Kanal Pengetahuan | Reportase Kongres InaHEA ke 3 Unun khamida
The Effects of Pro-Poor Health Insurance
on Health Facility Delivery (HFD) and
Skilled Birth Delivery (SBD) In Indonesia:
Lessons learned from jamkesmas
dissertation by m. ibrahim Brooks, Drph
presented at the third indonesian health association
(inahea) congress in yogya
by
unun khamida qodarina
July, 29 2016 M. Ibrahim (Bram) Brooks, MPH
(2)
Overview
Background
Maternal Mortality
UHC
Methodology
Research objectives
Results
Part I: Quantitative
Part II: Qualitative
Conclusion & Recommendations
(3)
(4)
Maternal Mortality – Global
Scenario
The
poorest
and
least
educated women
are
most vulnerable
Countries where women
are least likely to have
skilled birth delivery
(SBD)
and
health
facility delivery
(HFD)
have higher MMR
Source: WHO, 2008; UN, 2011; WHO, 2014
Background Methodology Results Conclusion & Recommendations
(5)
Significance
Strong push for UHC
Large investments have been made to increase
health access for the poor and near-poor
High MMR
Disproportionally affects the poor
Goal of dissertation
Public health question: Have the recent pro-poor
health insurance programs improved maternal
health services among poor women in
Indonesia?
(6)
UHC in Indonesia
UHC timeline
2004: Askeskin (national
health insurance for the poor)
2008: Jamkesmas (national
health insurance for the poor & near-poor)
Jamkesda (regional health
insurance for the poor & near-poor)
2011: Jampersal (universal
maternal health insurance)
2014: JKN (national health
insurance)
All SHI merged under one
agency
GOAL: achieve UHC by
2019
Background Methodology Results Conclusion & Recommendations
(7)
Study framework Research objectives Research design
(8)
Study Framework
Ref: Comfort, Peterson, Hatt, 2014
Figure 3. Pathways for effect of insurance on the use of MH service, quality, and health outcomes
Outcome : skilled
birth delivery (SBD)
Outcome: health facility delivery (HFD)
Outcome: MMR
Background Methodology Results Conclusion & Recommendations
(9)
Research Objectives
Objective 1
Estimate the effect of
Jamkesmas
health
insurance coverage on HFD and SBD
among poor women
Objective 2
Describe the success and challenges of
health insurance membership and maternal
health services among poor women
(10)
Research Design
Part I: Quantitative Component (Quant)
Secondary analysis of Indonesian Demographic Health
Survey (IDHS) from 2007 and 2012
Design: cross-sectional household survey Method: two-stage cluster sampling design
Respondents: women of reproductive age (15-49) Data: reproductive, maternal, and child health issues
Part II: Qualitative Component (Qual)
Interviews with poor women, community
representatives, and key informants
Ethical review and approval:
BUMC IRB: Protocol # H-33905, study determination =
EXEMPT
UI: Ministry and local government approvals for
interviews
Background Methodology Results Conclusion & Recommendations
(11)
Part I (Quant): IDHS
Timeline
2003-2012: Jamkesda (regional health insurance for the near-poor) implemented in select Provinces and Districts
2007: IDHS time point 1 (data collection = Jun – Dec 2007; N=32,895)
Live birth data from 2003-2007 (n=14,042)
2008: Jamkesmas (national health insurance for the poor & near-poor) implemented nationally
2011: Jampersal (universal maternal health insurance) implemented nationally
2012: IDHS time point 2 (data collection = May – Jul 2012; N=45,605)
Live birth data from 2008-2012 (n=14,783)
2014: JKN (national health insurance) implemented nationally
merging all social health insurance programs, including Jamkesmas,
Jamkesda, and Jampersal
(12)
Part I (Quant): Data
Analysis Plan
Quantitative analysis performed in SAS v9.4
Descriptive statistics
Comparison of HFD and SBD overtime
Cross-tabulation of pro-poor health insurance status
Difference-in-Differences (DiD) estimate
Absolute difference of HFD and SBD between poor
and non-poor
Multivariate analysis
Propensity Score Matching (PSM) analysis to
measure the association of
Jamkesmas
on HFD and
SBD among the poor
Background Methodology Results Conclusion & Recommendations
(13)
Part II (Qual): Approach
Background Methodology Results Conclusion & Recommendations
Qualitative analysis
performed in Nvivo
v10
Data analysis plan:
framework analysis
Ref: Judith & Thorogood, 2009; Ritchie, Lewis, Nicholls, & Ormston, 2003
(14)
Part I: Quantitative (Quant) Part II Qualitative (Qual)
Results
(15)
Objective 1
Estimate the effect of
Jamkesmas
health insurance coverage on HFD and
SBD among poor women
Part I (Quant)
(16)
Part I (Quant): Study
Population
Table 8. Background characteristics of women of reproductive age (15-49) who had a live birth in the five years preceding the IDHS 2007 and IDHS 2012
Background Methodology Results Conclusion & Recommendations
(17)
Figure 6. Change in health facility delivery and skilled birth
delivery among poor and non-poor women in Indonesia from 2007 to 2012
Part I (Quant): Change in
HFD and SBD between
2007 and 2012 (Obj 1)
(18)
Objective 1 summary
Among women of reproductive age, HFD
and SBD delivery increased from
2007-2012
Poor women potentially benefited from the
scale-up of pro-poor health insurance
programs from 2007-2012
Percentage point increase in HFD and SBD was
much higher among poor women
Part I (Quant): Change in
HFD and SBD between
2007 and 2012 (Obj 1)
Background Methodology Results Conclusion & Recommendations
(19)
Part I (Quant): Description
of women with
Jamkesmas
Wealth Quintile None
Jamkes
mas Other*
Total (N) All (wealth index 1-5) 63.0% 19.1% 17.9% 45,533
Lowest (wealth index 1) 64.0% 28.3% 7.7% 7,759
Second (wealth index 2) 65.1% 22.8% 12.1% 8,755
Middle (wealth index 3) 65.3% 19.0% 15.8% 9,237
Fourth (wealth index 4) 64.4% 19.4% 16.2% 9,727
Highest (wealth index 5) 57.1% 8.6% 34.3% 10,056
Table 11. Health insurance coverage among Indonesian women of reproductive age (15-49), 2012 - by wealth quintile
*Includes: Civil servant health insurance, military/veteran health insurance, social health insurance for private sector workers, private health insurance, other health insurance schemes.
(20)
Summary
In 2012, approx two-thirds of women in
Indonesia were not covered by any health
insurance schemes
Among the poor, only one-fourth of poor
women were covered by
Jamkesmas
A large proportion of non-poor women are
also covered by
Jamkesmas
Part I (Quant): Description
of women with
Jamkesmas
Background Methodology Results Conclusion & Recommendations
(21)
Part I (Quant): Effect of
Jamkesmas
on HFD and SBD
among poor women
Primary Outcome No Insurance [Ref] % Jamkesmas % Crude OR (95% CI) Adjusted* OR (95% CI)% of women with health facility delivery
35.4% 38.6%
1.15 (1.01-1.31) 1.21 (1.05-1.39)
% of women who had skilled birth delivery
65.8% 68.6%
1.13 (0.99-1.30) 1.20 (1.03-1.39)
Table 14. Comparison of health facility delivery and skilled birth delivery among poor women of reproductive age (15-49) with and without Jamkesmas health insurance using PSM dataset, Indonesia 2012
*Controlling for women’s age, marital status, education level, wealth, residence, provincial region, employment status, sex of household head, household number, and media exposure to paper, radio, and television.
(22)
Summary
In 2012, poor women with
Jamkesmas
were
more likely to have HFD and SBD in
comparison to poor women without any
health insurance
Moderate effect of
Jamkesmas
on HFD and SBD
Part I (Quant): Effect of
Jamkesmas
on HFD and SBD
among poor women
Background Methodology Results Conclusion & Recommendations
(23)
Objective 2
Describe the success and challenges of
health insurance membership and
maternal health services among poor
women
Part II (Qual)
(24)
Part II (Qual): Study
participants
Table 6. Sample size for qualitative component
Background Methodology Results Conclusion & Recommendations
(25)
Part II (Qual): Health
insurance access among
poor women
Table 15. Barriers for health insurance access among
poor women
(26)
Perception that health insurance is unimportant
“I'm not sick yet, so I don't need it.”
- Poor woman, Jakarta
Lack of valid government identification
“
Puskesmas
[community health center] has already offered
health insurance, but I didn't have the documents… I didn't
have time to take care of the
Kartu Keluarga
(KK)
[government family card].”
- Poor woman, Banten
Misidentification of the poor
“For
Jamkesmas
there needs to be a household survey [to
identify the poor], after that, the government provides
health insurance for those that are poor. However, there is
some nepotism that takes place so that some well-off
families will also get
Jamkesmas
health insurance.”
- Midwife, Banten
Part II (Qual): Health
insurance access among
poor women
Background Methodology Results Conclusion & Recommendations
(27)
Part II (Qual): Maternal
health services among poor
women
Table 16. Barriers for maternal health services
among poor women
(28)
Socio-cultural
Preference to deliver at parental village
"My parents are there, [if I deliver here] no one will help take care of me."
- Poor woman, Jakarta
Use of traditional birth attendants (TBA)
"Women like to use paraji [TBA] because they accept whatever you have... they also help raise the baby, take care of the
mother, and help with other household chores." - Midwife, Banten
Fatalistic point of view
"There was one woman who was delivering her fourth baby with a dukun [TBA]... she had heavy bleeding but did not want any assistance from a midwife or any skilled birth attendant because she believed that life and death is God's will...both mother and baby died."
- Midwife, Banten
Part II (Qual): Maternal
health services among poor
women
Background Methodology Results Conclusion & Recommendations
(29)
Accessibility
Distance to health facility
"The puskesmas [community health center] is very far... I delivered with my midwife and dukun [TBA] at home."
- Poor woman, Banten
Poor referral system
"Our referral system is a mess... there is a lot of hospital
"touring" as we look for hospitals that can deal with emergency situation... as a result, we have a lot of deaths in transit."
- Government representative, Banten
Non-facility based expenditure
"When we refer patients to higher level health facilities, they sometimes refuse. We tell them that it's free, but they respond, "It may be free for me, but how do we pay for food for the
people that will be waiting with me?" - Midwife, Banten
Part II (Qual): Maternal
health services among poor
women
(30)
Quality of care
Shortage of qualified health providers
"I was afraid last time I was [in the puskesmas]... I was yelling "help doctor, help midwife, my baby is coming!" No one was there, everyone was on vacation... there was only one nurse in the puskesmas."
- Poor woman, Jakarta
Overcrowded health facilities
"Here in this puskesmas, the number of patients is very high...the one that I met on Wednesday originally came down on Monday...ha-ha-ha... there are not enough seats in the waiting room for all the patients." - Midwife, Banten
Lack of health facility accreditation
"The cost associated with health facility accreditation is very high... you need to hire a consultant and a team to identify the issues... then you need a lot of resources to fix all the issues so you can be
accredited... most puskesmas don't have the money to be accredited." - Government representative, Banten
Part II (Qual): Maternal
health services among poor
women
Background Methodology Results Conclusion & Recommendations
(31)
Overview
Study limitations Recommendations
(32)
Conclusion
Pro-poor health insurance can remove
financial barriers to maternal health care
Increase access to key maternal health services
Pro-poor health insurance will not solve high
MMR
Modest effect of health insurance on HFD and SBD
In order to reduce MMR in Indonesia
Increase health insurance coverage among the
poor
Address supply side issues
Background Methodology Results Conclusion & Recommendations
(33)
Recommendations
Provide strong support from multi-sectoral and
inter-governmental stakeholders:
Strong buy-in from local governments can increase district and
village government support and help increase community awareness of pro-poor health insurance and maternal health programs in the community
Multisector involvement (ie. private sector, donor agencies,
etc) will be required to implement long-term investment for improving road infrastructure, transportation, and delivery of health services in remote areas
Improve coverage of health insurance membership
among the poor:
Increase awareness of health insurance among the poor
through integration with community-based programs and targeted education campaigns
Ensure community awareness of health insurance registration
for the poor
Address non-facility cost
(34)
Recommendations
Improve access and quality of maternal health
programs:
Increase awareness of maternal health issues and programs Improve human resources for health availability and
distribution
Implement accreditation system for health facilities
Increase access to facilities that provide comprehensive
emergency obstetric care
Background Methodology Results Conclusion & Recommendations
(35)
(36)
Thank you!
Dissertation committee
Lora Sabin
Rich Feeley
Veronika Wirtz
Matt Fox
Hasbullah Thabrany
Team UI
Yuniar Hajaraeni
Unun Khamida
Arinditya Pujiastuti
SAS support group
Tej Mishra
Alana Brennan
DrPH colleagues
“No quitters club”
Gene Declercq
Sebastian Bach
Family and friends
Erin
Mark & Farida
Adam & Reza
CGHD
(1)
Overview
(2)
Conclusion
Pro-poor health insurance can remove
financial barriers to maternal health care
Increase access to key maternal health services
Pro-poor health insurance will not solve high
MMR
Modest effect of health insurance on HFD and SBD
In order to reduce MMR in Indonesia
Increase health insurance coverage among the
poor
Address supply side issues
Background Methodology Results Conclusion & Recommendations
(3)
Recommendations
Provide strong support from multi-sectoral and
inter-governmental stakeholders:
Strong buy-in from local governments can increase district and
village government support and help increase community awareness of pro-poor health insurance and maternal health programs in the community
Multisector involvement (ie. private sector, donor agencies,
etc) will be required to implement long-term investment for improving road infrastructure, transportation, and delivery of health services in remote areas
Improve coverage of health insurance membership
among the poor:
Increase awareness of health insurance among the poor
through integration with community-based programs and targeted education campaigns
Ensure community awareness of health insurance registration
(4)
Recommendations
Improve access and quality of maternal health
programs:
Increase awareness of maternal health issues and programs Improve human resources for health availability and
distribution
Implement accreditation system for health facilities
Increase access to facilities that provide comprehensive
emergency obstetric care
Background Methodology Results Conclusion & Recommendations
(5)
(6)
Thank you!
Dissertation committee
Lora Sabin
Rich Feeley
Veronika Wirtz
Matt Fox
Hasbullah Thabrany
Team UI
Yuniar Hajaraeni
Unun Khamida
Arinditya Pujiastuti
SAS support group
Tej Mishra
Alana Brennan
DrPH colleagues
“No quitters club”
Gene Declercq
Sebastian Bach
Family and friends
Erin