Can a National Health Insurance Policy Increase Equity in the Utilization of Skilled Birth Attendants in Indonesia? A Secondary Analysis of the 2012 to 2016 National Socio-Economic Survey of Indonesia

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

A quasi-experimental study on health insurance coverage and health services in Nigeria

BACKGROUND

Nigeria has the highest maternal mortality rate among sub-Saharan African countries. Recently, universal health insurance coverage has been embraced as a means to enhance population health in low- and middle-income countries. Hitherto, the effect of health insurance coverage on the utilisation of facility-level delivery is largely unknown in the face of the earnest need to lower maternal mortality rates in developing countries.

AIM

To empirically investigate the association of health insurance coverage on health services utilisation of facility-level delivery and the extent to which public- and private-sector facility delivery in Nigeria had a disproportionate associational effect with health insurance coverage, in the universal health coverage era.

SETTING

A cross-sectional study conducted for Nigeria.

METHODS

This study employed a quasi-experimental method using propensity scores along with different matching methods that were applied to the most recent wave of Nigeria's Demographic and Health Survey (2020) data.

RESULTS

Evidence suggests that childbearing mothers from insured households had an average of 25% probability of utilising facility-level delivery relative to mothers from uninsured households in the year that preceded the survey. Moreover, private-sector facility delivery had a 31% higher associational effect with health insurance coverage than public-sector facility delivery, which had an estimated probability of 21%.

CONCLUSION

Expansion of health insurance coverage in Nigeria will be a desirable way to stimulate the utilisation of facility-level delivery by women of childbearing age. Consequently, coverage expansion has the potential to save many maternal and newborn lives in Nigeria.Contribution: This study has contributed to the urgent attention of the federal government of Nigeria to monitor and revamp the health insurance coverage policies of the country for better facilitation of health services to the Nigerian population.

Factors contributing to socio-economic inequality in utilization of caesarean section delivery among women in Indonesia: Evidence from Demographic and Health Survey

BACKGROUND

Most of the existing literature in developing countries focused on either the rising trend of CS or its determinants. There is a paucity of population-based studies on existing socioeconomic inequalities in availing CS services by women in Indonesia. This study aimed to assess the factors associated with caesarian section (CS) delivery and explore the various factors contributing to inequalities in CS delivery rates in Indonesia.

METHODS

The study utilized nationally representative cross-sectional data from the Indonesia Demographic and Health Survey (IDHS), 2017. We conducted multivariable logistic regression to find the factors associated with CS delivery. Concentration index and Wagstaff's decomposition analysis were used to examine the socioeconomic inequalities in CS delivery among women and associated factors.

RESULTS

About 17% of women in Indonesia delivered babies through CS. A concentration index of 0.31 in CS delivery rate showed a higher CS delivery rate among women belonging to rich households. About 44.7% of socioeconomic status inequality in CS delivery was explained by educational status among women who went for CS delivery. Women's place of residence explained 30.1% of socioeconomic inequality, and women's age at first birth explained about 11.9% and reporting ANC visits explained 8.4% of the observed inequality. Highest socioeconomic inequality was witnessed in central Sulawesi (0.529), followed by Maluku (0.488) and West Kalimantan (0.457), whereas the lowest was recorded in Yogyakarta (0.021) followed by north Sulawesi (0.047) and east Kalimantan (0.171). Education (44.7%) followed by rural-urban place of residence (30.1%) and age of first birth (11.9%) contributed most to explain the gap in CS delivery among rich and poor women.

CONCLUSION

The study highlighted the higher CS delivery rates among women from higher socioeconomic groups and thus, it is important to frame policies after identifying the population subgroups with potential underuse or overuse of CS method of delivery.

The effect of health insurance and socioeconomic status on women's choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis

BACKGROUND

Evidence suggests that women gave birth in diverse types of health facilities and were assisted by various types of health providers. This study examines how these choices are influenced by the Indonesia national health insurance programme (Jaminan Kesehatan Nasional (JKN)), which aimed to provide equitable access to health services, including maternal health.

METHODS

Using multinomial logit regression models, we examined patterns and determinants of women's choice for childbirth, focusing on health insurance coverage, geographical location and socioeconomic disparities. We used the 2018 nationally representative household survey dataset consisting of 41 460 women (15-49 years) with a recent live birth.

RESULTS

JKN coverage was associated with increased use of higher-level health providers and facilities and reduced the likelihood of deliveries at primary health facilities and attendance by midwives/nurses. Women with JKN coverage were 13.1% and 17.0% (p<0.05) more likely to be attended by OBGYN/general practitioner (GP) and to deliver at hospitals, respectively, compared with uninsured women. We found notable synergistic effects of insurance status, place of residence and economic status on women's choice of type of birth attendant and place of delivery. Insured women living in Java-Bali and in the richest wealth quintile were 6.4 times more likely to be attended by OBGYN/GP and 4.2 times more likely to deliver at a hospital compared with those without health insurance, living in Eastern Indonesia, and in the poorest income quantile.

CONCLUSION

There are large variations in the choice of birth attendant and place of delivery by population groups in Indonesia. Evaluation of health systems reform initiatives, including the JKN programme and the primary healthcare strengthening, is essential to determine their impact on disparities in maternal health services.

Hospital utilization among urban poor in Indonesia in 2018: is government-run insurance effective?

BACKGROUND

An urban poor is a vulnerable group that needs government financing support to access health services. Once they are sick, they will fall deeper into poverty. The study aims to analyze the effectiveness of government-run insurance in hospital utilization in urban poor in Indonesia.

METHODS

The research analyzed the 2018 Indonesian Basic Health Survey data. This cross-sectional survey collected 75,970 participants through stratification and multistage random sampling. Meanwhile, the study employed hospital utilization as an outcome variable and health insurance ownership as an exposure variable. Moreover, the study looked at age, gender, marital status, education, and occupation as control factors. The research employed a binary logistic regression to evaluate the data in the final step.

RESULTS

The results show that someone with government-run insurance is 4.261 times more likely than the uninsured to utilize the hospital (95% CI 4.238-4.285). Someone with private-run insurance is 4.866 times more likely than the uninsured to use the hospital (95% CI 4.802-4.931). Moreover, someone with government-run and private-run insurance has 11.974 times more likely than the uninsured to utilize the hospital (95% CI 11.752-12.200).

CONCLUSION

The study concluded that government-run insurance is more effective than the uninsured in improving hospital utilization among the urban poor in Indonesia. Meanwhile, private-run is more effective than government-run and uninsured in improving hospital utilization among the urban poor in Indonesia. Moreover, the most effective is to combine the kind of health insurance ownership (government-run and private-run).

Regional differences in primary healthcare utilization in Java Region-Indonesia

BACKGROUND

Policymakers must understand primary healthcare utilization disparity to minimize the gap because they must seek fair service for every citizen. The study analyzes regional differences in primary healthcare utilization in Java Region-Indonesia.

METHODS

The cross-sectional research analyzes secondary data from the 2018 Indonesian Basic Health Survey. The study setting represented Java Region-Indonesia, and the participants were adults 15 years or more. The survey explores 629,370 respondents. The study used primary healthcare utilization as an outcome variable and province as the exposure variable. Moreover, the study employed eight control variables (residence, age, gender, education, marital, employment, wealth, and insurance). The study evaluated data using binary logistic regression in the final step.

RESULTS

People in Jakarta are 1.472 times more likely to utilize primary healthcare than those in Banten (AOR 1.472; 95% CI 1.332-1.627). People in Yogyakarta are 1.267 times more likely to use primary healthcare than those in Banten (AOR 1.267; 95% CI 1.112-1.444). In addition, people in East Java are 15% less likely to utilize primary healthcare than those in Banten (AOR 0.851; 95% CI 0.783-0.924). Meanwhile, direct healthcare utilization was the same between West Java, Central Java, and Banten Province. They are sequentially starting from the minor primary healthcare utilization: East Java, Central Java, Banten, West Java, Yogyakarta, and Jakarta.

CONCLUSION

Disparities between regions exist in the Java Region-Indonesia. They are sequentially starting from the minor primary healthcare utilization: East Java, Central Java, Banten, West Java, Yogyakarta, and Jakarta.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces

BACKGROUND

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance.

METHODS

Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants.

RESULTS

The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less).

CONCLUSION

Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Associations between Indonesia's national health insurance, effective coverage in maternal health and neonatal mortality: a multilevel interrupted time-series analysis 2000-2017

BACKGROUND

We assessed the effect of Indonesia's national health insurance programme (Jaminan Kesehatan Nasional (JKN)) on effective coverage for maternal and child health across geographical regions and population groups.

METHODS

We used four waves of the Indonesia Demographic and Health Survey from 2000 to 2017, which included 38 880 women aged 15-49 years and 144 000 birth records. Key outcomes included antenatal and delivery care, caesarean section and neonatal and infant mortality. We used multilevel interrupted time-series regression to examine changes in outcomes after the introduction of the JKN in January 2014.

FINDINGS

JKN introduction was associated with significant level increases in (1) antenatal care (ANC) crude coverage (adjusted OR (aOR) 1.81, 95% CI 1.44 to 2.27); (2) ANC quality-adjusted coverage (aOR 1.66, 95% CI 1.38 to 1.98); (3) ANC user-adherence-adjusted coverage (aOR 1.80, 95% CI 1.45 to 2.25); (4) safe delivery service contact (aOR 1.83, 95% CI 1.42 to 2.36); and (5) safe delivery crude coverage (aOR 1.45, 95% CI 1.20 to 1.75). We did not find any significant level increase in ANC service contact or caesarean section. Interestingly, increases in ANC service contact and crude coverage, and safe delivery crude coverage were larger among the poorest compared with the most affluent. No statistically significant associations were found between JKN introduction and neonatal and infant mortality (p>0.05) in the first 3 years following implementation.

INTERPRETATION

Expansion of social health insurance led to substantial improvements in quality of care for maternal health services but not in child mortality. Concerted efforts are required to equitably improve service quality and child mortality across the population in Indonesia.

The Role of Government-run Insurance in Primary Health Care Utilization: A Cross-Sectional Study in Papua Region, Indonesia, in 2018

Health development in the Papua region often lags behind other areas of Indonesia. The study aims to analyze the role of government-run insurance in primary health care utilization in the Papua region, Indonesia. The study examined 17,879 Papuan. The study used primary health care utilization as an outcome variable and health insurance ownership as an exposure variable. The study also employed nine control variables: province, residence, age, gender, marital status, education, employment, wealth, and travel time to primary health care. The research employed data using binary logistic regression in the final analysis. The results show that Papuans with government-run insurance were three times more likely to utilize primary health care than uninsured Papuans (AOR 3.081; 95% CI 3.026-3.137). Meanwhile, Papuan with private-run insurance were 0.133 times less likely to utilize primary health care than uninsured Papuans (AOR 0.133; 95% CI 0.109-0.164). Moreover, Papuans who have two types of health insurances (government-run and private-run) were 1.5 times more likely to utilize the primary health care than uninsured Papuan (AOR 1.513; 95% CI 1.393-1.644). The study concluded that government-run insurance increases the chance of primary health care utilization in the Papua region, Indonesia. Government-run insurance has the most prominent role compared to other health insurance categories.

Health insurance ownership among female workers in Indonesia: does socioeconomic status matter?

BACKGROUND

Female workers are vulnerable groups in the Indonesian context, and female workers must be responsible for domestic problems and earn a living. The study aimed to analyze the role of socioeconomic on health insurance ownership among female workers in Indonesia.

METHODS

The study population was all female workers in Indonesia. This cross-sectional study involved 7,943 respondents. The study analyzed health insurance ownership as an outcome variable and socioeconomic status as an exposure variable. The study also involved five control variables: residence, age, marital, education, and occupation. The research used multinomial logistic regression in the final step.

RESULTS

The results show the poorest female workers have a possibility of 0.735 times more than the richest to have NHI (AOR 0.733; 95% CI 0.733-0.737). The poorer female workers have 0.939 times less likely than the richest to have NHI (AOR 0.939; 95% CI 0.937-0.942). Female workers with middle socioeconomic status are possibly 0.833 times less than the richest to have NHI (AOR 0.833; 95% 0.831-0.835). Moreover, the richer female workers have 1.028 times more likely than the richest to have NHI (AOR 1.028; 95% CI 1.025-1.030). Moreover, all socioeconomic statuses have a lower possibility than the richest of having other health insurance.

CONCLUSIONS

The study concluded that socioeconomic has a role in health insurance ownership among female workers in Indonesia.

A critical review of definitions of rural areas in Indonesia and implications for health workforce policy and research

Background

Choosing the appropriate definition of rural area is critical to ensuring health resources are carefully targeted to support the communities needing them most. This study aimed at reviewing various definitions and demonstrating how the application of different rural area definitions implies geographic doctor distribution to inform the development of a more fit-for-purpose rural area definition for health workforce research and policies.

Methods

We reviewed policy documents and literature to identify the rural area definitions in Indonesian health research and policies. First, we used the health policy triangle to critically summarize the contexts, contents, actors and process of developing the rural area definitions. Then, we compared each definition’s strengths and weaknesses according to the norms of appropriate rural area definitions (i.e. explicit, meaningful, replicable, quantifiable and objective, derived from high-quality data and not frequently changed; had on-the-ground validity and clear boundaries). Finally, we validated the application of each definition to describe geographic distribution of doctors by estimating doctor-to-population ratios and the Theil-L decomposition indices using each definition as the unit of analysis.

Results

Three definitions were identified, all applied at different levels of geographic areas: “urban/rural” villages (Central Bureau of Statistics [CBS] definition), “remote/non-remote” health facilities (Ministry of Health [MoH] definition) and “less/more developed” districts (presidential/regulated definition). The CBS and presidential definitions are objective and derived from nationwide standardized calculations on high-quality data, whereas the MoH definition is more subjective, as it allows local government to self-nominate the facilities to be classified as remote. The CBS and presidential definition criteria considered key population determinants for doctor availability, such as population density and economic capacity, as well as geographic accessibility. Analysis of national doctor data showed that remote, less developed and rural areas (according to the respective definitions) had lower doctor-to-population ratios than their counterparts. In all definitions, the Theil-L-within ranged from 76 to 98%, indicating that inequality of doctor density between these districts was attributed mainly to within-group rather than between-group differences. Between 2011 and 2018, Theil-L-within decreased when calculated using the MoH and presidential definitions, but increased when the CBS definition was used.

Conclusion

Comparing the content of off-the-shelf rural area definitions critically and how the distribution of health resource differs when analysed using different definitions is invaluable to inform the development of fit-for-purpose rural area definitions for future health policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00847-w.

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia

Background

Despite the increased access to facility-based delivery in Indonesia, the country’s maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia.

Methods

This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors.

Findings

Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups.

Conclusions

The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system.

Barriers to Expanding the National Health Insurance Membership in Indonesia: Who Should the Target?

Background:

The Indonesian government initiated National Health Insurance (NHI) to reduce health service barriers. The study aimed to analyze specific targets for expanding the NHI’s membership in Indonesia.

Methods:

The study population was all populations in Indonesia. Meanwhile, the study involved a 47 644 weighted sample. The analyzed variables included NHI’s membership, residence, age, gender, education, employment, marital status, and wealth. The study employed binary logistic regression in the final step.

Results:

The urban population was 0.608 times less likely than the rural population to become a non-member of NHI. Aging younger was one of the barriers to becoming an NHI member, and the male gender is one of the barriers to becoming an NHI member. Meanwhile, the lower the education level, the greater the obstacles to becoming an NHI member in Indonesia. Besides, the unemployed population was 1.002 more likely than the employed population to become a non-member of NHI. The result shows that never married or married have a higher chance of becoming a non-member of NHI. Finally, all wealth status categories are more likely to become barriers to the most prosperous population becoming an NHI member.

Conclusions:

The study concluded that 7 population characteristics become specific targets for expanding NHI membership in Indonesia. The 7 characteristics are the population who live in rural areas, are young, male, poor education, unemployed, never married or married, and poor.

Determinants of out-of-district health facility bypassing in East Java, Indonesia

Background

Several large-scale reforms, including policies aimed at achieving universal health coverage, have been implemented to overcome health disparities in Indonesia. However, access to health services remains unequal. Many people ‘bypass’ health services in their home district to access health services in neighbouring districts, even though their health insurance does not cover such services. This study aims to identify the factors that are associated with this out-of-district bypassing behaviour.

Methods

We surveyed 500 respondents living in the outermost districts of East Java province. We used data on education, income, district, age, gender, household size, district accessibility, insurance coverage status and satisfaction with health facilities in the home district and logistic regression analysis to model the predictors of out-of-district health facility bypassing.

Results

The most important predictors of the bypassing behaviour were education and poor access to health facilities in the home district. Open-ended data also found that the most important reason for seeking care in another district was mostly geographic. In contrast, health insurance coverage does not appear to be a significant predictor.

Conclusions

Education and geographic factors are the main predictors of out-of-district bypassing behaviour, which appears to be how border communities express their health facility preferences. Local and central governments should continue their work to reduce inequality in access to health facilities in Indonesia's geographically challenged districts.

The disparities in health insurance ownership of hospital-based birth deliveries in eastern Indonesia

BACKGROUND

Development in Eastern Indonesia tends to be left behind compared to other Indonesian regions, including development in the health sector. The study aimed at analyzing the health insurance ownership disparities in hospital delivery in Eastern Indonesia.

METHODS

The study draws on secondary data from the 2017 Indonesia Demographic and Health Survey. The study population was women aged 15-49 years who had given birth in the last five years in Eastern Indonesia. The study analyzes a weighted sample size of 2299 respondents. The study employed hospital-based birth delivery as a dependent variable. Apart from health insurance ownership, other variables analyzed as independent variables are province, residence type, age group, marital status, education level, employment status, parity, and wealth status. The final stage analysis used binary logistic regression.

RESULTS

The results showed that insured women were 1.426 times more likely than uninsured women to undergo hospital delivery (AOR 1.426; 95% CI 1.426-1.427). This analysis indicates that having health insurance is a protective factor for women in Eastern Indonesia for hospital delivery. There is still a disparity between insured and uninsured women in hospital-based birth deliveries in eastern Indonesia. Insured women are nearly one and a half times more likely than uninsured women to give birth in a hospital.

CONCLUSION

The study concludes that there are health insurance ownership disparities for hospital delivery in eastern Indonesia. Insured women have a better chance than uninsured women for hospital delivery.

The Determinants of Four or More Antenatal Care Visits Among Working Women in Indonesia

This study aimed to analyze the determinants of four or more antenatal care (ANC) visits among working women in Indonesia. The researchers extracted data from the Indonesian Demographic and Health Survey 2017 and obtained a sample size of 8239 working women aged between 15 and 49 years. Women’s residence, age, marital status, education level, parity, economic status, and health insurance were selected as the independent variables. Binary logistic regression was used for the analysis. Older working women, married working women, educated working women, those in higher economic status, and those with health insurance were more likely to complete four or more of their ANC visits. The more children the working women had, the less likely they would complete their ANC visits. In conclusion, age, marital status, education, parity, economic status, and health insurance are the determinants for completing ANC visits among working women in Indonesia. At the same time, place of residence does not affect the frequency of ANC visits.

The regional and referral compliance of online healthcare systems by Indonesia National Health Insurance agency and health-seeking behavior in Indonesia

PURPOSE

Whether the provision of online health care referral systems by the Indonesia National Health Insurance Agency has ensured healthcare referral compliance raises much concern due to the continuing deficit. This study examines the pattern of healthcare referral process, regional and referral compliance from 2015 to 2016. To provide comprehensive analysis on how people seek treatment, this study also aims to understand health-seeking behavior in Indonesia, the utilization of alternative treatment, and health information-seeking behavior on social media.

METHOD

The data come from three data files, namely the National Health Insurance membership master data, the First Level Health Facilities transaction data and the Advanced Referral Health Facilities transaction data of 1,697,452 individuals. The regional compliance applies a logit regression model, while referral compliance applies descriptive statistics of the referral pathway. This study also follows a quantitative approach using an online questionnaire, with 463 respondents who have National Health Insurance which applies an ordered logit model.

RESULT

We found that several demographic variables and regional health facility availability affect regional compliance. Moreover, we found 19.3% of the transactions did not comply with the prescribed referral sequence. The prescribed referral sequence was mostly followed for patients with malignant diseases. We also found men who perceive that their health condition is healthy will less likely seek health services compared to women. Further, the tendency of alternative treatment increases health-seeking behavior, and the tendency of seeking health information on social media increases the frequency seeking health services.

CONCLUSION

We recommend the prescribed referral sequence to be re-evaluated especially for patients with malignant disease; the referral process should not be based on hospital classes but on the competency of the healthcare facility which may indirectly address the deficit issue. It is imperative that the government evaluate health promotion approaches to men and women, both direct and indirect through their significant others.

The determinant of health insurance ownership among pregnant women in Indonesia

BACKGROUND

Health insurance ownership is one indicator of the readiness of pregnant women for the delivery process. The study aimed to analyze the determinants of health insurance ownership among pregnant women in Indonesia.

METHODS

The study population was pregnant women in Indonesia. The study involved 2542 pregnant women in Indonesia. The variables analyzed included type of place of residence, age group, education level, employment status, marital status, parity, wealth status, and know the danger signs of pregnancy. In the final step, the study employed binary logistic regression to explain the relationship between health insurance ownership and predictor variables.

RESULTS

The results show that pregnant women with higher education were 3.349 times more likely than no education pregnant women to have health insurance. Pregnant women with wealth status in the middle category were 0.679 times the poorest pregnant women to have health insurance. Meanwhile, the richest pregnant women had 1.358 times more chances than the poorest pregnant women to have health insurance. Grande multiparous pregnant women were 1.544 times more likely than primiparous pregnant women to have health insurance. Pregnant women who know the danger signs of pregnancy were 1.416 times more likely than pregnant women who don't see the danger signs of pregnancy to have health insurance.

CONCLUSIONS

The study concluded that four variables, including education level, wealth status, parity, and knowledge of the danger signs of pregnancy, were significant determinants of health insurance ownership in Indonesia.

Meeting Maternal and Reproductive Health Needs in a Post-Disaster Setting: A Qualitative Case Study From Indonesia

Meeting and planning for maternal and reproductive health (MRH) needs during post-disaster scenarios is paramount, however, not without considerable challenges. This study was aimed at understanding the provision of MRH services in Siosar, a relocation site for a population displaced by the volcanic eruption in 2013 of Mount Sinabung, Indonesia. A qualitative case study approach was used, and data were collected through focus group discussions and individual interviews with women of reproductive age, community leaders, health personnel, and policymakers. The findings show that while considerable efforts were made to provide MRH services, these were described as "unfinished," due to challenges such as changes to funding, inadequate provision of supplies and health personnel, and geographical location. Recommendations are that health and other sectors design a relocation site that counts physical, psychological, and social needs of a community and policymakers integrate humanitarian and development plans that include MRH services into World Health Organization's Building Blocks of Health System.

Factors Associated With Working in Remote Indonesia: A National Cross-Sectional Study of Early-Career Doctors

Background: Doctor shortages in remote areas of Indonesia are amongst challenges to provide equitable healthcare access. Understanding factors associated with doctors' work location is essential to overcome geographic maldistribution. Focused analyses of doctors' early-career years can provide evidence to strengthen home-grown remote workforce development.

Method: This is a cross-sectional study of early-career (post-internship years 1–5) Indonesian doctors, involving an online self-administered survey on demographic characteristics, and; locations of upbringing, medical clerkship (placement during medical school), internship, and current work. Multivariate logistic regression was used to test factors associated with current work in remote districts.

Results: Of 3,176 doctors actively working as clinicians, 8.9% were practicing in remote districts. Compared with their non-remote counterparts, doctors working in remote districts were more likely to be male (OR 1.5,CI 1.1–2.1) or unmarried (OR 1.9,CI 1.3–3.0), have spent more than half of their childhood in a remote district (OR 19.9,CI 12.3–32.3), have completed a remote clerkship (OR 2.2,CI 1.1–4.4) or internship (OR 2.0,CI 1.3–3.0), currently participate in rural incentive programs (OR 18.6,CI 12.8–26.8) or have previously participated in these (OR 2.0,CI 1.3–3.0), be a government employee (OR 3.2,CI 2.1–4.9), or have worked rurally or remotely post-internship but prior to current position (OR 1.9,CI 1.2–3.0).

Conclusion: Our results indicate that building the Indonesian medical workforce in remote regions could be facilitated by investing in strategies to select medical students with a remote background, delivering more remote clerkships during the medical course, deploying more doctors in remote internships and providing financial incentives. Additional considerations include expanding government employment opportunities in rural areas to achieve a more equitable geographic distribution of doctors in Indonesia.

Barriers to Institutional Delivery Services in Districts With the Lowest Institutional Delivery Coverage in Bhutan

Bhutan aims to achieve 100% institutional delivery coverage. While evidence indicates improved institutional delivery coverage over the years, coverage in some of the districts is only 49%. This study was aimed at exploring barriers to institutional delivery in three low-coverage districts. In-depth qualitative interviews and six focus group discussions were conducted in December 2015. The analysis was done as per the Braun and Clarke's 6-phase guide to doing thematic analysis. This study sheds light on 15 barriers for institutional deliveries, which include hesitancy to seek health care when the pregnancy is out of wedlock, the restriction of alcohol consumption at health centers, fear of hypothermia in cold places, pastoralism, health care providers shortage, lack of maternity waiting home and food, distance, difficult terrain, lack of transportation services, and financial constraints. Some of these barriers could be unique to Bhutan. The coverage could be improved considerably if the recommendations in this article are implemented.