statistics & numerical data; D011203:Poverty / Q000191:economics / Q000706:statistics & numerical data*; D011247:Pregnancy; D019472:Universal Health Insurance / Q000191:economics / Q000706:statistics & numerical data; D055815:Young Adult
Health facility delivery; Health insurance; Indonesia; Institutional delivery; Jamkesmas; Maternal health; Poor; Skilled birth attendant; Skilled birth delivery; Universal health coverage