Influence Analysis of BPJS Kesehatan Ownership on Participant’s
Health Behavior in Surabaya
Nita Kusuma Wardani, Sherly Dwi Agustiningrum, Malida Nurul Hidayah, Dwi Elsa Mardiana,
Rina Wahyu Andani
Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
Keywords: BPJS Kesehatan, Health behaviour, Ex-ante moral hazard.
Abstract: The Government of Indonesia aims to have Universal Health Coverage by 2019 which means that all
citizens will be covered by JKN, a national health insurance program. Some studies have found the
existence of ex ante moral hazard that can bring disadvantages for the government and the community itself.
This research is intended to analyse the influence of BPJS Kesehatan towards health behaviour of the
participants. The research design is analytic and cross-sectional with a multi-stage random sampling
method. 250 respondents from two districts that had been randomly selected were enrolled in the study. A
binary logical regression test was used to analyse the data obtained. The results showed a positive and
significant influence of BPJS Kesehatan towards the participant’s health behaviour, with a significance
value of 0.039. The value is smaller than the alpha 0.05 which means that the statistical hypothesis has been
rejected. Furthermore, OR analyses shows an exp.value of 1.951. In conclusion, the participation of BPJS
Kesehatan influences the preventive health behaviour of the participants and they have the tendency to
behave 1.951 times healthier than people who do not have health insurance at all.
1 INTRODUCTION
Health is the right of every individual. Protecting
and ensuring the fulfilment of these rights for every
citizen is the responsibility of the government. To
make it happen, the government established an
agency named Badan Penyelenggara JaminanSosial
(BPJS) which officially began operating on January
1st, 2014. BPJS is in charge of organising the JKN
(National Health Insurance) program with the
services offered divided into BPJS Kesehatan and
BPJS Ketenagakerjaan. Up until October 16th,
2016, there were 169,574,010 Indonesians registered
on the JKN program (BPJS, 2016) out of a total of
237,641,326 Indonesians according to the
Population Census of Indonesia, 2010.
In 2019, in accordance with the Indonesian
Ministry of Health's strategic plan of 2015-2019, all
Indonesian citizens must be registered as BPJS
Kesehatan participants. It means that two years on
from this year, all residents will have health
insurance that allows them to access health services.
This is one of the government commitment steps to
achieve Universal Health Coverage (UHC) in
Indonesia. However, even when the whole of society
has been insured, there will be the possibility of ex
post moral hazards and ex ante moral hazards.
The results of the previous studies have shown
the existence of ex post moral hazard and increased
visits to health service agencies to get curative and
rehabilitative facilities, while the existence of ex
ante moral hazard is still not consistent. Anderson
E.Stanciole's (2008) study shows that health
insurance has an effect on lifestyle selection,
increasing the tendency for active smoking, a lack of
exercise and obesity, and decreasing the tendency to
consume alcoholic beverages. Dhaval Dave and
Robert Kaestner (2006) pointed out that otherwise,
the ex ante moral hazard was not found consistently
in women, but showed consistent evidence as having
an effect on men.
This study is designed to analyse the influence of
BPJS Kesehatan ownership towards health
behaviours (preventive) of the participants in
Surabaya. The results of this study are expected to
be used as a reference for the Government or the
58
Wardani, N., Agustiningrum, S., Hidayah, M., Mardiana, D. and Andani, R.
Influence Analysis of BPJS Kesehatan Ownership on Participant’s Health Behavior in Surabaya.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 58-60
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

parties associated with the implementation of JKN to
allow them to be more prepared for the possibilities
that can arise after the achievement of UHC 2019. In
addition, the results of this study can be used as
government considerations to improve the quality of
the National Health Insurance (JKN) program.
2 METHODS
This explanative quantitative research explains and
tests the hypothesis of the research variables. The
study was conducted over a period of five months,
starting from March to July 2017. The study design
was cross-sectional with a population consisting of
the BPJS Kesehatan participants in Surabaya. The
design was used because the study examined two
variables at the same time. The independent variable
is the ownership of BPJS Kesehatan in Surabaya.
The dependent variable is health behavior. The
sampling technique used was multi-stage random
sampling. The location of the research was obtained
by randomly taking individuals as samples from 2
sub-districts from the 31 sub-districts in Surabaya,
and then selecting 2 urban villages until the final 2
RW (Rukun Warga) were chosen as the research
location. The selected RWs were RW 1 Krembangan
Utara, Pabean Cantian and RW 7 Nginden
Jangkungan, Sukolilo, Surabaya.
The equation used to determine the sample size
is known as the Lemeshow formula (1997):
𝑛 =
𝑁 𝑍
2
𝑃(1 − 𝑃)
(
𝑁 − 1
)
𝑑
2
+ 𝑍
2
𝑃(𝑃 − 1)
(1)
From the formula above, we have got a sample
size of 250 people, with a ratio of 4:1 which was
obtained from the number of participants of
Surabaya City BPJS 2016 and the number of people
who do not have health insurance (the population in
2016 - the number of participants of BPJS in 2016,
assuming that non-BPJS participants are included in
the community who do not have health insurance
because of the difficulties in knowing the number of
people who do not have BPJS Kesehatan in
Surabaya. The assumption is only used to determine
the ratio of the research sample). The data used in
this study was the primary data obtained from the
data collection in the field using the aid of a
questionnaire instrument with a Likert scale (1-4).
The questionnaire passed the test of validity and
reliability before being given to the community.
Based on the research objectives and the data scale
of each variable (the scale of the independent
variable data is nominal, the dependent variable is
the ratio), the linear regression test with a dummy
variable could be used. However, because there are
some unfulfilled assumptions in the test, the Binary
Logistic Regression test was used to perform the
data analysis.
3 RESULTS
A total of 250 respondents participated in this
research. Each of them was asked to fill the
questionnaire to assess their health behavior.
The data obtained are analysed by binary logistic
regression test. Below is the result of partial test and
model formation:
Table 1: Variable in the Equation
B
S.E
Wald
df
Sig.
Exp
(B)
Step 1
BPJS
owner-
ship
0.668
0.323
4.267
1
0.039
1.951
Constant
-0.804
0.292
7.599
1
0.006
0.447
Based on Table 1, it can be seen that the
coefficient of the participation of BPJS is 0.668
(value significance (p) = 0.039). This value is less
than alpha 0.05, which means that it has been
rejected. This, in turn, means that "there is a
significant influence of BPJS Kesehatan
participation on the health behaviour of the
participants" or "BPJS participation affects the
participant's health behaviours". In addition, from
the Table 1, Exp(B) shows a value of 1.951 which
means that the probability of societal members who
have health insurance behaving more healthily is
1.951 times better than those who do not have health
insurance at all.
4 DISCUSSIONS
Risk management theory states that people do not
like to be in risky circumstances, so they try to hand
over the responsibility of risk to others. The other
party in this study is the provider of health
insurance, but with the granting of this
responsibility, a person will have two possibilities
related to moral hazards. It describes the changes of
behaviors in prevention and treatment caused by
Influence Analysis of BPJS Kesehatan Ownership on Participant’s Health Behavior in Surabaya
59

health insurance (Yaohui Dong, 2017). Those moral
hazards are called ex post moral hazard, when there
is increase in visits to health services and ex ante
moral hazard, which is the possibility of increasing
risky behaviours or decreased health preventive
behaviours.
Research that has been done shows that the ex
ante moral hazard effect has not been consistent, that
in some behaviours can be seen to have a significant
impact whereas in others, the behaviour has not.
However, other studies have shown that the
ownership of health insurance had an effect on the
increase in risky behaviour. The inconsistency of
similar research results suggests that health
insurance can have ex ante moral hazard risks or not,
when under different circumstances.
This research study indicates that there is
influence when it comes to BPJS Kesehatan
insurance ownership toward the health behavior of
the participants, but does not prove the existence of
ex ante moral hazard. The results of this study show
that people who have BPJS Kesehatan insurance
will actually behave twice as healthy as those who
have no insurance at all. This can be used to deduce
that the ownership of BPJS Kesehatan actually
increases health preventive behaviours among the
participants. The participants in Surabaya City still
maintain and suggest that even if they already have
insurance, they can keep on maintaining their health,
by not tending towards risky behaviours which lead
to bringing in negative effects towards their health.
The health behaviors mentioned in this study are
behaviours related to physical activity, hygiene, diet,
sleep patterns, health checks, smoking behaviours,
and other preventive behaviours.
5 CONCLUSIONS
From the discussion above, it can be concluded that
BPJS Kesehatan has an influence on the
participant’s health behaviour in the Surabaya
context. The result of the data analysis shows that
those who have health insurance have health
behaviour that is twice as good as those who do not
have health insurance at all. Having health insurance
will encourage the participants to behave more
healthily. They tend to have a good physical activity,
hygiene, diet, sleep patterns, health checks, smoking
behaviours (do not smoke in public areas or do not
smoke at all) and other preventive behaviours.
REFERENCES
Anderson ES. Health Insurance and Lifestyle Choices:
Identifying Ex Ante Moral Hazard in the US Market.
The Geneva Papers [Internet]. 2008 [cited 2017 Mar
30]; 33:627-644. Available from: www.palgrave-
journals.com/gpp
Badan Perencanaan Pembangunan Nasional. Proyeksi
Penduduk Indonesia 2010-2035. Jakarta: Badan Pusat
Statistik; 2013. 458 p. Report No.: 04110.1301.
Dhaval D, Robert K. Health Insurance and Ex Ante Moral
Hazard. NBER working paper series [Internet]. 2006
Dec (cited 2017 Mar 20); 12764:1-50. Available from:
http://www.nber.org/papers/w12764
John W.C. Research Design: Qualitative, Quantitative,
and Mix Method Approaches. 4
th
ed. SAGE
Publications: California; 2014. 265 p.
Jonathan S. Metode Penelitian Kuantitatif & Kuantitatif.
1
th
ed. Graha Ilmu: Yogyakarta; 2006. 286 p.
Laure BdP. Ex Ante Moral Hazard and Aticipatory
Behavior: Some Evidence. HEDG Working Papper
[Internet]. 2010 Jul [cited 2017 Mar 23]; -: 1-31.
Availabel from:york.ac.uk/res/herc/hedgwp.
Stanley L, David WHJ, Janelle K. Adequacy of Sample
Size in Health Studies. WHO: England; 1990. 239 p.
Yaohui Dong. Moral Hazard in Prevention and
Treatment: A Reference Dependent Model.
sciencesconf.org:lagv2017:136577.
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
60