Has Indonesia’s National Health Insurance Scheme Improved Family Planning Use?

Introduction

Background

Indonesia has made great progress in improving access to family planning (FP) services over the last three decades.

Beginning in 1976, under President Suharto, contraceptives were subsidized by the government and provided free of

charge, which increased public demand for the commodities. In 1987, the Government of Indonesia made eorts to

increase the private sector’s role in supplying FP services under the KB Mandiri (self-reliant) FP program.

Under the

“Blue Circle” campaign, the Government of Indonesia promoted use of FP services through private providers and

supplied these providers with contraceptives, leaving clients responsible only for covering the cost of services. Between

1987 and 1991, the percentage of FP users who received services from private sources increased from 12% to 22% while

the percentage of users who paid a fee for FP services increased from

36% to 62%.

The government’s eorts were successful in including

the private sector in addressing FP needs while instituting a norm of

consumers paying for FP services out-of-pocket in Indonesia.

Between 1976 and 2002, the total fertility rate (TFR) decreased from

5.6 to 2.6 lifetime births per woman in Indonesia.

Estimates for 2015

indicate that unmet need for contraception is low, at 11%.

iii

Data from

Indonesia Demographic and Health Surveys (IDHS) over time highlight

improvements in modern contraceptive prevalence rate (mCPR)

between 1987 and 2012 (see Figure 1). However, recent data indicates

that mCPR progress has stalled, decreasing from 57.9% in 2012 to

57.1% in 2017 among married Indonesian women.

Family Planning within National Health Insurance in Indonesia

In 2014, Indonesia launched Jaminan Kesehatan Nasional, or JKN, a national health insurance program that aims

to achieve universal health coverage (UHC) by 2019. The central purpose of the JKN scheme is to address existing

inequities in access to healthcare, with particular emphasis on ensuring that the poor and near-poor can access

quality care without facing ﬁnancial hardship. The beneﬁt package under JKN is a “negative list” whereby services must

be explicitly excluded to be considered not covered by the scheme. FP services are not explicitly excluded, though

contraceptive commodities for FP are not covered in practice under JKN reimbursements to primary or secondary

facilities. All FP service delivery costs are otherwise covered by JKN and reimbursed to providers in various ways.

Under Indonesia’s decentralized health system, both national and local government entities procure commodities

for FP, though this responsibility appears to be shifting to the latter. But much remains uncertain regarding how local

governments plan for, quantify, and submit procurement orders for FP commodities and deﬁne which population

groups they intend to cover.

Multiple agencies are involved in the oversight and provision of FP services, including the National Population and

Family Planning Board (Badan Koordinasi Keluarga Berencana Nasional, or BKKBN), the Ministry of Health (MOH), and

the national health insurance agency (Badan Pelaksana Jaminan Sosial-Kesehatan, or BPJS-K) that manages JKN.

BKKBN’s central role is to develop integrated programs across government sectors to meet the goals of the 2015–

2019 National Medium Term Development Plan (Rencana Pembangunan Jangka Menengah Nasional, or RPJMN) with

May 2018

Has Indonesia’s National Health

Insurance Scheme Improved

Family Planning Use?

Authors: Lyubov Teplitskaya, Rebecca Ross, and Arin Dutta

Percentage using a

modern method

10%

1987 1992 1997 2007 2012 2017

20%

30%

40%

50%

60%

70%

2002

Figure 1. mCPR among Indonesian

married women in IDHS

relation to FP (see Box 1). Some overlap exists between the MOH

and BKKBN in FP service provision responsibility, in part because

the MOH manages a youth reproductive health program alongside

BKKBN’s eorts to increase FP coverage among adolescents.

BPJS-K is responsible for covering all FP service delivery

reimbursements to providers for long-acting reversible methods,

permanent methods, FP counseling, and other sexual and

reproductive health services, as well as short-acting FP commodities

such as pills and condoms (see Table 1). Until recently, BKKBN

was responsible for purchasing intrauterine devices (IUDs) and

injectables and coordinating these purchases with BPJS-K; this

responsibility will soon shift to local governments.

Challenges Surrounding Family Planning Under JKN

An Indonesia case study from 2016 indicated the potentially challenging nature of coordinating the many players

responsible for FP service provision in Indonesia with relation to JKN.

Adequate coordination between BPJS-K

and BKKBN is needed to ensure FP service availability—for example, BKKBN was responsible for IUD and injectable

commodity procurement while BPJS-K has been responsible for payment of most individualized FP services. In

addition, coordination between BKKBN, local government, and health providers is needed to ensure that supply-side

constraints do not occur at the provider level. Box 2 summarizes the challenges related to FP service provision and

coordination noted in the literature.

Although FP services are oered at all healthcare levels, according to the Ministry of Health, most (46%) of BPJS-K-

contracted providers at the primary level consist of public centers (puskesmas). Currently, BPJS-K does not directly

contract with private midwives because they do not typically oer the full spectrum of primary healthcare services

Box 2: Summary of FP Challenges in Indonesia

• Coordination between BKKBN, MOH, and BPJS-K on FP services and reducing unmet need

• Coordination between BKKBN, local government, BPJS-K, and health providers on FP commodity needs

• Limitation of FP services to cohabiting couples in Indonesia

• Limited knowledge of the inclusion of FP services in JKN beneﬁts packages

• Inadequate capacity of public and private facilities to provide quality FP services

• Preference of midwives to practice in urban areas/lack of sucient incentivization for healthcare providers to

work in the poorest rural areas

• Limited number of BPJS-K-contracted private providers

• Reliance on FP services at uncontracted private facilities leading to out-of-pocket payments

• Ineective referral mechanisms

Sources: Authors; Avenir Health (2016); Ensor et al. (2009); World Bank Group (2016).

Box 1: BKKBN’s Role

1. Purchase FP commodities, speciﬁcally

IUDs and injectables, in coordination

with BPJS-K

2. Coordinate with local government

3. Promote FP programs to young people

4. Increase FP coverage through various

means, including mobile provision of

FP services and increasing FP coverage

among the poor

Table 1: Summary of FP Services Covered Under JKN

Services covered by primary healthcare facilities Services covered by hospitals

Capitation

• FP counseling

• Sexual and reproductive health services

• Other FP commodities such as pills and condoms

Fee-for-service*

• Insertion and/or removal of IUD/implant

• Injectables

• Treatment for FP complications

• Tubectomy/vasectomy

INA-CBGs**

• Post-partum sterilization

• Male sterilization

* Also referred to as “non-kapitasi” (non-capitation) fees, **INA-CBGs: Indonesia case-based groups

at their clinics.

v, 1

Data from the Ministry of Health indicate that there are an estimated 163,541 midwives in Indonesia,

constituting 16.3% of health personnel in 2016, with many leading their own clinics. These individual practitioners do

not typically employ electronic record keeping. From an administrative perspective, this lends to diculties in BPJS-K’s

ability to feasibly directly contract with midwives. Additional evidence indicates that midwives are not appropriately

incentivized to practice in rural areas, preferring to practice in urban areas for both ﬁnancial and non-ﬁnancial reasons.

These issues are particularly problematic given that many Indonesian women, particularly the poor and those who

reside in rural areas, continue to access FP services through private sector midwives and pay out-of-pocket for such

services. This reliance on private providers for FP services extends beyond poor and rural—as of 2009, an estimated

40% of all women rely on private sector providers for FP services.

vii

From anecdotal sources, the capitation payments

currently instituted by BPJS-K are discouraging wide private primary provider involvement in the scheme.

Other challenges concern quality and supply of FP services at the facility level. Findings from the 2014 Indonesia Family

Life Survey noted deﬁciencies in the quality of FP services provided at both public and private facilities. An estimated

80% of puskesmas lacked a single sta member trained in FP services within the previous two years and an estimated

40% of private clinics lacked combined oral contraceptive pills while 20% lacked injectable contraceptives.

viii

Given the limited evidence available on trends in FP coverage since JKN’s introduction, this brief explores mCPR

and modern method mix over time using household survey data. Although IDHS and surveys such as Performance

Monitoring & Accountability 2020 (PMA2020) have explored mCPR and method mix by wealth quintile, such analyses

have not disaggregated these measures by insurance status. As part of the Government of Indonesia-led JKN

Comprehensive Assessment coordinated by the National Team for the Acceleration of Poverty Reduction (TNP2K) with

support from the U.S. Agency for International Development (USAID)-funded Health Policy Plus (HP+) project, this

analysis focuses on these disaggregated measures by insurance status, socioeconomic status (SES), and island grouping

using Indonesia’s National Socioeconomic Survey (Susenas) data. This approach allows for annual tracking of FP trends

over time, and before and after and after JKN. The study provides insight to the key policy question of whether JKN has

improved use of key interventions in Indonesia—speciﬁcally FP services—in the three years since its launch.

Methodology and Data Sources

We used Susenas datasets to examine mCPR and modern method mix prior and subsequent to JKN implementation,

and analyzed these measures using 2015 PMA2020 data. We expanded upon previously published PMA2020 data

analysis by exploring locations where modern contraceptive methods were procured by insured and uninsured FP users

and examined the average amount paid for FP services by insured and uninsured users. Table 2 further elaborates on

data sources, years, and key variables used in this analysis.

Results

Has utilization of FP services in Indonesia changed since 2011?

The mCPR progress has plateaued in recent years.

Susenas and IDHS results indicate that mCPR progress has stagnated in recent years. As Figure 2 shows, according to

Susenas, the mCPR among married women decreased from 50.2% in 2014 to 44.9% in 2016. This data is lower than the

rates found in PMA2020 data for 2015 (59.3%) and IDHS data for 2017 (57.1%).

Although BPJS-K does not directly contract midwives, there are three ways in which they may receive JKN funding. (1) Midwives can be staff within a BPJS-K-

contracted primary care facility; (2) they can develop an agreement with a BPJS-K-contracted primary care facility to have patients referred to them, and are paid

non-kapitasi fees from the contracted facility once they provide the services; (3) they can also hire a doctor to provide the full package of primary care services in

their clinics, thereby allowing them to be eligible for BPJS-K to contract with their facility directly.

Table 2: Summary of Datasets and Key Measures

Dataset Years Key Measures

Susenas 2011–2016 • mCPR

• Method mix (permanent, long-acting reversible, and short-acting methods)

PMA2020 2015 • mCPR

• Method mix (permanent, long-acting reversible, and short-acting methods)

• Amount paid for FP services at last FP visit

• Modern method source mix (public facility, private facility, or other [through

friends/relatives, at a shop, or other])

BPJS-K

INA-CBG

2014–2016 • JKN expenditure on male sterilization and female sterilization following delivery

• Male sterilization and female sterilization caseload through JKN

Rich married women use long-acting and permanent

contraceptive methods at much higher rates than do

other SES groups.

Use of long-acting reversible contraceptive methods

is increasing over time for all SES groups in Indonesia,

though a signiﬁcantly higher proportion of rich married

FP users use permanent and long-acting reversible

contraceptive methods as compared to their poor,

near-poor, and middle-income counterparts (see Figure

3). Although these groups used short-acting methods at

rates much higher than the rich, the utilization of short-

acting methods has decreased between 2011 and 2016

nationwide. 2015 PMA2020 data substantiates these

general trends in method mix by wealth quintile.

Research incorporating data from twenty countries has shown that wealthier women are more likely than poorer

women to use long-acting and permanent methods in place of short-acting methods.

Common reasons for using

short-acting methods include ease of access, lower cost, privacy, and freedom to discontinue use without involving a

health provider.

These reasons may help to explain the higher use of short-acting methods among poor Indonesian

women given the prevalent use of FP services in the private sector. If poor women prefer to seek FP services in the

private sector and cost is a factor, they are more likely to seek out lower-cost FP services, which mainly consist of short-

acting methods.

Has use of FP services changed since JKN

implementation?

The mCPR declined for both insured and uninsured.

Susenas household survey data reveals that mCPR

had been increasing among the insured prior to 2014

and began to decline for both uninsured and insured

married women following JKN implementation (see

Figure 4). The data also show that with the exception

of one year (2013), mCPR is consistently higher

among the uninsured compared to the insured.

Trends indicate JKN is more important for FP use

among poor women compared to rich women.

Since JKN implementation, mCPR has consistently

decreased among all SES groups, though the trend is most pronounced for insured rich women (see Figure 5). The

mCPR among insured rich women decreased by 16.6% from 2011 to 2016, whereas mCPR among insured poor women

2011 2012 2013 2014 2015 2016

25%

20%

15%

2011 2012 2013 2014 2015 2016

10%

rich middle near-poor poor

100%

80%

60%

20%

40%

2011 2012 2013 2014 2015 2016

Data source: Analysis using 2011–2016 Susenas data

Figure 3: Shifts in method mix nationwide among married women from 2011—2016, by SES

Use of permanent methods Use of long-acting methods Use of short-acting methods

Percentage using

modern method

55%

50%

45%

40%

2011 2012 2013 2014 2015 2016

Insured Uninsured

Figure 4: mCPR among insured and uninsured

married women

Data source: Analysis using 2011–2016 Susenas data

Percentage using a

modern method

10%

2011 2012 2013 2015 2016

20%

30%

40%

50%

60%

2014

Susenas

49.4%

50.2%

50.4%

50.2%

46.0%

44.9%

IDHS PMA2020

Figure 2. Trends in mCPR among married women,

2011–2017

decreased by 5.7% during the same period. The

mCPR is signiﬁcantly higher among the insured

poor compared to the insured rich throughout

the study period, and the gap widens between

2011 and 2016: in 2011, mCPR for the insured

poor was 48.6% compared to 43.4% (a 12%

dierence); by 2016, mCPR for the insured

poor was 46.0% compared to 36.2% (a 21%

dierence). These results indicate that JKN

insurance coverage may be more important for

FP use among the poor than the rich.

Trends indicate JKN is important for

insured women’s use of long-acting and

permanent methods.

Insured married women in Indonesia use permanent and long-acting reversible methods at higher rates compared to

uninsured married women (see Figure 6). Our Susenas analysis highlights an increase in use of permanent methods by

insured FP users after 2015 and a steady increase in use of long-acting reversible methods among insured FP users after

2013. The data likewise reveals a steady decline in insured married women’s use of short-acting methods since 2013.

These results suggest that JKN coverage may be important for insured women’s access to long-acting and permanent

methods of contraception.

Method mix trends for the insured compared

to the uninsured are consistent by SES, as

seen previously in Figure 3. For example, the

insured poor use short-acting methods at lower

rates compared to the uninsured poor, and

use of short-acting methods for the insured

poor continues to decline following JKN

implementation. Similarly, the insured rich use

long-acting reversible methods at higher rates

than the uninsured rich. These ﬁndings bolster

the ﬁnding that JKN insurance may serve as a

factor inﬂuencing method mix in Indonesia.

Method mix is improving by island group,

particularly in Eastern Indonesia.

Our analysis also explored FP trends by island

group (see Figures 7 and 8). We hypothesized that FP use may dier by geographical location and other inﬂuences, such

as supply-side factors. We found that mCPR is consistently highest in Kalimantan, the island grouping with the highest

55%

50%

45%

40%

2011 2012 2013 2014 2015 2016

rich middle near-poor poor

Percentage using

modern method

Figure 5: mCPR among insured married women, by SES

Data source: Analysis using 2011–2016 Susenas data

90%

85%

80%

70%

65%

2011 2012 2013 2014 2015 2016

75%

2011 2012 2013 2014 2015 2016

15%

10%

2011 2012 2013 2014 2015 2016

All married FP users Insured women Uninsured women

Figure 6: Method mix among married FP users, by insurance status

Data source: Analysis using 2011–2016 Susenas data

Use of permanent methods Use of long-acting methods Use of short-acting methods

70%

50%

20%

2011 2012 2013 2014 2015 2016

Java

Kalimantan

10%

Eastern Indonesia

Sumatra

Sulawesi

30%

40%

60%

Percentage using

modern method

Figure 7: mCPR among JKN-insured married women by

island grouping

use of short-acting methods and lowest use of long-acting and permanent methods. By contrast, mCPR is lowest in

Eastern Indonesia, where use of long-acting methods has increased and use of short-acting methods has signiﬁcantly

decreased since 2013. These changes in method mix may be the result of community-level initiatives, such as the

Improving Contraceptive Method Mix (ICMM) Program, which have been implemented throughout Eastern Indonesia

to improve uptake of long-acting and permanent methods of contraception.

Following JKN implementation, mCPR

decreased in Java to the levels seen in Sumatra. Use of permanent methods is highest in Java, where more than half

of Indonesians live. This method mix may be due to improved access to a variety of healthcare facilities that oer FP

services in Java.

Insured women obtain modern contraceptive methods at

public facilities at greater rates than do uninsured women.

PMA2020 data highlighted the source mix for married

Indonesian women in 2015 (see Figure 9). The results

indicate that a greater proportion of insured married women

acquire modern methods at public facilities (18%) compared

to uninsured women (13%). However, the most prevalent

modern method source was private facilities, where 55%

of insured and 63% of uninsured women obtained their

contraceptive methods in 2015.

Analysis of PMA2020 data indicated that, on average, the

wealthiest quintile (Q5) paid the most out-of-pocket for FP

services at their last visit (IDR 34,967, or US$2.59) whereas

the poorest quintile (Q1) paid the least (IDR 23,492, or

US$1.74). On average the insured wealthiest quintile paid

more than three times the cost for long-acting reversible

methods compared to the insured poorest quintile (see

Table 3). The uninsured poorest quintile paid more out-of-

pocket for short-acting and long-acting reversible methods compared to the insured poorest quintile. In the PMA2020

dataset, only one observation was noted for out-of-pocket payments made for permanent services.

2011 2012 2013 2014 2015 2016

25%

10%

15%

20%

95%

85%

80%

70%

65%

2011 2012 2013 2014 2015 2016

75%

90%

Java Sumatra Kalimantan Sulaweisi Eastern Indonesia

Figure 8: Shifts in method mix nationwide among married women from 2011–2016, by island group

Use of permanent methods Use of long-acting methods Use of short-acting methods

100%

50%

All Insured Uninsured

Public facility Private facility Other

26%

59%

15%

27%

55%

18%

25%

63%

13%

Figure 9: Modern method source mix among

married women

Data source: Analysis using 2015 PMA2020 data

Table 3: Average Amount Paid for FP Services at Last Visit (in Indonesian Rupiah)

Method mix

Insured Uninsured

Q1 Q5 Q1 Q5

Short-acting 20,525 21,329 21,540 20,803

Long-acting reversible 84,004 352,729 94,406 348,602

Permanent -- 250,000 -- --

Data source: Analysis using 2015 PMA2020 data

JKN expenditure on permanent methods at the

hospital level decreased between 2014 and 2016.

JKN expenditure on permanent methods decreased

from 2014 to 2016 and the majority was spent on female

sterilization following vaginal labor at the hospital level

(see Figure 10). Only four cases of male sterilization

were recorded between 2014 and 2016 while a total

of 76 outpatient and 10,849 inpatient cases of female

sterilization following labor took place during the same

period.

Analysis of JKN expenditure on female sterilization

compared to the share of female reproductive-aged

women by island grouping reveals that costs are

not equitable across islands (see Figure 11). Sulawesi

only accounts for 7% of Indonesia’s reproductive-

aged women but constitutes between 19% and 64%

of total JKN expenditure on post-partum sterilization

costs. Compared to Sulawesi, expenditure in Java and

Kalimantan is still over-represented compared to its

share of the reproductive-aged female population,

but by a smaller amount. By contrast, expenditure in

Eastern Indonesia shifted from being over- to under-

represented in the same time period. These shifts cannot

be interpreted as inherently positive or negative—for

instance, a shift toward under-represented expenditure

as a share of population could indicate greater use of

services at the primary healthcare level (data that are not

captured in this analysis).

Discussion and Conclusions

Although mCPR is quite high in Indonesia, echoing the

data captured in the IDHS, our results ﬁnd that mCPR

is decreasing, indicating stalled FP progress. Since JKN

was launched in 2014, mCPR has been higher among

the uninsured compared to the insured. Many FP users

face far distances to and long wait times at puskesmas. As a result, many continue to access FP services in clinics

through private providers, which may not be BPJS-K-contracted. This arrangement may help to explain the discrepancy

in mCPR between the insured and uninsured. Furthermore, in our analysis of average mCPR by SES, we found that

the mCPR decrease was larger for the insured rich compared to the insured poor. These results indicate that being

covered by JKN insurance may be more important for accessing FP services among the insured poor compared to the

insured rich.

Short-acting methods have historically been most commonly used in Indonesia; however, our results highlight a shift

in method mix since JKN implementation among the insured toward long-acting and permanent methods. Given that

price can be a factor in the decision to choose short-acting methods, this shift in method mix indicates that JKN may

be alleviating some of the ﬁnancial burden women face when accessing long-acting and permanent methods.

Our analysis by island grouping indicates that geographical disparities for FP access remain, with mCPR lowest in the

most rural island grouping, Eastern Indonesia. These geographical inequities highlight the possibility of other barriers

existing in the health system, such as lack of adequately trained health personnel and/or health facilities that do not

provide a broad method mix of FP services. Given that private midwives are not incentivized to work in rural areas,

higher FP uptake by more urban island groupings such as Java may at least be partially explained by this supply-side

deﬁciency. However, improvements in method mix in Eastern Indonesia highlight that community-level initiatives can

be eective in increasing long-acting and permanent method uptake.

2014 2015 2016

Female sterilization Male sterilization

30.2

25.9

29.7

Indonesian Rupiah, billions

Figure 10: JKN expenditure on permanent

methods at the hospital level

Data source: Analysis using BPJS-K data

40%

20%

-20%

-40%

-60%

2014 2015

2016

Java Sumatra

Kalimantan Sulawesi

Eastern

Indonesia

Figure 11: Share of JKN post-partum sterilization

costs at the hospital level compared to share of

female population, by island

Data source: Analysis using BPJS-K data

Health Policy Plus (HP+) is a ve-year cooperative agreement funded by the U.S. Agency for International

Development under Agreement No. AID-OAA-A-15-00051, beginning August 28, 2015. The project’s

HIV activities are supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). HP+ is

implemented by Palladium, in collaboration with Avenir Health, Futures Group Global Outreach, Plan

International USA, Population Reference Bureau, RTI International, ThinkWell, and the White Ribbon

Alliance for Safe Motherhood. Funding for TNP2K was partially supported by the Australian Government.

This publication was produced for review by the U.S. Agency for International Development. It was

prepared by HP+. The information provided in this document is not ofcial U.S. Government information

and does not necessarily reect the views or positions of the U.S. Agency for International Development

or the U.S. Government.

Health Policy Plus

1331 Pennsylvania Ave NW, Suite600

Washington, DC 20004

www.healthpolicyplus.com

policyinfo@thepalladiumgroup.com

To improve FP access through JKN, policymakers and health systems decision-makers should consider the

following recommendations:

• Prioritize facilitating the inclusion of more private providers as BPJS-K-contracted providers

• Improve coordination between BKKBN and BPJS-K as well as between BKKBN and health providers to ensure

the availability of FP methods at all health facilities

• Ensure necessary health facilities and adequately trained health providers are available nationwide, particularly in

the most geographically disadvantaged island groups such as Eastern Indonesia

Acknowledgments

This brief was developed as part of the government-led JKN Comprehensive Assessment, conducted from 2016–2018,

coordinated by TNP2K with technical assistance from HP+. The assessment would not have been possible without

continuous support of Prastuti Soewondo of TNP2K and her team. The brief merited from data analysis contribution

by Thomas Fagan of HP+. Authors greatly appreciate the review by Prastuti Soewondo, and Edhie Rahmat and Zohra

Balsara of USAID.

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