The Impact of Health Insurance for Children Under 5 Years Old
in Surabaya
Rina Dwi Novita
Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
rinadnov@gmail.com
Keywords: Children, Health insurance, Health facilities.
Abstract: The study was established to examine the impact of various health insurances for children under 5 years old.
This paper uses the descriptive analysis method to get a detailed explanation from online questionnaires.
The population of this study was 217.183 children and the sample consisted of 100 children using incidental
sampling. This paper has evaluated the impact of health insurance on the health care utilisation of children
under 5 years old in Surabaya. The results are that there are still many children who do not have health
insurance. In addition, the parents do not go for treatment in health facilities in accordance with the health
insurance that they have.
1 INTRODUCTION
Health Development is a part of national
development, in relation to the health development
objectives of improving optimal public health.
Jaminan Kesehatan Nasional (JKN) has been
implemented since January 1st, 2014 based on
Undang-Undang Dasar 1945 No. 40/2004 about the
National Social Security System (SJSN) in order to
achieve universal health coverage.
According to the Health Insurance Association of
America, health insurance is defined as coverage
that provides for the payments of benefits as a result
of sickness or injury. It includes insurance for losses
from accident, medical expenses, disability, or
accidental death and dismemberment (Caxton,
2002). The importance of having health insurance is
according to our needs. Having health insurance can
protect from the sudden, unexpected cost of
hospitalization which would otherwise make major
dent into household savings or even lead to
indebtness. Healthcare is increasingly expensive,
with technological advances, new procedures and
more effective medicines that have also driven up
the costs of healthcare. While these high treatment
expenses may be beyond the reach of many, taking
the security of health insurance is much more
affordable. (IRDA, 2007).
Organization of the health services in the era of
JKN covers all health facilities in collaboration with
Badan Penyelenggaraan Jaminan Sosial Kesehatan
(BPJS Kesehatan) including primary health care and
secondary healthcare, where primary health care is
formed of Puskesmas or the equivalent, doctors,
dentists, clinics and hospitals, which must organise
their offered health services in a comprehensive
manner. Health services before the era of JKN
covered many different health facilities. Health
facilities include Jaminan Kesehatan Masyarakat
(Jamkesmas), Jaminan Kesehatan Tenaga Kerja
(Jamsostek), Asuransi Kesehatan (Askes) for civil
servants, pensioners, veterans, independent pioneer
families and Jaminan Kesehatan Daerah (Jamkesda)
which differs between the organiser and other
organisers.
Child health has received a great deal of attention
in all countries. The improvement of children’s
health in low-income countries is challenging
because of nutrition problems and poor health care
services. Children can be more vulnerable to illness.
Poor children have limited access to preventive and
sanitised facilities such as clean water and a flushing
toilet, and it might be easier for them to get diseases
and illnesses.
Members of BPJS Kesehatan including
everyone, including foreigners who work a
minimum of 6 (six) months in Indonesia, which
includes been paying their dues. Non-PBI consists of
civil servants, members of the military, members of
the national police, officials of state, non-
government civil service employees and private
96
Novita, R.
The Impact of Health Insurance for Children Under 5 Years Old in Surabaya.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 96-99
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
employees that have had children who have never
been married or do not have their own income; the
children are still dependant family members.
The benefits of Jaminan Kesehatan Nasional
(JKN) in primary healthcare includes the
administration of the service, promotive and
preventive services, examinations, treatment and
medical consultations, non-specialist medical
measures both operative and non-operative, care
drugs and medical consumable materials, blood
transfusions as needed, and a medical laboratory
investigation and diagnosis at the first level.
Health insurance can improve health, health
insurance certainly increases the quantity of health
care consumed, and many medical interventions
have proven to be greatly beneficial (Levy &
Meltzer, 2008). In this study, we aimed to examine
the impact of various health insurances for children
under 5 years old in Surabaya.
2 METHODS
This study was conducted in Surabaya City, capital
of East Java, the second largest city in Indonesia.
The spread of the questionnaires was conducted over
four days. The questionnaire was presented in the
form of an electronic questionnaire, which is the
Google docs app that can be accessed online via the
internet. The data that was processed was analysed
by the author to get a detailed explanation of the
research. The intended target population in this
study was the parents who had children (0-4 years)
in Surabaya, amounting to 217,183 children (Census
2011).
In this study, there were several factors that
made researchers unable to examine the entire
population; cost, power, and time. The sample
selection technique used was non-probability
sampling which involves techniques that do not
provide an equal opportunity for each element of the
population to be elected as members of the sample.
The researchers also used incidental sampling which
is based on chance for the sample to meet with the
researchers to be used as a sample; if it is deemed
that they were found to be suitable as a data source.
In this study, the researchers used a formula called
the Yamane guidelines as follows:

 
 
(1)


  
 
(2)
 
n = sample size
N = population size
D = looseness of accuracy, because the sample
error which can be tolerated (10%)
3 RESULTS
The study evaluates the number of BPJS cards have
been used particularly for children under 5 years old,
where the card has been used or if the card has been
used properly in terms of the place of treatment, and
the reason why they choose the health service. After
the distribution of the questionnaire concerning the
known kinds of health insurance held by the
respondents, the results were as follows
Table 1: Kinds of Health Insurance Held By The
Respondents
Health Insurance
Number
BPJS Kesehatan
68%
ASKES
21%
Private Health Insurance
7%
Do not have insurance
4%
From the table above, it can be seen that there
are still people who are not covered by the JKN
from when it has been around since 2014. With the
ownership of health insurance, the wage earners
with a biological child not yet 21 years old or 25
years old in a period of study will be certain to take
insurance from BPJS Kesehatan following their
parents. 21% of children in Surabaya do not have
health insurance as in the following table,
Table 2: Number of Children Own Health Insurance
Children's Health insurance
Number
Yes
79%
No
21%
When the children are sick, not all of the parents
get their child to a medical facility in accordance
with the health insurance they had. The respondents'
answers were diverse as in the following table.
The Impact of Health Insurance for Children Under 5 Years Old in Surabaya
97
Table 3: Health Care Facility Used by The Children
Children’s Health Service
Number
According to health insurance
34%
Hospital
21%
Specialist doctor
23%
Private clinic
14%
The reason was an assortment of visiting health
facilities for children who are sick as the following
table
Table 4: Reason to Choose Health Care Facility
Number
34%
17%
7%
28%
2%
12%
4 DISCUSSIONS
Universal health coverage for the entire population
of Indonesia will become a reality later in January
1st, 2019, when all residents will have health
insurance and get the same medical benefits. People
without health insurance are at risk of financial
hardship when in need of health care, which includes
the vulnerable population groups. Children without
health insurance, in a study at Hopkins Children's,
led by Fizan Abdullah, MD, Ph.D. said that ‘If you
are a child without insurance, if you are seriously ill
and ended up in the hospital, you are 60 percent
more likely to die than the sick child in the next
room who has insurance’ (Nolan, et al., 2005).
There might be at least two possible reasons why
some children do not have health insurance. Firstly,
the premium of health insurance can be costly for
poor households. Secondly, health insurance is
sometimes to blame for poor health care services,
and people can find it unhelpful to have health
insurance. For children, a comprehensive package
that covers not only health services but also
developmental services, such as rehabilitation
services that help children attain, maintain, or
improve skills to maximise their function, is ideal.
In addition, the coverage of health insurance
participants who choose healthcare did not
correspond with the registered health facilities have
also become a concern in this study. In providing
health care to its participants, BPJS Kesehatan
applies what is known as a referral system. This
system has been summarised in the terms and
conditions for the participants of BPJS Kesehatan
who want to get healthcare. If sick, the health
facilities wherever they go are free or wherever the
patient wants. It can be a hospital, Puskesmas, or
clinic. However, it does not mean that the patients
free to choose the health facility. They need to know
whether the insurance company has worked together
with a given health facilities or not.
BPJS Kesehatan has a different system. The
healthcare provided is divided into three levels:
Primary Healthcare which is the health service first
attended by BPJS patients who want treatment, such
as Puskesmas, clinics, or a general practitioner.
Then, there is the Secondary Health care: this is a
continued health service after receiving a referral
from Primary Healthcare conducted by a specialist
or dentist. Tertiary Healthcare is the last advanced
health service if Secondary Health care cannot
handle the patient, such as the main clinic or
equivalent, public hospitals, and speciality hospitals.
The objective is keeping health care carried out in
stages. In practice, secondary healthcare will only be
granted on the basis of a reference given by primary
healthcare. Then, tertiary healthcare will be provided
on the basis of a referral from secondary healthcare.
Primary health care is the starting gate for
participants of BPJS Kesehatan to obtain health
care. BPJS Kesehatan patients are required to come
to primary healthcare if they have health problems
and want to get treatment. If after checking it is
necessary to be referred, the doctor will be made a
referral to a specialist or another hospital. In the
BPJS system, the patients choose the primary
healthcare that they want to go (such as Puskesmas,
or a public clinic).
However, based on this study, as many as 66%
of respondents did not bring their children to
primary healthcare but to other health facilities such
as hospitals, clinics, specialist doctors, and others.
The reason also varies including easier access, cost,
already being a subscriber to the health service, good
quality of service, and a recommendation from the
workplace.
Regarding the quality of service, the patient
perception of quality of service is associated as
being between expectation and reality. It is, as stated
by Bustami (2011), the ratio of the patient to
reliability, responsiveness, assurance, empathy,
physical appearance good facilities and the nursing
services expected. When the service is obtained in
accordance with the expectations of the patient, the
patient's perception of the quality of hospital
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
98
services going to be good. Otherwise, if the service
received does not match the expectations of the
patient, the patient's perception of the quality of
hospital services is going to be bad.
In addition, the cost of health care which is
cheaper, speedier and more accurate in the delivery
of services is one of the factors that affects the
timing or duration of treatment for patients.
The utilisation of healthcare services is related to
public trust in a health institution. When people say
they would take advantage of health care services,
they have to consider the quality that is to be
obtained, the facilities accepted and the cost to
obtain the health care services.
Health insurance is a powerful predictor of
children’s degree of access to and use of primary
care, including such aspects as entry into the
healthcare system, identification of a regular
clinician, level of satisfaction with care, and the
amount of physicians’ service received. The effect
of insurance remained substantial and statistically
significant even after we controlled for several
potentially confounding variables, such as family
income and children’s health status (Newacheck, et
al., 1998).
5 CONCLUSIONS
This study help provide a picture of children’s health
insurance ownership and their utilization. Health
insurance for children has been an effective program
providing comprehensive coverage and financial
protection. It has also helped to reduce the
disparities in health coverage and care that affects
low-income children. But there are still many
children who do not have health insurance. In
addition, the parents do not go for treatment to
health facilities in accordance with the health
insurance listed for several reasons such as easier
access, cost, already being a subscriber to the health
service, good quality of service, and following a
workplace recommendation. Suggestions to the
BPJS Kesehatan are for them to disseminate the
flow of health service at BPJS Kesehatan, so that the
vision of BPJS Kesehatan that Universal Health
Coverage 2019 seeks to complete can be achieved.
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