The effects of pro-poor health insurance on health facility delivery and skilled birth delivery in Indonesia: A mixed-methods evaluation.

다국어 초록 (Multilingual Abstract)

Problem.
As part of Indonesia's strategy to achieve the goal of Universal Health Coverage (UHC), large investments have been made to increase health access for the poor. These have resulted in the implementation of various public health insurance (PHI) schemes, including Jamkesmas, the largest health insurance program in Indonesia in 2012, targeted towards the poor and near-poor. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. With the implementation of various pro-poor PHI programs in Indonesia, there is limited understanding of how these programs impact maternal health services among poor women.
Methods.
This study used a mixed-methods design. The quantitative component entailed secondary analysis of the Indonesian Demographic and Health Survey (IDHS) from 2007 and 2012 on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). Qualitative interviews (n=55) were conducted from May-Aug 2015 in the province of Jakarta and Banten among community representatives and key stakeholders to describe the successes and challenges of health insurance membership and maternal health services among the poor.
Results.
Controlling for all independent variables, poor women with Jamkesmas were 21% (OR=1.21 [1.05--1.39]) more likely to have HFD and 20% (OR=1.20 [1.03--1.39]) more likely to have SBD compared to poor women without health insurance. Qualitative interviews provide some explanation to the modest effect of Jamkesmas health insurance on HFD and SBD seen in the quantitative analysis, including: the preference for pregnant women to deliver in their parents' village; the use of traditional birth attendants; lack of proper documentation for health insurance registration, distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation.
Conclusion.
Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings indicate that pro-poor PHI schemes may be able to reduce financial barriers to care. 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.