Brooks Mohamad I, Thabrany Hasbullah, Fox Matthew P, Wirtz Veronika J, Feeley Frank G, Sabin Lora L
Pathfinder International, 9 Galen St, Suite 217, Watertown, 02472, MA, USA.
Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown 3rd Fl, Boston, 02118, MA, USA.
BMC Health Serv Res. 2017 Feb 2;17(1):105. doi: 10.1186/s12913-017-2028-3.
The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia's strategy to achieve the goal of UHC, large investments have been made to increase health access for the poor, resulting in the implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jamkesmas program. In the backdrop of Indonesia's aspiration to reach UHC is the high rate of maternal mortality that disproportionally affects poor women. The objective of this study was to evaluate the association of health facility and skilled birth deliveries among poor women with and without Jamkesmas and explore perceived barriers to health insurance membership and maternal health service utilization.
We used a mixed-methods design. Utilizing data from the 2012 Indonesian Demographic and Health Survey (n = 45,607), secondary analysis using propensity score matching was performed on key outcomes of interest: health facility delivery (HFD) and skilled birth delivery (SBD). In-depth interviews (n = 51) were conducted in the provinces of Jakarta and Banten among poor women, midwives, and government representatives. Thematic framework analysis was performed on qualitative data to explore perceived barriers.
In 2012, 63.0% of women did not have health insurance; 19.1% had Jamkesmas. Poor women with Jamkesmas were 19% (OR = 1.19 [1.03-1.37]) more likely to have HFD and 17% (OR = 1.17 [1.01-1.35]) more likely to have SBD compared to poor women without insurance. Qualitative interviews highlighted key issues, including: lack of proper documentation for health insurance registration; the preference of pregnant women to deliver in their parents' village; the use of traditional birth attendants; distance to health facilities; shortage of qualified health providers; overcrowded health facilities; and lack of health facility accreditation.
Poor women with Jamkesmas membership had a modest increase in HFD and SBD. These findings are consistent with economic theory that health insurance coverage can reduce financial barriers to care and increase service uptake. However, factors such as socio-cultural beliefs, accessibility, and quality of care are important elements that need to be addressed as part of the national UHC agenda to improve maternal health services in Indonesia.
为全民提供优质且负担得起的医疗保健的势头日益强劲，引发了近期的全球全民健康覆盖（UHC）运动。作为印度尼西亚实现全民健康覆盖目标战略的一部分，已投入大量资金以增加贫困人口的医疗服务可及性，从而实施了各种针对贫困和接近贫困人群的医疗保险计划，包括“全民健康保险计划”（Jamkesmas）。在印度尼西亚渴望实现全民健康覆盖的背景下，孕产妇死亡率居高不下，且贫困妇女受到的影响尤为严重。本研究的目的是评估有无参加“全民健康保险计划”的贫困妇女在医疗机构分娩和熟练接生方面的关联，并探究医疗保险参保和孕产妇保健服务利用方面的感知障碍。
我们采用了混合研究方法。利用2012年印度尼西亚人口与健康调查的数据（n = 45,607），对感兴趣的关键结果进行倾向得分匹配的二次分析：医疗机构分娩（HFD）和熟练接生（SBD）。在雅加达和万丹省对贫困妇女、助产士和政府代表进行了深入访谈（n = 51）。对定性数据进行主题框架分析，以探究感知障碍。
2012年，63.0%的妇女没有医疗保险；19.1%的妇女参加了“全民健康保险计划”。与未参保的贫困妇女相比，参加“全民健康保险计划”的贫困妇女进行医疗机构分娩的可能性高19%（OR = 1.19 [1.03 - 1.37]），接受熟练接生的可能性高17%（OR = 1.17 [1.01 - 1.35]）。定性访谈突出了关键问题，包括：医疗保险登记缺乏适当文件；孕妇倾向于在其父母所在村庄分娩；使用传统接生员；距离医疗机构较远；合格医疗服务提供者短缺；医疗机构人满为患；以及医疗机构缺乏认证。
参加“全民健康保险计划”的贫困妇女在医疗机构分娩和接受熟练接生方面有适度增加。这些发现与经济理论一致，即医疗保险覆盖可以减少医疗保健的经济障碍并增加服务利用。然而，社会文化观念、可及性和医疗质量等因素是作为国家全民健康覆盖议程的一部分需要解决的重要因素，以改善印度尼西亚的孕产妇保健服务。
