The Impact of National Health Insurance Program on Equity of
Inpatient Care Access in Hospital: The Indonesian Family Life
Surve
y
Data
Wahyu P. Nugraheni
1*
, Hasbullah Thabrany
2
, Budi Hidayat
2
, Mardiati Nadjib
2
, Soewarta Kosen
1
,
Eko Setyo Pambudi
3
, Indang Trihandini
2
, Pujiyanto Pujiyanto
2
, Fachmi Idris
4
1
National Institute of Health Research and Development Ministry of Health,Ministry of Health, Setiabudi, Jakarta,
Indonesia
2
Faculty of Public Health, Universitas Indonesia, Depok, Jakarta, Indonesia
3
World Bank, Jakarta, Indonesia
4
National Health Insurance Corporation (BPJS, Palmerah Barat, Jakarta, Indonesia
Keywords: JKN, Equity of JKN, Equity of inpatient care, Propensity score matching-difference in difference,
Concentration index.
Abstract: Access to health care is a basic right of every resident. The State has an obligation to ensure the health for
every citizen. By implementing the National Health Insurance Program (Program Jaminan Kesehatan
Nasional, JKN). The main objectives of the JKN is to improve access of health services and to improve
egalitarian equity. To evaluate how far the JKN meeting the goal studies are needed. The purpose of this
study is to evaluate the impact of the JKN equity of inpatient care. The design of this research is
retrospective quasi experiment using IFLS data of 2007 and 2014. The sample is IFLS respondents which is
≥ 40 years old. The analysis used Probit, Propensity Score Matching and Difference in Difference. The
results showed that the JKN increase inpatient probability by 115.8%. The study found significant
improvement of concentration index (more equitable) among JKN member. The researcher recommended
acceleration of JKN membership and the availability of hospital beds within reasonable geographical access
to further improve equity.
1 INTRODUCTION
Access to health services is a basic right of every
resident. Access is defined as the opportunity and
ability of a person to obtain the necessary health
services and protection from financial risks (Appiah
et al 2011; Braveman 2006; vans et al 2013).
The
fulfillment of human rights to access to health
services is a means of equitable distribution of
health services that must be accepted by every
resident regardless of economic level (egalitarian
equity).
Egalitarian equity is agreed as the most
important goal in any health system in the world
5
.
Unfairness in access and utilization of health
services will have an impact on health inequalities
(Liu et al, 2012). The disparities in access to health
services occur in almost all countries, including
Indonesia. Access disparities occur in all types of
primary and secondary health services. But in this
study, researchers focused on inpatient disparities
that can impoverish the population, if they do not
have an insurance. One characteristic of complex
advanced health care services is there is a huge cost
for each service that is generally unaffordable for
each family. Out-of-pocket health spending causes a
high gap (there will be no equity).
The facts of inequality in access to health
services in Indonesia are caused by several aspects
such as geographical aspects, limited health
facilities, limited health budget and unequal
distribution of health personnel throughout
Indonesia. The fact of inequality of access in
Indonesia from various aspects mentioned above has
long been a concern of the government. Until the
end of Law number 40 of 2004 mandated to the state
to develop a national social security system which
one of them is health insurance
(Bappenas, 2015).
On January 1, 2014 Indonesia officially launched the
National Health Insurance (JKN) program managed
268
Nugraheni, W., Thabrany, H., Hidayat, B., Nadjib, M., Kosen, S., Pambudi, E., Trihandini, I., Pujiyanto, . and Idris, F.
The Impact of National Health Insurance Program on Equity of Inpatient Care Access in Hospital: The Indonesian Family Life Survey Data.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 268-271
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

by National Health Insurance Corporation (Badan
Penyelenggara Jaminan Kesehatan, BPJS) in
accordance with Act No.24 / 2011.
The National Health Insurance Program (JKN)
is organized nationally with the primary objective to
improve the access to formal health care and to
improve the equity of healthcare. The JKN program
is the state's effort to ensure the fulfilment of basic
public health needs so that they can live healthy,
productive and prosperous lives.
The result of monitoring and evaluation of JKN
by some independent institutions, mass media and
also academics showed that the main problem of
JKN on health service in hospital. Based on the facts
presented above, it is necessary to continuously
evaluate JKN to see how far the goal of improving
access to and equity of health services is achieved.
2 METHODS
This study is an impact evaluation that aims to
measure the effects of the National Health Insurance
(JKN) Program on the equity of inpatient services
access at the hospital. This study used a quasi-
retrospective experimental design. The picture of the
effects of JKN on inpatient care equity is derived
from the measurement of equity utilization of
inpatient services prior to JKN and after the current
JKN program. This study using IFLS (Indonesian
Family Life Survey) data in 2007 (describe
condition before there JKN program) and 2014
(describe condition after JKN program
implemented). The data sets are also supplemented
with Village Potential Survey data (Survei Potensial
Desa, PODES) to complement the description of
health facility variables. The location of this study
covers all areas of IFLS samples in 13 provinces in
Indonesia (IFLS I): in Java, Sumatera, Bali, West
Nusa Tenggara, Kalimantan and Sulawesi.
The sample of this research is IFLS
respondents who have age ≥40 years with sample
number 12,964 respondents. The basic selection of
research samples with age ≥ 40 years is inpatient
services largely due to chronic conditions and
questions related to chronic conditions in IFLS are
only asked on respondents who have age ≥ 40 years.
The analysis used in this research is a combination
of propensity score matching and difference in
difference (PSM-DID), concentration curve and
concentration index
3 RESULTS
The impact of the JKN program on inpatient access
in this study was measured using a combination of
propensity score matching and difference in
difference (PSM-DID) methods. The result of PSM-
DID calculation in this study as follows:
Table 1: Difference of In-patient Utilization in Hospital in Before and After JKN Program
Before JKN After JKN DID
Variable JKN Non-JKN Diff JKN Non-JKN Diff Diff Sig
Mean Mean Mean Mean
Total In-
p
atient 0.029 0.010 0.019 0.053 0.012 0.041 0.021 ***
In-
p
atient in Public Hos
p
ital 0.023 0.006 0.017 0.031 0.006 0.024 0.007 ***
In-
p
atient in Private Hos
p
ital 0.006 0.004 0.002 0.024 0.005 0.019 0.016 ***
Note :significant: p value <0.01
The difference values indicate the magnitude of
the impact of the JKN program on the utilization of
inpatient services in hospitals. The result of the
analysis shows that the JKN program significantly (p
value <0.01) gives the same impact on access of
inpatient service in hospital that is 115,8% (2,1
points). When the analysis was done separately on
each type of hospital (not combined), the PSM-DID
analysis results showed differences in both types of
samples. In the main sample of the study
(respondents ≥ age 40 years) it appears that the JKN
program significantly (p value <0.01) had an effect
on access to inpatient services in private hospitals of
850% (1.6 points) and at government hospitals
41.2% (0.7 points). The results of this study are in
line with several studies conducted in Indonesia as
well as in some countries where health insurance is
significantly able to improve access to health
services. A study of the compulsory health insurance
effect on outpatient equity in Indonesia conducted
by Budi Hidayat, et al (2004) proves that ASKES
insurance for civil servants has a strong positive
impact on access to outpatient services in
government health facilities.
The ultimate goal of this study was to identify
changes in the equity of access to inpatient health
care services in hospitals after 1 year of the current
JKN program. The equity of inpatient health
The Impact of National Health Insurance Program on Equity of Inpatient Care Access in Hospital: The Indonesian Family Life Survey Data
269

services in this study was analyzed using
concentration and concentration index.
Figure 1: Concentration Curve of Hospital’s In-patient
Care in The Before and After Implementing JKN in JKN
and Non-JKN Group
The concentration curve in figure 1 indicates that
the JKN program is able to improve access inpatient
care gaps in hospitals. This can be proven in the
JKN group in 2014 (after the JKN program is
implemented) the position of the curve moves closer
to the equity line compared to 2007 (before the JKN
program is implemented) the curve is below the
equity line. The same thing happened to non- JKN
group, but the biggest change of equity in inpatient
care occurred in JKN group.
The magnitude of the equity value of the JKN
and Non-JKN group curves in the figure 1 can be
measured using the concentration index. Differences
of the equity value of the JKN and Non-JKN groups
are the magnitude of the impact of JKN on the
equity of inpatient care access at the hospital.
Table 2: The Impact of National Health Insurance
Program on Equity Of Inpatient Care Access in Hospital
Variable
JKN Group
Non-JKN
Group
Diff
2007 2014 2007 2014
CI CI CI CI
Total
In-
patient
0.226 0.006 0.263 0.151 (0.108)
In-
patient
Public
Hospital
0.218 (0.055) 0.182 0.104 (0.196)
In-
patient
Private
Hospital
0.293 0.084 0.414 0.205 0.000
Table 2 shows that the impact of the JKN
program on the equity of inpatient care access in
hospitals is -0.108. A negative concentration index
gives meaning that hospitalization services provided
by the JKN program are more utilized by the poor
4 DISCUSSION
This study proved that after 1 year have
implemented, JKN program able to give positive
impact on access of inpatient service in hospital by
115.8% (2.1poin) in the sample of the research with
age ≥40 years old.
The results of this study are in line with several
studies conducted in Indonesia as well as in some
countries where health insurance is significantly able
to improve access to health services. A study of the
compulsory health insurance effect on outpatient
equity in Indonesia conducted by Budi Hidayat et al
(2004) have been proved that ASKES insurance for
civil servants has strongly positive impact on
access to outpatient services at government health
facilities
(Hidayat, et al, 2004). Sparrow et al (2013)
conducted a study on Askeskin in Indonesia, the
results showed that the Askeskin program was able
to improve the utilization of health services in both
outpatient and inpatient services (Sparrow, et al,
2013). Another similar study showed that health
insurance is able to provide economic protection to
civilian civil servants on inpatient and outpatient
health services so that their access to health services
is widespread (Sparrow et al,2013; Szarcwald, CL et
al 2010).
Equal conditions in access to health care for all
residents are an ideal condition expected by each
country (Bonfrer, et al, 2016). Findings from studies
from various countries show that social insurance
can improve the equity of access to health services
(Braveman,2006; David HP et al, 2008; Hidayat,
2004). When access equity can be achieved it will
affect the occurrence of macro efficiency (low health
costs). Efficiency is one of the expected outcomes of
a market mechanism in healthcare (Szarchwald et al,
2010).
The improvement of equity in inpatient
services in hospitals on the findings of this study has
an influence on the main national policies on the
JKN program. Although the access of inpatient
services has not reached a perfect condition of
equity but the findings of this study indicate
scientifically that the JKN program is able to
improve access to in-patient hospital health services
and be able to change the condition of equity
inpatient access to equity is perfect compared to
before the program JKN. Thus it can be said that the
government needs to make continuous efforts to
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
270

expand the participation of JKN so that access
equity can be immediately achieved according to the
main purpose of JKN.
5 CONCLUSION
This study proved that after 1 year have
implemented, JKN program able to give positive
impact on access of inpatient service in hospital by
115.8% (2.1poin) in the sample of the research with
age ≥40 years old.
This study concludes that there has been a
change in utilization of inpatient services after the
JKN program runs 1 year. The impact of the JKN
program on inpatient care access was 115.8% of
samples aged ≥ 40 years. This study also proves that
the JKN program is able to narrow the gap of
inpatient service access in hospitals in all income
groups. Researchers recommend suggesting
accelerated coverage of hospital coverage and
availability of hospitals within adequate geographic
coverage for equity improvement.
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