Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis

Background Reducing inequality in maternal, neonatal and infant mortality
are key targets in the Sustainable Development Goals. This study is the first to
evaluate the impact of Indonesia’s national health insurance scheme, Jaminan
Kesehatan Nasional (JKN), on access to maternal health services by sociodemographic
status.
Methods: Using data from the 2017 Indonesia Demographic and Health Survey
(IDHS) on women with live births in 2016-2017, we conducted propensity
score matching (PSM) analysis to evaluate the association of JKN enrollment on
the following maternal health care utilisation outcomes: (1) at least four antenatal
care (ANC4+) visits; (2) ANC4+ visits and received essential components
of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal
care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the
national level and by economic subgroup and region of residence. Additionally,
we investigated the potential negative impact of JKN on access to maternal
health services among the uninsured population by looking at trends over time
using data from the 2012 and 2017 IDHS.
Results Of the 5429 women who had recently given birth, 61% were insured
by JKN in 2017. After matching treated and untreated women on key sociodemographic
characteristics, enrollment in JKN was associated with a higher
prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI) = 4.8-
9.39); ANC4+ visits and received essential components of ANC (5.6%, 95%
CI = 3.3-7.9); skilled birth attendance (3.0%, 95% CI = 1.5-4.5; facility-based
delivery (10.2%, 95% CI = 7.5-12.7); PNC (4.0%, 95% CI = 2.2-5.7); PNC with
skilled provider (4.5%, 95% CI = 2.6-6.5). Effect sizes were larger among the
poor and those living in less-developed areas, such as Eastern Indonesia and
Sulawesi, except for at least ANC4+ and received clinical components.
Conclusions Expansion of health insurance coverage was associated with reductions
in sociodemographic inequalities in access to maternal health services
in Indonesia. However, large differences in utilisation persist across regions and
by economic subgroup. Accelerating progress toward universal health coverage
may reduce health inequalities in other low and middle-income countries