Partnership Analysis of National Health Insurance Pooling

Mechanism Among Informal Workers in Banyumas Regency

Harry Fauzi

, Diah Ayu Puspandari

, Ambar Widaningrum

Public Health Science Program, Faculty of Medicine, Universitas Gadjah Mada, Sleman, Yogyakarta, Indonesia

Magister of Public Administration Program, Universitas Gadjah Mada, Sleman, Yogyakarta, Indonesia

auziharr

y@g

mail.com

Keywords: BPJS Kesehatan, Informal worker, Partnership, Premium collecting, Universal coverage.

Abstract: Indonesia in achieving Universal Health Coverage has the challenge to protecting informal workers. But,

informal sector workers covered BPJS Kesehatan by the Workers Not Receiver Wages is still low

enrolment. Premium collection of BPJS Kesehatan for members especially informal workers is important to

the sustainability of National Health Insurance program. The premium collection of BPJS Kesehatan can’t

reach for informal sector as a whole. Expansion of premium collection BPJS Kesehatan is needed to

facilitate the informal sector to register and pay BPJS Kesehatan premiums. The aim of this research is

describe the partnership in collecting premiums of BPJS Kesehatan for informal workers in Banyumas. This

research is qualitative research with 14 informans. Research location in informal sector worker of palm

sugar farmer and batik worker in Banyumas. Data collection was done by in-depth interview, observation

and documentation. The results of this research indicate that the partnership in collecting premiums desired

by informal sector workers in Banyumas is partnership through association or cooperative. This partnership

facilitates the payment of contributions BPJS Kesehatan by associations or cooperatives that they are

regular contact or who they trust. Oversight and guidance to the partnership were done by the Department of

Labor and Cooperative Banyumas and BPJS Kesehatan.

1 INTRODUCTION

Indonesia's efforts to achieve universal health

coverage still face challenges to be faced, previous

research says that the challenge faced in reaching

Universal Health Coverage (UHC) is to provide

protection to informal sector workers. However, in

this time, informal sector workers covered by

national health insurance with non-PBI members

category for non-wage workers or Pekerja Bukan

Penerima Upah (PBPU) are still low enrollment.

Data BPJS Kesehatan in August 2017, indicating

that the recipient contributions or Penerima Bantuan

Iuran (PBI) is the type of membership in Indonesia,

as many as 109.54 million participants (61%).

Unlike the case with non-PBI members is wage

workers or Pekerja Penerima Upah (PPU), that is as

much as 42.32 million participants (24%). Non-PBI

membership for Non-Wage Workers (PBPU) or

informal sector has the least amount, only 27.60

million participants (15%).

Informal sector people have certain

characteristics that must be well understood.

Informal workers in the 2012-2019 JKN roadmap

are non-wage Workers (PBPU) or workers outside

the working relationship (self-employed), most of

whom do not occupy permanent business locations

and irregulary income. Collection of premium

contributions from workers in the informal sector

requires processes and procedures that are very

different from the formal sector. This difference is

causing the current premium arrears in BPJS

Kesehatan. The biggest arrears come from segments

of Non-Wage Member (PBPU) or the informal

sector. Up to the 3 rd Quarter of 2015, the segment's

premium debt reached more than Rp. 2.43 trillion.

Data from BPJS Kesehatan Purwokerto Branch

shows in 2015, about 57.84% of members aren’t pay

contribution, the majority of arrears by informal

sector workers covered by national health insurance

with categories of non-wage workers.

Efforts to expand the member BPJS Kesehatan

of the informal sector and the collection of informal

sector premiums in Banyumas, especially for palm

farmers and batik worker, need an innovative

approach. Innovative approach one by doing

Fauzi, H., Puspandari, D. and Widaningrum, A.

Partnership Analysis of National Health Insurance Pooling Mechanism Among Informal Workers in Banyumas Regency.

In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 46-50

ISBN: 978-989-758-335-3

partnerships in the collection of premiums in the

informal sector so they regularly pay premiums and

willing to join a member BPJS Kesehatan. This

partnership can be carried out between BPJS

Kesehatan Purwokerto Branch and Cooperatives or

associations of informal sector workers. The scheme

of increasing informal sector members through

cooperatives will bring ease in the collection of

premiums from informal sector workers. Payment of

insurance premiums can be made directly one year

or monthly using the loan facility from the

Cooperative. Cooperatives provide ease of

supervision, communication, advocacy and

provision of information in this channelling between

stakeholders and the agency of health insurance to

the informal sector.

2 METHODS

This research is qualitative research with case study.

The research location in Banyumas district at Nira

Satria Cooperative as an association of informal

sector workers of palm farmers and Perbain as

association of batik workers. Data collection was

done by in-depth interview, observation and

documentation. The study began in March until July

2017. The subjects were 16 participants consisting

of 1 head of Cooperative Nira Satria, 1 head of batik

association of Perbain, 1 head of membership unit of

BPJS Kesehatan Purwokerto Branch, 1 head of batik

worker, 1 head of Banyumas Cooperation Office,

coconut, 5 palm farmers and 5 batik workers.

All Interviews were digitally recorded and then

transcribed for analysis in OpenCode 4.03

qualitative analysis software. Two researchers

analyzed the transcripts through direct content

analysis, a qualitative data analysis method, using

OpenCode 4.03. Codes were developed primarily

according to the four themes. The researchers

analyzed transcripts line by line and assigned new

codes to additional emerging concepts. OpenCode

4.03 was used to sort and organize the themes and to

examine the patterns emerging from each of the

themes. To ensure consistency and common

understanding of code concepts, the analysts

discussed the coding process and one senior member

of the team checked the analysis results.

3 RESULT

As mentioned in the Methods section, the

partnership analysis identified four key topics for

assessment; below, we summarize and describe the

interviews by topic.

3.1 The Perception of Informal Sector

Workers on Registration Becomes A

Member of BPJS Kesehatan.

Participants who are palm farmers want the

cooperative to register the farmers who have not

enroll into BPJS Kesehatan member. They want

Cooperative Nira Satria willing to register palm

farmers to become member of BPJS Kesehatan. This

can be seen in the following participant quote:

“I want a cooperative willing to help register

health insurance, if we have difficulties,

difficulty registering, cooperatives can register us

to have health insurance. I want it like that. The

cooperative should help us register BPJS

Kesehatan.”

Informal sector workers want the ease of

registration into BPJS Kesehatan members. The ease

of registering to become a member of BPJS

Kesehatan, according to the participants by

registering through Nira Satria Cooperative. Nira

Satria Cooperative can facilitate registration of

informal sector workers, especially palm farmers

become BPJS member because the cooperative is

where they sell the production of coconut sugar they

make. They sell coconut sugar every five days to the

cooperative

3.2 Perceptions of Informal Sector

Workers About Paying Premiums

BPJS Kesehatan

Member of BPJS Kesehatan especially member

which including Non-Wage Worker (PBPU) must

pay premium every month. This is also what must

be done by the batik workers who joined the BPJS

Kesehatan member. According to the participants,

the ease of payment of premium BPJS Kesehatan by

batik workers by paying premiums to batik

associations. They are not used to Banks or

Automatic Teller Machine (ATM). Premium

collection through batik association coordinator.

Coordinator of batik association who became

channel between BPJS Kesehatan with batik

association member who became member of BPJS.

When the premiums have been collected by the

coordinator of batik, then from the BPJS Kesehatan

contacted to make payment premiums BPJS Health.

This can be seen in the following quote information:

Partnership Analysis of National Health Insurance Pooling Mechanism Among Informal Workers in Banyumas Regency

“...Ease of premium collection for batik workers

through batik association. In batik association there

is one coordinator. The coordinator can be a channel

with BPJS Kesehatan. The batik coordinator will

contact BPJS Kesehatan when the premiums of

batik workers have gathered When there is new

information or regulations from BPJS regarding

premiums can be through the coordinator of the

association.”

Informal sector workers want ease in paying

BPJS premiums. The paying premium of member

BPJS Kesehatan can ease through coordinator of

batik association. This coordinator can facilitate the

payment premium of informal sector workers

because of the batik coordinator where they sell

their batik work

3.3 Giving Information to Informal

Sector Workers Makes Them

Interested in Becoming a Member of

BPJS Kesehatan

Palm farmers and batik workers to be willing to

participate BPJS Kesehatan needed information that

makes them interested. Participants say that palm

farmers and other batik workers are willing to join

BPJS Kesehatan, they must first be given

socialization by BPJS Kesehatan. Participants want

to socialize about BPJS Kesehatan in Nira Satria

Cooperative for palm farmers and batik association

in Perbain cooperative. Nira Satria Cooperative and

Perbain Cooperative every thirty-five days once

there is a meeting. When the meeting at Nira Satria

Cooperative and Perbain Cooperative has been

completed can also be socialized from BPJS

Kesehatan to palm farmers and batik workers.

“We want socialization at Cooperative. BPJS

Kesehatan give socialization to us in Cooperative.

Cooperative held a meeting at Wage Wednesday or

meeting in Cooperative every Thirty-five days.

When the meeting is completed BPJS can also

socialize to us.”

“I prefer socialization from BPJS Kesehatan rather

than a brochures about BPJS Kesehatan. The

brochure can’t give me information about benefits of

BPJS Kesehatan. BPJS Kesehatan can socialize to

batik workers through batik association. Batik

association at Perbain Cooperative. Batik owners

and batik workers gathered at meetings in Perbain so

BPJS Kesehatan can easy to give information to

batik association during meeting at Perbain.”

Cooperatives can partner with BPJS Kesehatan

in providing information to its members and

informal sector workers who do not know about

BPJS Kesehatan. Cooperatives can be a channel of

BPJS Kesehatan. The cooperative room can also be

a place of socialization about BPJS Kesehatan that

can be provided by BPJS Kesehatan itself or from

cooperatives. Therefore, if the information provided

by the cooperative or association, the information

provided from the cooperative to the member must

be the same as the information provided by BPJS

Kesehatan to the cooperative.

3.4 Partnership in The Collection of

Premium BPJS Kesehatan

The member is not a recipient of the wages (PBPU)

or informal sector workers who have participated in

BPJS Kesehatan membership and joined in a

community, such as cooperatives can collect BPJS

Kesehatan premiums within a group. The collection

of premiums within a group or through this

community is known as the collective PBPU. The

collective PBPU is a collection of premium PBPU

participants with a minimum of 100 members.

Members of the informal sector are grouped in an

association or cooperative can also register its

members collectively, through the cooperative.

Requirements that must be met such as family card,

resident card, and form. The cooperative can register

its members to become a member of BPJS

Kesehatan collectively and can collect the

contribution of member's premiums collectively as

well. In a cooperative there will be a coordinator

who will be channel with BPJS Kesehatan. The

following information from the Head Unit member,

BPJS Kesehatan Purwokerto Branch, through the

quote below.

“ So for the collection ... ee ... independent members

or the general public, the community joined in a

cooperative community, it could be, it could be in a

group.. the group name is a collective PBPU...

independent memberss of the collective, where a

minimum of memberss is 100 people. So, within a

community... there is a cooperative ... included in

BPJS collectively with on behalf of the cooperative,

the registration will bring the requirements such as

Family Card, Resident Card etc. Through

cooperative.. So that collects the contribution from

the cooperative, which pays to the BPJS is from the

cooperative. There is one coordinator cooperative.

This cooperative who register the collect, collect to

BPJS.. later from the BPJS Health relationship with

the cooperative..”

Cooperatives or associations can be a place for

informal sector workers. It can be formed to become

an association of informal sector workers with the

same job. The purpose of the establishment of the

INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association

association is as a partner between BPJS Kesehatan

and members of informal sector workers, the benefit

is that informal sector workers know about the

benefits of being a member BPJS Kesehatan.

Partnerships in the collection of premiums desired

by informal sector workers in Banyumas district are

partnerships through associations or cooperatives.

This partnership facilitates the payment of

contributions by partnerships between associations

or cooperatives that they are regular contacts or who

they trust

4 DISCUSSION

Efforts to expand the participation of the informal

sector and the collection of premium contributions

of the informal sector, especially palm farmers and

batik workers need an innovative approach.

Innovative approach one by using cooperatives as a

method of gathering premiums. Membership in a

microfinance institution such as a cooperative serves

as a community-based association to participate in

health insurance [5]. Cooperatives are the

determinants of informal sector workers in access to

premium payments to health insurance.

In Kenya, since 2003, the National Hospital

Insurance Fund (NHIF) has been cooperating with

cooperatives through savings and community credit.

NHIF and cooperatives are also working together to

increase membership of health insurance, taking

photos in making NHIF identity cards, submitting

NHIF identity cards and NHIF premium collection

agencies. The cooperative also helps NHIF in

socialization and promotion to its cooperative

members who do not yet have health insurance.

After working with cooperatives, NHIF can expand

its membership to rural communities that have no

health insurance. Cooperatives benefit by providing

protection to their members through health insurance

managed by NHIF.

Efforts to increase membership and awareness to

regularly pay contributions to the informal sector in

national health insurance found many obstacles. The

low level of enrolment in the informal sector is

triggered by several factors including low income,

uncertain income, lack of awareness to participate in

health insurance, if they join an irregular health

insurance to pay premiums.

Approach with door to door premium collection

or Door to Door collection. This approach is

appropriate for cooperative members who are

reluctant or difficult to reach payment points.

Cooperative members will choose a door-to-door

collection method with a person in charge of

collecting premium contributions from the

cooperative. This effort allows members of the

cooperative to regularly pay premium contributions

each month. Members of the cooperative who have

paid, are given proof of payment from the

cooperative in charge of collecting contributions.

Proof of payment is useful in preventing fraud in

collecting contributions.

There is an increasing willingness to pay health

insurance contributions to the informal sector after

routine and intensive socialization of health

insurance to the informal sector. This study shows, if

routinely performed on informal sector workers such

as coconut farmers and batik workers, their

awareness will increase to follow the health

insurance program and the willingness to regularly

pay premiums will increase as well.

The provision of information on health insurance

programs relates to the level of community

participation incorporated in the dairy farm

cooperatives against the health insurance program in

Kenya. The more intensive the provision of

information about the health insurance program the

higher the level of participation of dairy farmers in

the cooperative against the health insurance scheme.

In Uganda, the community participating in

community health insurance is low enrolment due to

the lack of information to the public about the

benefits of being a participant of the health

insurance. Kenya uses cooperatives in covering the

informal sector with support by governments in the

country. This cooperative is capable as a supporting

tool in increasing the participation of informal sector

into health insurance in that country because based

on community or group. Informal participants will

be easy to get information, register and collect

premiums in health insurance.

In Philippines, Philhealth applies group-based

participation by requiring individuals to enroll in a

group or community-based health insurance scheme

through Kasapi. The purpose of group-based

participation is that expansion can be done more

quickly and facilitated in collecting membership

contributions.

All group members in the association

are enrolled, administrative costs are reduced and

the only ill phenomenon that comes with health

insurance or adverse selection can be reduced. Based

on their occupational categories, informal sector

workers may not be organized in groups or

associations based on their work, but they may be

members of community-based organizations such as

women's groups, religious groups, agricultural

groups or associations of traditional market.

Partnership Analysis of National Health Insurance Pooling Mechanism Among Informal Workers in Banyumas Regency

5 CONCLUSION

Partnerships in the collection of premiums desired

by informal sector workers in Banyumas District are

partnerships through associations or cooperatives.

This partnership facilitates the payment of

contributions with partnerships between associations

or cooperatives that they are regular contacts or who

they trust. Supervision and guidance is done by the

Office of Labour and Cooperatives with BPJS

Kesehatan.

REFERENCES

Basaza, R., Criel, B., & Van der Stuyft, P. 2008.

Community health insurance in Uganda: why

does enrolment remain low? A view from

beneath. Health Policy, 87(2), 172-184.

BPJS Kesehatan. 2015. Kajian Pengumpulan Iuran

Program JKN. Grup penelitian dan

Pengembangan BPJS Kesehatan.

Churchill, C. F. 2003. Making insurance work for

microfinance institutions: A technical guide to

developing and delivering microinsurance.

International Labour Organization.

De Groot-de Greef, T., Monareng, L. V., & Roos, J.

H. 2016. A quantitative study on factors

influencing enrolment of dairy farmers in a

community health insurance scheme. BMC

health services research, 16(1), 686.

DJSN. 2012. Peta Jalan Menuju Jaminan Kesehatan

Nasional 2012-2019. Jakarta: Dewan Jaminan

Sosial Nasional.

Khan, J. A., & Ahmed, S. 2013. Impact of

educational intervention on willingness-to-pay

for health insurance: A study of informal sector

workers in urban Bangladesh. Health economics

review, 3(1), 12.

Kimani, J. K., Ettarh, R., Kyobutungi, C., Mberu, B.,

& Muindi, K. 2012. Determinants for

participation in a public health insurance

program among residents of urban slums in

Nairobi, Kenya: results from a cross-sectional

survey. BMC health services research, 12(1),

66.

Kimball, M., Phily, C., Folsom, A., Lagomarsino,

G., & Holtz, J. 2010. Leveraging Health

Microinsurance to promote universal health

coverage. Microinsurance Innovation Facility,

International Labour Office. Meyer, J.,

Bovbjerg, R., Ormond, B., Lagomarsino, G,

1999-2009.

Macapanpan, M. L. 2015. Extending Universal

Health Coverage For The Informal Sector In

Philippines. BMJ Open, 5(Suppl 1), bmjopen-

2015.

Mathauer, I., Schmidt, J. O., & Wenyaa, M. 2008.

Extending social health insurance to the

informal sector in Kenya. An assessment of

factors affecting demand. The International

journal of health planning and

management, 23(1), 51-68.

Muiya, B. M., & Kamau, A. 2013. Universal Health

Care in Kenya: Opportunities and challenges for

the informal sector workers. Journal of

Education and Research, 1(11), 1-10.

Obermann, K., Jowett, M. R., Alcantara, M. O. O.,

Banzon, E. P., & Bodart, C. 2006. Social health

insurance in a developing country: the case of

the Philippines. Social Science &

Medicine, 62(12), 3177-3185

Yang, W. 2013. China’s new cooperative medical

scheme and equity in access to health care:

evidence from a longitudinal household

survey. International journal for equity in

health, 12(1), 20.

INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association