The impact evaluation of public health insurance in Indonesia on access to care, financial protection, and health status

Objectives This study evaluates the impact of an expanded national health insurance programme in Indonesia, focusing on three outcomes: access to health care, as measured by utilisation of health care services; financial protection, as measured by out-of-pocket (OOP) health expenditure and catastrophic health expenditure (CHE) indicators; and health status, as measured by levels of blood pressure and rates of diagnosed, treated and controlled hypertension. Research Methods This study uses longitudinal data from the Indonesian Family Life Survey (IFLS) collected from 13 Indonesia’s provinces, a total of 22,711 adults in 2007 who were followed up in 2014. The JKN enrolees are categorised into two groups: a contributory group who paid the premium voluntarily, and a subsidised group, paid by government. Each group is compared with the uninsured group who had no insurance coverage in both 2007 and 2014. Propensity score matching combined with difference-in-difference approaches are used to estimate the causal effect of the JKN programme. Heterogeneity of the effects of JKN is explored based on socioeconomic status, locality of residence (urban/rural), and availability of health facilities in the area. Results The JKN programme increased the probability of individuals in the contributory group seeking outpatient and inpatient care as well as the volume of care provided. The subsidised group also showed increased utilisation, but the magnitude of the effect is much smaller than in the contributory group. In relation to financial protection, the JKN programme had no statistically significant effect on OOP health expenditure or catastrophic health expenditure. In terms of health outcomes, while the programme had no significant effect on systolic or diastolic blood pressure, the data suggest a positive effect on increasing awareness and treatment of hypertension among the contributory group and, to a lesser extent, the subsidised group. Conclusions The JKN programme encouraged individuals in the contributory group to use more medical treatment, which had no effect, on average, on their health expenditure. The subsidised group appears not to have been able to maximise the JKN benefit, possibly due to other barriers in access to care, such as the inadequate supply of health facilities. The impact of the JKN programme on health status is yet to be confirmed as sufficient time has not passed for the programme’s effect on health status to be realise

The impact of public health insurance on healthcare utilisation in Indonesia : evidence from panel data

OBJECTIVES: This study is the first rigorous evaluation of the impact of Jaminan Kesehatan Nasional (JKN) on improving access to outpatient and inpatient care, utilising longitudinal data from the Indonesian Family Life Survey. METHODS: Two treatment groups were identified: a contributory group (N = 982), who paid the premium voluntarily, and a subsidised group (N = 2503), paid by government. Each group was compared with the uninsured group (N = 8576). Propensity score matching combined with difference-in-difference approaches was used to estimate the causal effect of the JKN programme. RESULTS: The results found that JKN increased the probability of inpatient admission for the contributory and subsidised groups by 8.2% (95% CI 5.9-10.5%) and 1.8% (95% CI 0.7-2.82%), respectively. The contributory group had an increase in probability of an outpatient visit of 7.9% (95% CI 4.3-11.4%). CONCLUSIONS: The JKN programme has increased the utilisation of outpatient and inpatient care in the contributory group. Those with subsidised insurance have an increase in access to inpatient facilities only, and this is of a smaller magnitude. Hence, while JKN has improved average utilisation, inequity in access to both outpatient and inpatient care may remain

Correction: The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review.

[This corrects the article DOI: 10.1371/journal.pone.0219731.]

Determinants of government spending on primary healthcare: a global data analysis.

In 2018 global leaders renewed their political commitment to primary healthcare (PHC) ratifying the Declaration of Astana emphasising the importance of building a sustainable PHC system based on accessible and affordable delivery models strengthened by community empowerment. Yet, PHC often remains underfunded, of poor quality, unreliable and not accountable to users which further deprives PHC of funding. This paper analyses the determinants of PHC expenditure in 102 countries, and quantitatively tests the influence of a set of economic, social and political determinants of government expenditure on PHC. The analysis is focused on the determinants of PHC funding from government sources as the government is in a position to make decisions in relation to this expenditure as opposed to out-of-pocket spending which is not in their direct control. Multivariate regression analysis was done to determine statistically significant predictors.Our analysis found that some economic factors-namely Gross Domestic Product (GDP) per capita, government commitment to health and tax revenue raising capacity-were strongly associated with per capita government spending on PHC. We also found that control of corruption was strongly associated with the level of total spending on PHC, while voice and accountability were positively associated with greater government commitment to PHC as measured by government spending on PHC as a share of total government health spending.Our analysis takes a step towards understanding of the drivers of PHC expenditure beyond the level of national income. Some of these drivers may be beyond the remit of health policy decision makers and relate to broader governance arrangements and political forces in societies. Thus, efforts to prioritise PHC in the health agenda and increase PHC expenditure should recognise the constraints within the political landscapes and engage with a wide range of actors who influence decisions affecting the health sector

The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: a systematic review

BACKGROUND: Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years. METHODS: We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status. FINDINGS: 8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies). INTERPRETATION: Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage

Improving the efficiency in spending for health: A systematic review of evidence

Background: Addressing inefficiencies in the way healthcare is financed has been identified as an important source of fiscal space for health systems. The WHO, for example, has argued that up to 40% of resources spent in health are wasted. Which reforms to focus on, their impact on fiscal space, and their feasibility have seldom been documented, however. The aim of this paper is to synthesise the evidence on these points, ascertaining the extent of fiscal space that has, to date, been created by implementing reforms aimed at addressing inefficiencies in health financing. Methods: systematic review of peer-reviewed literature in global databases (Medline, Embase, Global Health, Econlit, Africa-Wide information, Web of Science Core Collection and SciELO citation index). 20 articles were included for narrative analysis. Data extracted included: type of study; countries where the reform was implemented; the specific inefficiency discussed; the specific reform to tackle inefficiency; the efficiency indicator used; the baseline information given; the impact of the reform on health spending; and the feasibility and timing of the reform. Findings: Inefficiencies in health financing exist across the world, and reforms to address these remain important. Yet the empirical evidence on savings that can be created through addressing these inefficiencies is limited, mixed, and suggests that potential savings are more modest than indicated by the WHO. The feasibility of these reforms is seldom documented. The process of implementation of these reforms is similarly poorly documented, although the available evidence suggests that it takes three to ten years for these efficiency-enhancing health financing reforms to translate into actual results. Interpretation: Further research is needed to understand how to translate identified inefficiencies in the way healthcare is financed into additional fiscal space. Engaging with the political economy of designing and implementing these reforms will be key. Rooting fiscal space analysis projections in country-specific analysis of inefficiencies is also key, as the expectations of financial savings will otherwise be unrealistic

Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise.

BACKGROUND: Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. METHODS: A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem. RESULTS: Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were "Training and retention of specialist staff", "Health education/awareness of injury severity", "Geographical coverage of referral trauma centres", and "Lack of protocol for bypass to referral centres". The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map. CONCLUSION: Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions

Analisis Kepuasan Pengguna Sistem Informasi Akademik dalam Perspektif Manajemen di Politeknik Negeri Sriwijaya

User’s Satisfaction is one of the keys to the success of an Information System. This study aims to analyze the satisfaction of Academic Information System Users in the State Polytechnic of Sriwijaya based on organizational culture variables and the quality of the information system to the satisfaction of information system users and their implications for employee performance. Data analysis involves 71 participants who come from education personnel with variations in Gender, Age, Latest Education and Years of Service. Data analysis uses CFA of Exogenous and Endogenous Constructions and SEM Partial Least Square (PLS). The final results obtaine conclusion that Organizational Culture Variables have a positive and it do not have significant effect on the satisfaction towards the use of Information Systems while the Quality of Information Systems variable has a positive and significant effect on the Satisfaction towards the Use of Information Systems of  State Polytechnic of Sriwijaya Palembang.Keywords – CIO, User Satisfaction, Information System Managemen