dr.

Darius Erlangga, MPH

University of York

Darius Erlangga @2017

 Introduction of JKN in 2014; aiming to reach UHC by 2019
 Social Health Insurance --> relies on voluntary enrolment
 Poor people’s premium is subsidised

 Financial barrier is partially removed. Does it work?

 Randomised studies in developing countries:
 Robyn et al., 2012  positive effect in Burkina Faso
 Levine, Polimeni, and Ramage, 2016  positive effect in Cambodia
 Thornton et al., 2010  no statistically significant effect in Nicaragua
 King et al., 2009  no statistically significant effect in Mexico
 Sheth, 2013  reduced utilisation in India

 Aim of this study:

 Estimating the impact of JKN on healthcare utilisation for both subsidised and voluntary groups.

Darius Erlangga @2017

 Indonesian Family Life Survey
 13 provinces (Sumut, Sumbar, Sumsel, Lampung, Jakarta, Jabar, Jateng, DIY, Jatim, Bali, NTB,
Kalsel, dan Sulbar)  83% Indonesia population
 Panel data
 Comprehensive health variables
 Pre-JKN: IFLS 4 (2007)
 Post JKN: IFLS 5 (2014)  Sept 2014 – March 2015

Darius Erlangga @2017

 Propensity Score Matching and Difference-in-Difference

𝐷𝐷𝑃,𝑁𝑃 = 𝐸 ∆𝑦𝑖𝑡𝑃 − 𝐸 ∆𝑦𝑖𝑡𝑁𝑃

= 𝐸 𝑓 ∆𝑋𝑖𝑡 − 𝐸 𝑔 ∆𝑋𝑖𝑡 + 𝐸 𝐺𝑖1 + ∆𝜃𝑡𝑃 − ∆𝜃𝑡𝑁𝑃 + 𝐸(∆𝜀𝑖𝑡𝑃 ) − 𝐸(𝜀𝑖𝑡𝑁𝑃 )
 𝑓 𝑋𝑖𝑡 = independent variables from treated group
 𝑔 𝑋𝑖𝑡 = independent variables from control group
 𝐸 𝐺𝑖1 = treatment effect
 ∆𝜃𝑡𝑃 & ∆𝜃𝑡𝑁𝑃 = time-specific unobserved factors for treated and control group respectively
𝑃 𝑁𝑃
 𝐸 ∆𝜀𝑖𝑡 & 𝐸(𝜀𝑖𝑡 ) = idiosyncratic unobserved factors for treated and control group respectively
 PSM eliminates the first difference (observable factors); DID eliminates the second difference; no
unobserved factor that is person and time specific
 PSM is chosen over regression method due to its non-parametric nature

Darius Erlangga @2017

 Voluntary group
 Uninsured in 2007, insured under JKN in 2014

 Subsidised group
 Uninsured in 2007, insured under Jamkesmas in 2014 (IFLS still recorded Jamkesmas in 2014 even
though it was integrated into JKN already)
 Control group
 Uninsured in 2007 and still uninsured in 2014

 Excluded: people who had more than one insurance

 People who reported having both jamkesmas and jkn were recorded as subsidised

Darius Erlangga @2017

 Utilisation
 Outpatient
 Proportion of any outpatient visits (binary)
 Total outpatient visits (public + private)
 Inpatient
 Proportion of any inpatient visits in the past year (binary)
 Total inpatient days (public+ private)

Darius Erlangga @2017

 2007 2014

Voluntary Subsidised Uninsured Voluntary Subsidised Uninsured

N = 1,088 N = 3,227 N = 9,686 N = 1,029 N = 3,055 N = 9,125

Outpatient care

Any outpatient visit 15.2% 14.6%* 13.4% 26.6%*** 20.1%*** 18.2%

Number of total visit (all) 0.284*** 0.214 0.193 0.519*** 0.377*** 0.320
Number of total visit (public) 0.046 0.081*** 0.046 0.186*** 0.162*** 0.077

Number of total visit (private) 0.194*** 0.104* 0.120 0.273*** 0.158*** 0.178
Inpatient care

Any inpatient visit 3.9%*** 2% 2.3% 11.4%*** 4.5%*** 2.8%

Number of total visit (all) 0.042*** 0.021 0.026 0.148*** 0.058*** 0.039
Number of total visit (public) 0.017 0.012 0.012 0.085*** 0.040*** 0.018
Number of total visit (private) 0.020** 0.006** 0.011 0.060*** 0.016 0.017
Stars denotes statistical significance for mean difference in comparison with uninsured group in the same year
Darius Erlangga @2017 *=10%; **=5%; ***=1%;
Variables Voluntary Subsidised Control
Mean SD Mean SD Mean SD

Age 10 - 19 0.139*** 0.346 0.092*** 0.092 0.109 0.311

Age 20 - 29 0.334*** 0.472 0.27* 0.270 0.286 0.452
Age 30 - 39 0.246 0.431 0.258*** 0.258 0.227 0.419
Age 40 - 49 0.155 0.362 0.179 0.179 0.174 0.379
Age 50 - 59 0.073*** 0.260 0.105* 0.105 0.117 0.321
Age 60 - 69 0.042** 0.201 0.073** 0.073 0.062 0.240
Age 70+ 0.011*** 0.104 0.024 0.024 0.026 0.160
Gender (1=male) 0.429* 0.495 0.447 0.447 0.456 0.498
1 = Single 0.261*** 0.439 0.151*** 0.151 0.201 0.401
1 = Married 0.704 0.457 0.764*** 0.764 0.716 0.451
1 = Divorced 0.035*** 0.184 0.085 0.085 0.083 0.275
Urban/Rural (1=urban) 0.704*** 0.457 0.400** 0.400 0.423 0.494
Years of education 9.693*** 3.889 6.143*** 6.143
Stars denotes statistical significance for mean difference in comparison with uninsured group in the same year
7.242 4.212
*=10%; **=5%; ***=1%;

Darius Erlangga @2017

Variables Voluntary Subsidised Control
Mean SD Mean SD Mean SD
Asset Index 0.816*** 1.894 -1.093*** -1.093 -0.253 2.170

Number of chronic 0.143 0.491 0.138 0.138 0.154 0.488

condition
Number of acute 2.363*** 2.026 2.146 2.146 2.099 2.062
condition
Any disability 0.014* 0.117 0.011 0.011 0.112 0.091
Depression (1=yes) 0.08* 0.271 0.066 0.066 0.066 0.248

Recipient of 0.131*** 0.338 0.386*** 0.386 0.173 0.378

unconditional cash
transfer
Participation in any 0.212 0.409 0.246*** 0.246 0.197 0.398
community
organisation
Stars denotes statistical significance for mean difference in comparison with uninsured group in the same year
Darius Erlangga @2017 *=10%; **=5%; ***=1%;
 Treatment: Subsidised Voluntary
Outpatient care
Prob. of utilising any outpatient visit in the past month 1.24*** 1.83*** Note: Figures for likelihood are in

(0.08) (0.16) odds ratio while figures for number of

total visits are in incidence rate ratio.
Number of total visits (all) 1.23** 1.82**
Standard errors in parentheses have
(0.09) (0.17)
been adjusted for complex survey
Number of total visits (public) 2.21*** 2.68***
design.
(0.27) (0.38)
* p<0.1; ** p<0.05; *** p<0.01
Number of total visits (private) 0.96 1.76***
(0.09) (0.22)
Inpatient care
Prob. of utilising any inpatient visit in the past year 1.62*** 4.55***

(0.23 (0.61)
Number of total visits (all) 1.41* 4.15***
(0.20) (0.62)
Number of total visits (public) 1.97*** 6.64***
(0.37) (1.30)
Number of total visits (private) 1.01 3.26***
Darius Erlangga @2017 (0.22) (0.69)
 Voluntary Subsidised
ATT SE 95% CI ATT SE 95% CI

1. Outpatient care

Prob. of having outpatient visit 8.41%*** 2.27% 3.96% 12.86% 0.61% 1.48% -2.29% 3.50%

Number of total visit (all) 0.154*** 0.066 0.025 0.283 0.043 0.032 -0.020 0.106

Number of total visit (public) 0.116*** 0.025 0.067 0.166 0.056*** 0.020 0.017 0.096

Number of total visit (private) 0.050 0.055 -0.058 0.159 0.001 0.019 -0.039 0.037

2. Inpatient care

Prob. of having inpatient visit 7.55%*** 1.30% 5.01% 10.10% 1.79%*** 0.58% 0.66% 2.92%

Number of total visit (all) 0.097*** 0.020 0.058 0.136 0.025*** 0.009 0.008 0.042

Number of total visit (public) 0.066*** 0.014 0.038 0.093 0.020*** 0.007 0.007 0.033

Number of total visit (private) 0.035*** 0.013 0.010 0.060 0.006 0.005 -0.004 0.016

Note: ATT is calculated by simply taking the difference between treated (either voluntary or subsidised) and control (uninsured) group. The treated group was matched with the control
group through nearest neighbour matching with n=5 and caliper =0.01. The reported standard errors were calculated by bootstrapping with 600 replications.
* p<0.1; ** p<0.05; *** p<0.01
Darius Erlangga @2017
 Prob. Number of Number of Number of Prob. Inpatient Number of Number of Number of
Outpatient care outpatient visits outpatient visits outpatient visits care inpatient visits inpatient visits inpatient visits
(total) (public) private (total) (public) private

Q1 0.09 0.26* 0.13*** 0.11 0.03 0.07 0.03 0.03

Poorest (0.06) (0.15) (0.05) (0.11) (0.04) (0.07) (0.04) (0.05)

Q2 0.04 0.27 0.14* 0.17 0.07** 0.15** 0.09** 0.06*

(0.07) (0.24) (0.07) (0.23) (0.03) (0.06) (0.04) (0.03)

Q3 0.05 -0.03 -0.02 0.03 0.16*** 0.20*** 0.13*** 0.09***

(0.05) (0.11) (0.05) (0.08) (0.03) (0.05) (0.04) (0.03)

Q4 0.06 0.06 0.14** -0.07 0.04 0.05 0.05** 0.00

(0.05) (0.17) (0.06) (0.16) (0.03) (0.03) (0.02) (0.02)

Q5 0.17*** 0.36*** 0.18*** 0.16* 0.12*** 0.13*** 0.07*** 0.05**

Richest (0.05) (0.11) (0.05) (0.09) (0.03) (0.03) (0.02) (0.02)
* p<0.1; ** p<0.05; *** p<0.01
Darius Erlangga @2017
 Prob. Number of Number of Number of Prob. Number of Number of Number of
Outpatient outpatient outpatient outpatient Inpatient inpatient inpatient inpatient
care visits (total) visits (public) visits private care visits (total) visits (public) visits private

Q1 -0.032 -0.100 -0.007 -0.056 0.017* 0.020 0.018* 0.002

(0.025) (0.061) (0.036) (0.038) (0.010) (0.012) (0.011) (0.004)

Q2 0.086*** 0.193*** 0.098*** 0.078** -0.010 -0.023 -0.003 -0.020

(0.025) (0.059) (0.033) (0.039) (0.012) (0.018) (0.013) (0.013)

Q3 -0.037 -0.014 0.043 -0.039 0.034** 0.044** 0.029* 0.020*

(0.029) (0.067) (0.045) (0.041) (0.015) (0.018) (0.015) (0.011)

Q4 0.042 0.100 0.115** -0.014 0.025 0.057** 0.033 0.025*

(0.037) (0.084) (0.054) (0.055) (0.016) (0.028) (0.024) (0.015)

Q5 -0.038 0.105 0.050 -0.030 0.031 0.069 0.054** 0.022

(0.062) (0.144) (0.073) (0.084) (0.026) (0.047) (0.023) (0.042)

* p<0.1; ** p<0.05; *** p<0.01

Darius Erlangga @2017

Impact by urban/rural area

Voluntary Subsidised
Urban Rural Urban Rural
Prob. Outpatient care 0.102*** 0.036 0.020 -0.003

(0.029) (0.038) (0.022) (0.019)

Number of outpatient visits (total) 0.139* 0.210* 0.121** 0.014

(0.076) (0.123) (0.051) (0.044)

Number of outpatient visits (public) 0.125*** 0.108** 0.095*** 0.031

(0.032) (0.045) (0.035) (0.025)

Number of outpatient visits private 0.028 0.100 0.014 -0.001

(0.060) (0.107) (0.030) (0.027)

Prob. Inpatient care 0.085*** 0.058** 0.020* 0.016**

(0.017) (0.023) (0.011) (0.007)

Number of inpatient visits (total) 0.111*** 0.080** 0.033** 0.018*

(0.025) (0.034) (0.015) (0.010)

Number of inpatient visits (public) 0.073*** 0.052** 0.022* 0.016**

(0.018) (0.023) (0.011) (0.008)

Number of inpatient visits (private) 0.041** 0.033* 0.010 0.004

* p<0.1; ** p<0.05; *** p<0.01
Darius Erlangga @2017
(0.018) (0.020) (0.011) (0.005)
 Overall, JKN had appreciable impacts for both outpatient and inpatient care
 Impact on outpatient care for voluntary group > subsidised group
 Voluntary group might be:
 More affluent / higher socioeconomics status
 More educated  realise the benefit of insurance

 Does not necessarily mean a moral hazard effect because the goal of JKN itself is to promote
easier access to health care
 Those who chose to enrol might have chosen to forego the care had they had no insurance
 Fulfilling the unmet need; Nyman vs Pauli theory
 Unnecessary care? Not clear.

Darius Erlangga @2017

 Limited effect on outpatient care for subsidised group
 Positive effect from our naïve estimator, but PSM-DID analysis only showed positive impact
on total outpatient visits in public facilities
 Likely explanation is the subsidised may increase their consumption, but the control group
also increased their consumption by other means
 Other explanation might be the availability and quality of health facilities
 However, even voluntary group who lived in rural area still showed positive impact

 Voluntary group may be sicker than subsidised group

Darius Erlangga @2017

 Impact on inpatient care is bigger for both subsidised and voluntary group compared to
outpatient care
 Inpatient care is more expensive --> more incentives to enrol to/use the insurance
 For subsidised group, the positive effect is more significant among the wealthier
 More indication of the leakage story
 ‘Non-eligible’ receives the subsidy because of their higher demand of health care

 Inequity issue (the wealthier uses more services while the government subsidy contributes
more to JKN funding)

Darius Erlangga @2017

Category Total enrolled %

Previously Jamkesmas 91,096,147 52.9%

Previously Jamkesda 15,779,685 9.2%

Previously Askes 17,488,147 10.2%

Previously Jamsostek 23,308,717 13.5%

Informal sector 19,439,613 11.3%

Non-employee 5,062,092 2.9%

172,174,401 100.0%

Darius Erlangga @2017

 Encouraging to see positive impact overall
 Inequity issue still remains
 Majority of the funding comes from government (subsidised premium)

 Risk pooling is still not optimum

 Comprehensive enrolment strategy needs to be developed to attract more people to join
 Informal sector is the hardest one; Indonesia should learn from other countries

 More research to explore the moral hazard issue and reason for the limited effect among the
poorest
 Impact on health status is still not clear

Darius Erlangga @2017

Darius Erlangga @2017