Health Policy OPEN 2 (2021) 100050

Contents lists available at ScienceDirect

Health Policy OPEN

journal homepage: www.elsevier.com/locate/hpopen

Health services provision and decision to buy Jaminan Kesehatan Nasional

(JKN) in Indonesia
Khoirunurrofik Khoirunurrofik a,b,⇑, Giani Raras a
a
Department of Economics, Faculty of Economics and Business University of Indonesia, Depok 16424, Indonesia
b
Institute for Economic and Social Research (LPEM FEB UI), Jakarta Pusat 10430, Indonesia

A R T I C L E I N F O A B S T R A C T

Keywords: The biggest challenge for the Indonesian government in implementing Universal Health Coverage (UHC) is the
Universal health coverage coverage of Jaminan Kesehatan Nasional (JKN) owners, which is targeted to reach a minimum of 95%. The
Health facility study examines whether there are associations between the availability of health care services and the willing-
Health worker ness to pay (WTP) for the premium health insurance of non‐low‐income independent workers. Using a pooled
National Health Insurance
cross‐sectional study of 1.054.779 people living above the poverty line based on the 2017–2020 National
Indonesia
Economic Survey (SUSENAS) published by the Central Statistics Agency, we investigate the role of supply side
factors of health services on individual decisions to own JKN deploying the logistic regression. The WTP for
JKN participation will increase if additional supplies of health facilities, beds, and doctors in hospitals are pro-
vided. The finding of the study indicates that the availability of health services in the hospital represents ser-
vice qualities and will influence someone to attain JKN. Additionally, the availability of Community Health
Centres (CHCs) and doctors in CHCs will affect people’s behaviour and decision to purchase health insurance
due to the existing primary health care facilities in every sub‐district across Indonesia. This implies that the
government is obliged to afford adequate health care facilities and providers both in urban and rural areas
regardless of the level of WTP citizens.

1. Introduction the premium, not a WTP, as it is an obligation to be a member of

In early 2014, the Indonesian government issued social health
insurance for all Indonesians, namely, National Health
Insurance––Jaminan Kesehatan Nasional (JKN). JKN was targeted to
reach at least 95% of universal health coverage by the end of 2019.
In fact, this target could not be achieved owing to the slow growth
in JKN users from year to year. Based on Law No.24/2011 concerning
the Social Security Organizing Agency, all Indonesian citizens must
become JKN participants to allow their inclusive access to health ser-
vices. There are two kinds of memberships: government‐subsidized
and non‐government‐subsidized health insurance plans. The govern-
ment requires all employers to register their employees as JKN partic-
ipants and imposes administration sanctions on companies that do not
comply.
Indonesian health insurance scheme is public health insurance, and
is compulsory for all citizens, which is different from private health
insurance where individuals have freedoms to opt for a scheme. In
public health insurance, the main issue is an Ability to Pay (ATP) for
JKN. The government will normally afford memberships for individu-
als who cannot.
However, it is difficult to attract people who work in informal sec-
tors to purchase JKN. Our research participants included those
engaged in an informal sector such as employers, self‐employed indi-
viduals, and contractless workers who do not receive salaries (e.g.,
motorcycle taxi drivers, traveling traders, doctors, lawyers/advocates,
artists, etc.). Unlike formal sector workers, who are obliged by their
employers to participate in JKN, the informal sector workers have a
choice to arrange their memberships with JKN. This latter group is dif-
ficult to reach and no sanction is specifically imposed on them if they
are not willing to do so.
Previous studies have analyzed the factors influencing a person to
buy public health insurance. Health was found to be the main reason
affecting a person’s decision on this matter. Social and economic fac-
tors such as age, marital status, and residence can also be prominent
factors [1–4]. Although the government has no direct influences on
someone’s health, socioeconomic, or demographic condition in terms

⇑ Corresponding author at: Department of Economics, Faculty of Economics and Business Universitas Indonesia, Depok 16424, Indonesia.
E-mail address: khoirunurrofik@ui.ac.id (K. Khoirunurrofik).

https://doi.org/10.1016/j.hpopen.2021.100050
Received 6 September 2020; Revised 4 July 2021; Accepted 17 July 2021
Available online 31 July 2021
2590-2296/© 2021 The Author(s). Published by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
K. Khoirunurrofik, G. Raras
of encouraging them to become JKN participants, it can definitely
affect their decisions through supply‐side intervention, i.e., the avail-
ability of health services to attract JKN participation. One of the sim-
ulating factors in health insurance arrangement is the lack of direct
control of the government; therefore, doing research on supply sides
is considered significant.
According to the World Health Organization (WHO), one obstacle
in the creation of universal health coverage is the poor or inadequate
quality of health services [5]. However, health services that cannot
accomplish the level of demand will certainly lead to the inefficient
use of health insurance. For example, health facilities can be limited
and located too far from where users live, especially rural communi-
ties. Although rural residents can access health facilities with JKN
without having to meet their own costs, dwellers who live far from
health facilities remain struggling to make extra payments to access
them. Nugraheni et al.’s (2020) [6] in Indonesia found that JKN was
associated with the reductions of out of pocket expenses. However
some out of pocket expenditures still exist due to supply‐side factors
such as medicine stock availability and inpatient care shortages.
The WHO recommends a country to maintain a supply of one inpa-
tient bed per 1000 people. In 2008, six provinces in Indonesia had less
than the recommended number of beds based on Ministry of Health
[7], including Riau, Lampung, West Java, Banten, West Nusa Teng-
gara, and Central Kalimantan. Although the distribution was sufficient
at the provincial level, the availability of beds is only concentrated in
big cities so additional costs were required to obtain treatment from
small to big cities. Out of the 14 districts in West Kalimantan Province,
for instance, only 3 had satisfied the criteria although this province has
an ample number of beds.
Aside from the availability of health facilities, the number of health
workers continues to pose a problem. This lack of health workers
drives waiting costs and results in long queues when patients need
to receive their medications. Basic data from community health cen-
ters (CHCs) [8] show that 144 of 514 districts have more CHCs than
the number of doctors. This means there are CHCs in Indonesia that
lack doctors or even have no doctors despite the number of CHCs being
evenly distributed across districts. The WHO recommends 40 doctors
available per 100,000 people. According to the Indonesian Medical
Council [9], Indonesia had 45 doctors per 100,000 people in 2017 at
the national level. However, the same problem arises in the form of
an uneven distribution of health workers at the district level. 17 pro-
vinces continue to face a shortage of health workers, especially doc-
tors. This problem surfaces mainly in the eastern provinces of
Indonesia such as Papua, West Papua, and North Maluku. The greatest
number of doctors is concentrated in Java, especially the Special Cap-
ital Region of Jakarta (DKI) Jakarta province.
Furthermore, before being able to experience health services, the
poor and especially those who are far away from the CHCs have
encountered some problems. Health facilities such as CHCs are gener-
ally located in the sub‐district centers, and only operate at certain
hours. In addition, public transportation is very limited causing the
cost of transportation from the inland to the nearer health facilities
in the sub‐district centers is relatively expensive for the poor. Yieng-
prugsawa et al. [10] showed that disparities in quality of services
and access to specialized clinical facilities arise within a UHC system.
For example, Thailand, even though has witnessed a remarkable suc-
cess in its National Health Insurance system, showed a disparity in
these kind of health facilities being accessed by socioeconomic groups.
Only a limited number of studies have examined the supply‐side
influence. In a study that deployed the number of hospitals per popu-
lation as a proxy for health services in Colombia, Trijulo (2003) [10]
found that this has a significant influence on a person’s decision to
buy insurance. Meanwhile, one study by Lawanson and Ibrahim in
2015 [3] examined distance to the nearest health facilities in Nigeria
and found that this has no significant effects on someone buying health
cover.
2
Health Policy OPEN 2 (2021) 100050
A study by Dartanto et al in 2016 [12] about JKN in Indonesia
focused specifically on the supply side of health facilities using the
2014 primary data, finding the availability of hospitals is significantly
positive, while that of doctors has no effects on someone’s decision to
purchase JKN. However, the variable used was a dummy variable indi-
cating whether a district or city had health facilities. As such, the vari-
able did not take into account the current problem, which is the
distribution of health facilities. In addition, no attempt has been made
to investigate the CHCs in Indonesia. In fact, Indonesia has a system of
referral from CHCs to hospitals for JKN members.
The availability of health facilities and workers is a supply‐side fac-
tor in which the government can directly intervene. However, only a
few studies have included health service distributions in their research
models. None of the recently conducted studies has analyzed the influ-
ence of CHCs. This area is vital given that the Indonesian CHCs as a
part of the Indonesia’s UHC programme serve as a gatekeeper for med-
ical cases and public health endeavours [13]. Therefore, this paper
reports findings of a study on the impact of the accessibility of health
facilities and workers, both in hospitals and CHCs, on individual deci-
sions to become JKN members especially for non‐low‐income indepen-
dent workers. The present study focuses on the number of hospitals
and doctors which has some relations with individual decisions to pur-
chase health insurance.
2. Methodology
The model used in this study was adopted from Kirigia et al and
Dartanto et al. [1,12]. We aimed to determine the impact of the avail-
ability of health facilities and health workers on an individual’s choice
of whether to purchase JKN or not. In general, there are several types
of JKN plans based on the Indonesian Presidential Regulation Number
82/2018 (Table 1).
This study identified 1.054.779 individuals from 33 provinces in
Indonesia who lived above the poverty line over 4 years
(2017–2020). This is because the non‐beneficiary JKN membership
is merely eligible for the members who self‐pay their insurance premi-
ums. We also excluded individuals whose premiums were covered by
their employers, which are employee, staff, or worker.
The data were processed using pooled‐cross section logit to deter-
mine the probability of someone to buy non‐beneficiary JKN. Mathe-
matically, the expected utility function of an individual in choosing
health insurance plans can be formulated as follows:


EU ij ¼ f X ij ; Ri þ ɛ ð1Þ
where the expected utility of each choice is a function of the main inde-
pendent variable (Xi) and the control variable of household socioeco-
nomic characteristics (Ri), plus the stochastic error (ε), which
captures errors in both the model specification and data measurement.
EUij is the expected utility from the i‐individual that is obtained from
Table 1
Types of JKN plans. Source: Presidential Regulation of the Republic of Indonesia
No.82/2018 Regarding Health Insurance.
No. Type Participant Premium
Payer
1 JKN PBI (JKN People living below the poverty line or Central
Beneficiary) based on other criteria registered by the Government
central government
People living below the poverty line or Local
based on other criteria registered by the Government
local government
2 JKN Non-PBI Salaried worker (Including Civil Employer
(JKN Non– Servant).
beneficiary) Self-employed worker or non-worker Self-paid
who live above the poverty line
(Informal Sector)
K. Khoirunurrofik, G. Raras Health Policy OPEN 2 (2021) 100050

options of insurance plans j; j = 1 if the individual has insurance and Table 2

j = 2 if the individual does not. The basic assumption is that individual List of variables.
i will buy JKN if EUi1 > EUi2, will choose not to buy JKN if EUi1 < EUi2, Variables Label Description Hypothesis
and will be indifferent if EUi1 = EUi2. Thus, the probability that house-
Dependent
hold i prefers to have health insurance is Pi1 = P (EUi1 > EUi2). In con-
Jaminan JKN Dummy variable of the non-low-
trast, the probability that household i chooses not to have health Kesehatan income independent workers who
insurance is Pi2 = P (EUi1 < EUi2). Nasional have JKN or not. (1 : having JKN, 0
The model used to determine the probability of health insurance : not having JKN)
ownership is formulated as: Major Independent Variables
Community CHC The ratio of Number of CHCs per +
Health 100.000 population in a district or
Pij ¼ α þ β1 CHC þ β2 Hospital þ β3 CHC bed þ β4 Hospital bed Centre city
þ β5 CHC doc þ β6 CHC doc þ β7 Health þ β8 Inpatient Hospital Hospital Number of hospitals per 100.000 +
population in a district or city
þ β9 Outpatient þ β10 ln capita þ β11 marital þ β12 Age þ β13 Age2 Beds in CHC_bed Number of beds in CHCs per 1000 +
Community population in a district or city
þ β14 Male þ β15 Urban þ β16 ln gdpcapita þ β16 i:year þ ɛ ð2Þ
Health
Centre
where Pij = 1 if individual i has JKN (j = 1) and is equal to zero if not Beds in Hospital_bed Number of beds in a hospital per +
(j = 0). (α) is the intercept, (β) is the estimated coefficient of the inde- Hospital 1000 population in a district or city
Doctors in CHC_doc The number of doctors in CHCs per +
pendent variable, and ε is the stochastic error. The variables used in this Community 100.000 population in a district or
model are defined in detail (Table 2). Health city
The variables in the study were chosen based on the aspects of each Centre
factor. Health facilities, beds, and the number of doctors represent the Doctors in Hospital_doc The number of doctors in a hospital +
Hospital per 100.000 population in a district
supply side. Meanwhile, the demand side covers health conditions rep-
or city
resented by health conditions, inpatient/outpatient care, and expendi- Demand-side
ture per capita of an individual. Socio‐demographic characteristics are Health Health Dummy variable of asking whether –
represented by age, marital status, gender, residence, and regional condition the respondent's health is Good,
GDP per capita. means not sick in the last month, or
sick but not severe (1: Good, 0:
Bad)
Outpatient Outpatient Has the individual used outpatient +
3. Results Care facilities once a month? (1: Yes, 0:
No)
Inpatient Care Inpatient Has the individual used inpatient +
Table 3 shows the odds ratio of the logit regression for the model in
facilities once a month? (1: Yes, 0:
this study. Before processing the data using the model in Eq. (2), the No)
data are also regressed using three other models to test the goodness Expenditure ln_capita Natural log of expenditure per +
of fit. While the first model only uses the supply side variable as the per Capita capita
explanatory variable, the second model adds the demand variable. Socioeconomic & Demographics Conditions
Marital Status Marital Individual, marital status (1: +
Whereas the third model exploits the socio‐economic variability, the
Married, 0: Single, divorced, death)
last model adds the dummy year. Based on the goodness of fit test Age Age The age of the individual –
results, the best model to explain the effect of the supply side on the Squared of Age Age2 Squared of age +
decision to become a JKN participant is model 4. Gender Male Gender (1: Male, 0: Female) +
Residence Urban Individual's residence (1: Urban, 0: +
All of the independent variables were found to significantly influ-
Rural)
ence JKN ownership at an alpha level of 1%. However, the logit coef- Regional GDP ln_gdpcapita Natural log of regional gpd +
ficient is unable to directly interpret the precise extent of this impact of per Capita percapita
changes in the independent variables on the dependent variable. Pos- Year Year Dummy year
itive and negative signs in the logit coefficient indicate a correlation.
Note: Data are taken from the national social-economic survey (SUSENAS)
The independent variables, namely, all health facilities and work- from the Central Bureau of Statistics Indonesia and Ministry of Health.
ers in the hospital significantly and positively affect the probability
of becoming a JKN member. At the CHCs level, the number of CHC
beds indicates a significant negative effect. Meanwhile, the number 4. Discussion
of CHCs and doctors in CHCs has a significant positive effect on the
probability of someone to become a member of JKN. The significant 4.1. Analysis of health services in the CHCs
control variables that positively influence the probability of someone
to buy JKN are outpatient, inpatient, age, marital status, urban, GDP In the Indonesian context, the CHCs are the first health facilities
per capita and expenditure per capita. In contrast, the health, male, that communities visit when they encounter health problems. Based
and age2 variables have a significant and negative effect. on BPJS Regulation No. 4/2016, individuals must first undergo an
Table 4 shows the results of regression using the same model as the examination at a first‐level facility to get a referral for specialist treat-
four sub‐samples differentiated by year. In 2018 and 2019, the results ment at a recommended hospital, with the exception of cases in which
are consistent with the pooled‐cross section regression. Meanwhile in patients can be directly treated in the hospital in emergency situations.
the 2017 data, number of beds in CHCs and of doctors in hospitals, The result of logit regression shows that the number of beds in
marital status, and age2 have a significant and negative effect. The CHCs has a negative correlation with the probability of someone to
2020 data reveal a consistent result with the pooled cross‐section data, become a JKN member. In contrast, the number of CHCs and doctors
except the number of beds in CHCs which has a negative effect. Look- in CHCs is positively correlated. This result is also supported by the
ing at the goodness of fit test, the best model that can describe the Ministry of Health data which show 144 districts or cities of 514 dis-
effect of the supply side on the decision to become a JKN participant tricts with a greater number of CHCs than doctors [8]. Although some
is the 2018 data which demonstrate consistent results with the previ- provinces have more doctors at the provincial level than CHCs, there is
ous model.

3
K. Khoirunurrofik, G. Raras Health Policy OPEN 2 (2021) 100050

Table 3
Results of pooled-cross section logit. Source: SUSENAS 2017–2020, Central Bureau of Statistics Indonesia and Ministry of Health (adapted by authors).

Variables Model 1 Model 2 Model 3 Model 4

Jaminan Kesehatan Nasional
Logit Coeff Std. Error Logit Coeff Std. Error Logit Coeff Std. Error Logit Coeff Std. Error

Community Health Centre −0.0106*** (0.000604) 0.00304*** (0.000538) 0.0107*** (0.000551) 0.0162*** (0.000534)
Hospital −0.0680*** (0.00424) −0.0657*** (0.00327) −0.0430*** (0.00272) 0.0351*** (0.00271)
Beds in Community Health Centre −0.604*** (0.0105) −0.377*** (0.00936) −0.300*** (0.00945) −0.230*** (0.00942)
Beds in Hospital 0.111*** (0.00231) 0.106*** (0.00204) 0.0877*** (0.00187) 0.115*** (0.00196)
Doctors in Community Health Centre 0.0221*** (0.000386) 0.0167*** (0.000320) 0.0143*** (0.000310) 0.00669*** (0.000289)
Doctors in Hospital 0.0208*** (0.000575) 0.0104*** (0.000374) 0.00553*** (0.000237) 0.00180*** (0.000227)
Health condition 0.0526*** (0.00720) −0.0452*** (0.00759) −0.156*** (0.00775)
Outpatient Care 0.298*** (0.00755) 0.255*** (0.00794) 0.288*** (0.00812)
Inpatient Care 0.983*** (0.0116) 0.933*** (0.0121) 0.901*** (0.0123)
Expenditure per Capita 1.061*** (0.00428) 0.927*** (0.00450) 0.853*** (0.00455)
Marital Status 0.0601*** (0.00657) 0.0682*** (0.00676)
Age 0.0171*** (0.00102) 0.0182*** (0.00106)
Squared of Age −0.00003*** (0.00001) −0.000032*** (0.0000114)
Gender −0.319*** (0.00496) −0.322*** (0.00505)
Residence 0.686*** (0.00543) 0.499*** (0.00564)
Regional GDP per Capita −0.00629** (0.00259) 0.0636*** (0.00256)
2017.year 0 (.)
2018.year 0.241*** (0.00795)
2019.year 0.500*** (0.00747)
2020.year 1.150*** (0.00645)
_cons −1.372*** (0.00404) −16.13*** (0.0595) −14.89*** (0.0739) −15.47*** (0.0744)
N 1,098,580 1,098,580 1,054,779 1,054,779
chi2 36882.6 109542.3 121972.7 141192.1
bic 1222585.1 1136654.4 1054267.6 1022023.3
aic 1222501.7 1136523.4 1054065.8 1021785.9
ll −611243.9 −568250.7 −527015.9 −510872.9

Robust standard errors in parentheses.

***p < 0.01, **p < 0.05, *p < 0.1.

Table 4
Results of logit regression for sub-sample. Source: SUSENAS 2017–2020, Central Bureau of Statistics Indonesia and Ministry of Health (adapted by authors).

Variables 2017 2018 2019 2020

Jaminan Kesehatan Nasional
Logit Coeff Std. Error Logit Coeff Std. Error Logit Coeff Std. Error Logit Coeff Std. Error

Community Health Centre 0,0253*** (0,00086) 0,0169*** (0,00130) 0,00407*** (0,00138) 0,0112*** (0,00129)
Hospital 0,0194*** (0,00403) 0,0553*** (0,00803) 0,0780*** (0,00751) 0,0736*** (0,00628)
Beds in Community Health Centre −0,277*** (0,01370) −0,143*** (0,02740) −0,228*** (0,02800) 0,0526** (0,02540)
Beds in Hospital 0,201*** (0,00274) 0,0399*** (0,00384) 0,0658*** (0,00441) 0,0565*** (0,00359)
Doctors in Community Health Centre 0,00149*** (0,00051) 0,00435*** (0,00050) 0,0295*** (0,00159) 0,0209*** (0,00092)
Doctors in Hospital −0,00634*** (0,00049) 0,00669*** (0,00065) 0,00448*** (0,00055) 0,00239*** (0,00037)
Health condition −0,426*** (0,01750) −0,0192 (0,01730) −0,0334** (0,01650) −0,0704*** (0,01330)
Outpatient Care 0,405*** (0,01390) 0,294*** (0,01930) 0,268*** (0,01810) 0,234*** (0,01610)
Inpatient Care 0,904*** (0,01970) 1,008*** (0,03200) 1,031*** (0,03020) 0,859*** (0,02520)
Expenditure per Capita 0,639*** (0,00724) 0,857*** (0,01200) 0,871*** (0,01180) 1,091*** (0,00936)
Marital Status −0,271*** (0,01000) 0,319*** (0,01810) 0,364*** (0,01690) 0,446*** (0,01290)
Age 0,0429*** (0,00159) −0,00796*** (0,00277) −0,00753*** (0,00260) 0,0200*** (0,00219)
Squared of Age −0,000167*** (0,00002) 0,000186*** (0,00003) 0,000176*** (0,00003) −0,000233*** (0,00002)
Gender −0,505*** (0,00781) −0,187*** (0,01340) −0,197*** (0,01260) −0,177*** (0,00972)
Residence 0,301*** (0,00968) 0,693*** (0,01460) 0,550*** (0,01370) 0,603*** (0,01040)
Regional GDP per Capita 0,298*** (0,00665) 0,0497*** (0,01160) 0,119*** (0,01160) 0,0205*** (0,00280)
_cons −16,89*** (0,13100) −14,73*** (0,23900) −16,01*** (0,23400) −17,23*** (0,14200)
N 540,168 146,592 150,512 217,507
chi2 53544,2 14744,6 16140,6 29027,7
bic 447281,9 142031,5 158877,2 260147,3
aic 447091,5 141863,3 158708,6 259972,3
ll −223528,8 −70914,6 −79337,3 −129969,2

Robust standard errors in parentheses.

***p < 0.01, **p < 0.05, *p < 0.1.

still a shortage of doctors at the district level. This means that several
CHCs have either a scarcity of doctors or no doctors at all. A dearth of
doctors will result in long queues of patients. In addition, as the quality
of services offered by both doctors and supporting health workers is
deemed different due to their distinct expertise, patients will certainly
face difficulties having a proper treatment by the supporting health
workers alone.
The number of beds per population in CHCs is also negatively cor-
related with JKN ownership. Beds in CHCs are rarely used for inpatient
care, except for villagers or dwellers from small remote districts. This

4
K. Khoirunurrofik, G. Raras Health Policy OPEN 2 (2021) 100050

is because CHCs are not equipped with the same level of bed facilities previous research which found that health condition is negatively cor-
as hospitals. The result supported by the 2018 Indonesia Health Profile related with health insurance [1,2,4,15].
shows that only 57.24% of CHCs in Indonesia deliver standardized ser- As well, the outpatient and inpatient variables represent health
vices [14]. Thus, an increase in CHC beds will not encourage someone conditions. Both have a positive relationship, which means that when
to buy JKN because the CHCs are not perceived as having good health- someone has had outpatient or inpatient treatment over the past
care facilities. This suggests that the increase of the number of facilities month, the probability of their buying JKN will rise. This is in accor-
does not only mean the increased number of CHCs buildings, but also dance with the research findings of Dartanto et al. [11] which showed
more importantly enhance the quality of accreditation, bed ratios, and that the worse someone’s health condition, the more likely they are to
the health centers status. buy health insurance.
Furthermore, the variable of age using the quadratic function in the
model indicates that there is a positive relationship between the age
4.2. Analysis of health services in the hospitals
variable and the probability of acquiring JKN, which is followed by
a negative relationship with the age2 variable. This result is consistent
The logit regression results in the sample indicate that the expan-
with that of Kirigia et al. [1] who suggested that as individuals age, the
sion of hospital number will escalate the probability of someone pur-
inherited health condition decreases at an increasing rate and younger
chasing JKN. This is in line with previous research which suggested
people tend to increase investment in health (including health insur-
that the amount of hospitals has a significant positive influence on
ance) in an attempt to lower the depreciation rate. This is why older
someone’s decision to buy JKN [1,11,12]. This positive effect may
people are less likely to invest in their health compared to younger
be due to lower economic costs of visiting a health facility (such as tra-
people.
vel cost) or induced demand by providers [11]. Hospitals are equipped
The marital status variable shows a positive relationship with the
with more comprehensive health facilities and workers than CHCs.
probability of purchasing JKN. Married couples are considered decent
However, there is still an insufficient number of hospitals in Indonesia.
JKN customers because of their ability to combine their resources and
Data obtained from the online Hospital Information System demon-
incomes with those of their partners. This is in line with the findings of
strated that 52 districts do not possess either private or government
Trijulo [9]. Meanwhile, regional GDP per capita and expenditure per
hospitals [7]. As a result, access to a medical treatment at the nearest
capita have a positive relationship with the probability of becoming
hospital tends to be uneasy as this demands travels to a faraway
a JKN participant. This result mirrors those of the previous studies con-
hospital.
ducted by Trijulo and Vera‐Hernandez [11,15]. The results also
Meanwhile, the number of beds can encourage someone to become
showed that people who live in the urban area are more likely to
a JKN participant. This result is consistent with a previous find-
become JKN participants. This further supports the previous research
ing.[11]. It is also directly proportional to the data presented in the
conducted in Indonesia [16].
background. Whereas at the national level few provinces showed dis-
parity of hospital beds, at the district level, numerous districts indicate
a deficiency of hospitals. Therefore, an increase in the number of beds
5. Conclusion
will increase the probability of individuals buying JKN.
The availability of doctors in hospitals also bears a positive rela-
The study investigated the relationships between the availability of
tionship with the probability of someone procuring JKN. This result
health care services and the willingness to become JKN participant of
is consistent with the research conducted by Trijulo [11] which found
the non‐low‐income independent workers. The results of this study
that the number of doctors is positively correlated with JKN. This pos-
showed that hospital‐level health services play an important role in
itive correlation between the number of doctors in hospitals and the
increasing someone’s probability of participating in JKN, especially
probability of someone participating in JKN is due to the lack of doc-
the informal sector workers. The numbers of hospitals, beds, and doc-
tors in hospitals. People attempting to gain medical treatment in a hos-
tors are significantly and positively related. This has implications for
pital are required to wait in line for a long time because of the
the lack of equitable health facilities and workers at a district or city
insufficient doctors. This generates economic costs that discourage
hospital. The availability of CHCs and number of doctors in CHCs
communities from obtaining JKN. There is evidence that the availabil-
has a positive effect on someone’s decision to become a JKN partici-
ity of health workers to provide the services at the local level is lack-
pant. This is because most CHCs do not have sufficient doctors to pro-
ing. Hence, to overcome such shortage, both provincial government
vide care. Consequently, CHC treatment is delayed due to a long
and municipalities can offer them a temporary employment contract.
queue.
However, the central government should prioritize the procurement
Policy implications based on the previous analysis results suggest
of the civil servants health.
that in their attempts to attract informal sectors to plan their JKN
One factor that contributes maldistribution of health personnel is
memberships, the government is greatly commanded to augment the
Indonesia’s health regulations (Regulation of The Minister of Health
number of hospitals and beds. However, considering the length of time
Number 2052/MENKES/PER/X/2011) that allow health personnel to
required to build hospitals, the government can seek to redistribute
work in both public and private sectors, with a limit of a maximum
doctors from regions with an excess supply of doctors to regions with
of three practice locations. This regulation makes specialist doctors
a shortage of doctors in hospitals in the short term. Meanwhile, CHCs
reluctance to move to areas without private practice and with less
are compelled to enhance their standard services, especially CHCs in
well‐equipped medical facilities, where they would miss out on a sig-
regions that still lack doctors to enable patients to access closer health
nificant portion of income [13].
facilities.
Finally, this study suggests that supply set rates need to be deter-
4.3. Analysis of demand mined on the basis of economic principles by providing investment
costs paid by the government. In the local context, provincial and dis-
A person’s health condition is an important factor that influences trict governments must contribute to the operationalization and build-
their decision on whether or not to buy health insurance. As inter- ing of the supply and recruitment of health workers, while the role of
preted using the health variable, one's health condition has a negative the central government is expected to balance the supply shortage of
relationship with the probability of buying health insurance. This health facilities and health workers.
means that when someone experienced severe pain in the past month, The strength of this study lies in the deployment of supply‐side
the probability of their purchase of JKN will fall. This finding confirms variables at two levels of health facilities, at the district and sub‐

5
K. Khoirunurrofik, G. Raras
district levels, that have not been explored previously by any studies
related to JKN. Nonetheless, this study remains has a weakness in
the accuracy of defining informal workers. There is no straightforward
classification of informal workers in the SUSENAS dataset. The
approach was taken by excluding the individuals with staff, workers,
and employee positions to represent the independent informal worker.
CRediT authorship contribution statement
Khoirunurrofik Khoirunurrofik: Conceptualization, Methodol-
ogy, Validation, Writing – review & editing, Supervision, Funding
acquisition. Giani Raras: Conceptualization, Investigation, Methodol-
ogy, Validation, Writing – original draft.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
Acknowledgements
The authors are grateful for the support of 2019 PITMA Grant‐
Universitas Indonesia and to the anonymous reviewer(s) for their use-
ful suggestions.
References
[1] Kirigia JM, Sambo LG, Nganda B, Mwabu GM, Chatora R, Mwase T, et al.
Determinants of health insurance ownership among South African Women. BMC
Health Services Res 2005;5(17):1–10.
[2] Liu T-C, Chen C-S. An analysis of private health insurance purchasing decisions
with national health insurance in Taiwan. Soc Sci Med 2002;55(5):755–74.
[3] Lawanson AO, Ibrahim MN. Willingness to pay for community health insurance: a
study of hygeia operations in Shonga and Afon communities in Kwara State.
African J Health Econ 2015;4(1):1–15.
Health Policy OPEN 2 (2021) 100050
[4] Thornton RL, Hatt LE, Field EM, Islam M, Solís Diaz F, González MA, et al. Social
security health insurance for the informal sector in Nicaragua: a randomized
evaluation. Health Econ 2010 Sep;19(S1):181–206.
[5] WHO. Health system financing: the path to universal coverage World Health
Report; 2010. [cited 26 October 18]. Available from: http://apps.who.int/iris/
bitstream/handle/10665/44371/9789241564021_eng.pdf;jsessionid=
1EC4602EF23124F601614D3962E3258A?sequence=1.
[6] Nugraheni WP, Mubasyiroh R, Hartono RK, Hotchkiss D. The influence of Jaminan
Kesehatan Nasional (JKN) on the cost of delivery services in Indonesia. PLoS ONE
2020;15(7):e0235176. https://doi.org/10.1371/journal.pone.023517610.1371/
journal.pone.0235176.g00110.1371/journal.pone.0235176.g00210.1371/
journal.pone.0235176.g00310.1371/journal.pone.0235176.t00110.1371/journal.
pone.0235176.t00210.1371/journal.pone.0235176.t00310.1371/journal.
pone.0235176.t004.
[7] Ministry of Health. Sistem Informasi Rumah Sakit Online [cited 20 October 18].
Available from: http://sirs.yankes.kemkes.go.id/fo/.
[8] Ministry of Health. Data Dasar Puskesmas 2017 [cited 20 October 18] Available
from: https://www.kemkes.go.id/folder/view/01/structure-publikasi-pusdatin-
data-dasar-puskesmas.html.
[9] Ministry of Health. 2017. Program Pemenuhan Tenaga Kesehatan [cited 20 Oct
18]. Available from: https://depkes.go.id/resources/download/bahan_
rakerkesnas_2017/Badan%20PPSDM%20Kesehatan.pdf.
[10] Yiengprugsawan V, Carmichael G, Lim L-Y, Seubsman S, Sleigh A. Explanation of
inequity in utilization of ambulatory care before and after universal health
insurance in Thailand. Health Policy Plan 2011;26:105–14.
[11] Trujillo AJ. Medical care use and selection in a social health insurance with an
equalization fund: evidence from Colombia. Health Econ. 2003;12(3):231–46.
[12] Dartanto T, Rezki J, Pramono W, Siregar C, Bintara U, Bintara H, et al.
Participation of informal sector workers in Indonesia’s national health insurance
system. J Southeast Asian Econ 2016;33(3):317–42 [cited 15 Oct 18]. Available
from: www.jstor.org/stable/44132409.
[13] Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, et al. The
Republic of Indonesia Health System Review, Health Systems in Transition. WHO
Regional Office for South-East Asia 2017;7(1). https://apps.who.int/iris/handle/
10665/254716.
[14] Ministry of Health Indonesia. Profil Kesehatan Indonesia. 2018. Jakarta: Kemenkes
RI. [cited 15 Oct 18]. Available from: https://pusdatin.kemkes.go.id/
resources/download/pusdatin/profil-kesehatan-indonesia/PROFIL_KESEHATAN_
2018_1.pdf.
[15] Vera-Hernández ÁM. Duplicate coverage and demand for health care. the case of
Catalonia. Health Econ 1999;8(7):579–98.
[16] Bela S, Haerawati I. Determinant of Independent National Health Insurance
Ownership In Indonesia. Malaysian J Public Health Med 2019;19(2):109–15.
https://doi.org/10.37268/mjphm/vol.19/no.2/art.177.