Why did informal sector workers stop paying for health insurance in Indonesia? Exploring enrollees' ability and willingness to pay

PLoS One. 2021 Jun 4;16(6):e0252708. doi: 10.1371/journal.pone.0252708. eCollection 2021.

Abstract

Indonesia faces a growing informal sector in the wake of implementing a national social health insurance system-Jaminan Kesehatan Nasional (JKN)-that supersedes the vertical programmes historically tied to informal employment. Sustainably financing coverage for informal workers requires incentivising enrolment for those never insured and recovering enrolment among those who once paid but no longer do so. This study aims to assess the ability- and willingness-to-pay of informal sector workers who have stopped paying the JKN premium for at least six months, across districts of different fiscal capacity, and explore which factors shaped their willingness and ability to pay using qualitative interviews. Surveys were conducted for 1,709 respondents in 2016, and found that informal workers' average ability and willingness to pay fell below the national health insurance scheme's premium amount, even as many currently spend more than this on healthcare costs. There were large groups for whom the costs of the premium were prohibitive (38%) or, alternatively, they were both technically willing and able to pay (25%). As all individuals in the sample had once paid for insurance, their main reasons for lapsing were based on the uncertain income of informal workers and their changing needs. The study recommends a combination of strategies of targeting of subsidies, progressive premium setting, facilitating payment collection, incentivising insurance package upgrades and socialising the benefits of health insurance in informal worker communities.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Employment
  • Humans
  • Indonesia
  • Informal Sector*
  • Insurance, Health*
  • National Health Programs
  • Salaries and Fringe Benefits
  • Surveys and Questionnaires

Grants and funding

The main funder of the study is BPJS Kesahatan, which is the Social Insurance Administration Organization, which administers the Indonesian national health insurance for the Indonesian government. The funder was involved in the design of the study and supported the data collection process. The funder had no role in data analysis and the decision to publish. The funder had the opportunity to review the manuscript before publication, and did not ask for, or make any changes. The analysis and writing were supported, through academic mentorship, by the Dutch organisation for internationalisation in education (NUFFIC), which forms part of the project to strengthen capacity at The Centre of Health Insurance and Financing (KPMAK), Universitas Gadjah Mada, in addressing universal health coverage in Indonesia. NUFFIC has funded this project on behalf of the Netherlands Ministry of Foreign Affairs. Maarten Kok received additional funding through the Research Excellence and Innovation (REI) grant at Erasmus University Rotterdam, which supports research into Universal Health Coverage.