INPATIENT CARE UTILIZATION AFTER JKN: A STUDY CASE IN EAST NUSA TENGGARA
Background: Healthcare utilization is a predictor of health status among the population. The issues of its accessibility and equity have been raised, particularly after the government launched JKN (Jaminan Kesehatan Nasional)
Aim: This study aims to analyze the determinants of inpatient care utilization in East Nusa Tenggara.
Method: We used SUSENAS 2019 dataset and carried out descriptive and econometrics analysis to covariates including age, gender, educational level, type of health insurance, employment status, and type of residence.
Result: We found that all covariates analyzed were statistically significant in affecting the probability of inpatient care utilization (p-value<0.005). Different patterns of sociodemographic factors among people in East Nusa Tenggara will affect their rate of inpatient care utilization.
Conclusion: Inpatient care utilization rate is crucial to measure health accessibility and prevent any aggravated morbidity due to delayed treatment. Strategies to increase inpatient care utilization are needed to provide accessible treatment for all and increasing population health status.
Keywords: East Nusa Tenggara, health utilization, hospitalization, inpatient care
Introduction
Since health is one part of individual human rights, its accessibility and utilization become a crucial issue. Healthcare utilization is determined by whether people need and want care, as well as access of care(Sciences & , 2018). Health accessibility includes several dimensions, such as approachability, acceptability, availability and accommodation, affordability, and appropriateness(Pullyblank & , 2023). If health accessibility is usually discussed from a provider perspective, its utilization on the other hand is analyzed from a patient or consumer aspect. The issues about health utilization are raised since accessibility of services does not ensure the rate of its utilization being optimum.
Andersen’s model describes several factors which influence healthcare utilization, such as predisposing factors, enabling factors, and illness level or need factors(Alkhawaldeh & , 2023). Predisposing factors include traits which are pre-exist in individuals such as age, sex, beliefs or faiths, and other demographic factors. Enabling factors such as income, health insurance coverage, and health accessibility make it possible for individuals to seek and utilize health services. Meanwhile, illness levels or need factors are often reflected in perceived illness felt by patients and evaluated illness examined by health professionals.
Inpatient care is defined by OECD as formally admitted to hospitals or other health facilities to get treatment and stays for a minimum one night (OECD Glossary of Statistical Terms - In-patient care). It is often associated with the risk of out-of- pocket payment and catastrophic health expenditure, as a study in Indonesia found that inpatient care tended to contribute the most to high OOP spending among households(Manafe et al., 2021);(Maulana & , 2022).
Jaminan Kesehatan Nasional or JKN is a social health insurance established by the Indonesian government in 2014. Aiming to provide universal health coverage for all citizens, JKN has become the largest national health insurance in the world with more than 220 million citizens and 27 thousand healthcares included in the scheme. JKN plays an important role in ensuring access to health services with certain types of membership based on income and employment status. Formal workers are registered to JKN by the employers, while those categorized as poor and near-poor are included in Subsidized Contribution Recipients or Penerima Bantuan Iuran (PBI)(Maulana & , 2022). JKN has covered treatment for diseases and drugs listed in Indonesia Case Based Groups (INA CBG’s) and Formularium Nasional (Fornas).
East Nusa Tenggara (NTT) consists of many islands such as Flores, Sumba, and Timor with 22 regions. It is one of the provinces in Indonesia with low healthcare utilization rate for both inpatient and outpatient care, as well as primary and secondary healthcare(Ramadani & , 2021). Although nearly 60% of people in NTT had JKN, statistics report found that more than 70% of people did not go to healthcare and received treatment in 2021(Manafe et al., 2021). Most of them preferred to cure themselves, indicating issues in utilizing professional healthcare despite the availability of care and JKN. Therefore, this study aims to analyze factors related to healthcare utilization focusing on inpatient care in East Nusa Tenggara after JKN implementation.
Method
This study uses SUSENAS 2019 dataset to conduct econometric analysis using logit regression. This study included 51,754 individual observations in East Nusa Tenggara. We conducted logistic regression to find the best model which defines the inpatient care utilization. Outcome variable in this study is the likelihood of inpatient care utilization, which varies between 0 and 1. Utilization of inpatient care is influenced by many factors: demographic factors, socioeconomic factors, health service- related factors, factors related to individual health status, and health insurance-related factors(Azimzadeh & , 2019).
We carried out analysis on other covariates such as type of residence (urban or rural), age group, gender, employment (formal or informal), type of health insurance owned, and education. We divided the health insurance types into private insurance, regional insurance (Jamkesda), JKN non-PBI (Peserta Bantuan Iuran), and JKN PBI. JKN PBI is a type of JKN membership which premium paid by the government. Age variable in this study was divided into five groups: group 1 (0-5 years), group 2 (6-11 years), group 3 (12-25 years), group 4 (26-65 years), and group 5 (above 65 years). We also grouped education variable based on its level, which were elementary school, junior high school, senior high school, and diploma/bachelor degree or higher. The empirical model for this study is as follows.
\( \documentclass{article} \usepackage{amsmath} \begin{document} \displaystyle \text{Inpatient}_i = \beta_0 + \beta_1 \text{insurance} + \beta_2 \text{age} + \beta_3 \text{gender} + \beta_4 \text{employment} + \beta_5 \text{education} + \beta_5 \text{residence} + uit \end{document} \)The model explains that inpatient utilization is defined by independent variables including residence, age, gender, employment, education, health insurance ownership, and any other factors that are not included in this study. The confidence interval used in this study was 95%.
Result and Discussion
Population Characteristics
Analyzing the proportion of each category in independent variables, we found that most respondents lived in urban areas with the proportion of 83% compared to rural areas. Furthermore, the proportion of gender and employment type were relatively similar with almost 50% proportion for male and female as well as formal and informal work. The highest percentage of the age group was detected at 25-65 years old (43%), indicating the high proportion of the productive age group. Most respondents finished elementary school as their highest educational level (44%). Respondents
Alkhawaldeh, A. et al. (2023) ‘Application and Use of Andersen's Behavioral Model as Theoretical Framework: A Systematic Literature Review from 2012–2021', Iranian Journal of Public Health [Preprint]. Available at: https://doi.org/10.18502/ijph.v52i7.13236.
Anwar, M.N. and Pujiyanto, P. (2022) ‘Analysis of Socioeconomic Factors on Healthcare Facilities Utilization for Inpatient Care in Indonesia', PREPOTIF : Jurnal Kesehatan Masyarakat, 6(1), pp. 696–709. Available at: https://doi.org/10.31004/prepotif.v6i1.3265.
Azimzadeh, S. et al. (2019) ‘Effective Factors of Utilization of Inpatient, Outpatient, Diagnostic, and Pharmaceutical Health Services: A Systematic Review', Galen Medical Journal, 8, p. e1236. Available at: https://doi.org/10.22086/gmj.v8i0.1236.
Bland, J.S. (2018) ‘Age as a Modifiable Risk Factor for Chronic Disease', Integrative Medicine: A Clinician's Journal, 17(4), pp. 16–19. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6469457/.
Erlangga, D. et al. (2019) ‘The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review', PLOS ONE, 14(8), p. e0219731. Available at: https://doi.org/10.1371/journal.pone.0219731.
Farrell, C.M. and Gottlieb, A. (2020) ‘The Effect of Health Insurance on Health Care Utilization in the Justice-Involved Population: United States, 2014–2016', American Journal of Public Health, 110(Suppl 1), pp. S78–S84. Available at: https://doi.org/10.2105/AJPH.2019.305399.
Feng, G. et al. (2019) ‘Disease spectrum analysis of hospitalized children in China: A study of 18 tertiary children's hospitals', Pediatric Investigation, 3(3), pp. 159–164. Available at: https://doi.org/10.1002/ped4.12144.
Idris, I.B. et al. (2023) ‘Women's autonomy in healthcare decision making: a systematic review', BMC Women's Health, 23, p. 643. Available at: https://doi.org/10.1186/s12905-023-02792-4.
Johar, M. et al. (2019) ‘"Tahukah kamu?”: Analisis Set Data Survei Sosial Ekonomi Nasional (Susenas):', Jurnal Ekonomi dan Pembangunan Indonesia, 19(2), pp. 191–208. Available at: https://doi.org/10.21002/jepi.v19i2.843.
Laksono, A.D., Wulandari, R.D. and Soedirham, O. (2019) ‘Urban and Rural Disparities in Hospital Utilization among Indonesian Adults', Iranian Journal of Public Health, 48(2), pp. 247–255. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556184/.
Lee, J. and Di Ruggiero, E. (2022) ‘How does informal employment affect health and health equity? Emerging gaps in research from a scoping review and modified e-Delphi survey', International Journal for Equity in Health, 21(1), p. 87. Available at: https://doi.org/10.1186/s12939-022-01684-7.
Manafe, A., Sinurat, D. and Sukin, M. (2021) Statistik Kesehatan Provinsi Nusa Tenggara Timur 2021. 53000.2210.
Maulana, N. et al. (2022) ‘How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia', PLOS Global Public Health. Edited by H.H. Farooqui and H.H. Farooqui, 2(7), p. e0000203. Available at: https://doi.org/10.1371/journal.pgph.0000203.
Ministry of Health (2021) Indikator Kinerja Program PPSDMK 1 Periode Tahun 2021 Berdasarkan Aplikasi SISDMK Kemenkes, Tableau Software. Available at: https://public.tableau.com/views/IndikatorKinerjaProgramPPSDMK1-2021/Dashboard1?:embed=y&:showVizHome=no&:host_url=https%3A%2F%2Fpublic.tableau.com%2F&:embed_code_version=3&:tabs=no&:toolbar=yes&:animate_transition=yes&:display_static_image=yes&:display_spinner=no&:display_overlay=yes&:display_count=yes&:language=en-US&publish=yes&:loadOrderID=0 (Accessed: 2 March 2023).
Hassan, N.Z.A.M. et al. (2022) ‘The inequalities and determinants of Households' Distress Financing on Out-off-Pocket Health expenditure in Malaysia', BMC Public Health, 22(1), p. 449. Available at: https://doi.org/10.1186/s12889-022-12834-5.
Mulyanto, J., Kringos, D.S. and Kunst, A.E. (2019) ‘Socioeconomic inequalities in healthcare utilisation in Indonesia: a comprehensive survey-based overview', BMJ Open, 9(7), p. e026164. Available at: https://doi.org/10.1136/bmjopen-2018-026164.
Muttaqien, M. et al. (2021) ‘Why did informal sector workers stop paying for health insurance in Indonesia? Exploring enrollees' ability and willingness to pay', PLOS ONE, 16(6), p. e0252708. Available at: https://doi.org/10.1371/journal.pone.0252708.
Naicker, N. et al. (2021) ‘Health Services Use and Health Outcomes among Informal Economy Workers Compared with Formal Economy Workers: A Systematic Review and Meta-Analysis', International Journal of Environmental Research and Public Health, 18(6), p. 3189. Available at: https://doi.org/10.3390/ijerph18063189.
National Academies of Sciences, E. et al. (2018) ‘Factors That Affect Health-Care Utilization', in Health-Care Utilization as a Proxy in Disability Determination. Available at: https://www.ncbi.nlm.nih.gov/books/NBK500097/ (Accessed: 18 April 2024).
OECD (2008) OECD Glossary of Statistical Terms. OECD. Available at: https://doi.org/10.1787/9789264055087-en.
Osamor, P. and Grady, C. (2018) ‘Factors Associated with Women's Health Care Decision-Making Autonomy: Empirical Evidence from Nigeria', Journal of Biosocial Science, 50(1), pp. 70–85. Available at: https://doi.org/10.1017/S0021932017000037.
Pratiwi, A.B. et al. (2021) ‘Is Indonesia achieving universal health coverage? Secondary analysis of national data on insurance coverage, health spending and service availability', BMJ Open, 11(10), p. e050565. Available at: https://doi.org/10.1136/bmjopen-2021-050565.
Pullyblank, K. et al. (2023) ‘Exploring Multiple Dimensions of Access to and Preferences for Telehealth Use', Telemedicine Reports, 4(1), pp. 348–358. Available at: https://doi.org/10.1089/tmr.2023.0049.
Ramadani, R. et al. (2021) Statistik JKN 2015-2019 Fakta dan Data Capaian Program Jaminan Kesehatan Nasional. (1).
Siswoyo, B.E., Prabandari, Y.S. and Hendrartini, Y. (2019) ‘Kesadaran Pekerja Sektor Informal terhadap Program Jaminan Kesehatan Nasional di Provinsi Daerah Istimewa Yogyakarta', Jurnal Kebijakan Kesehatan Indonesia : JKKI, 4(4), pp. 118–125. Available at: https://jurnal.ugm.ac.id/jkki/article/view/36116.
Tesfaye, G. et al. (2019) ‘Predisposing, enabling and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia', Reproductive Health, 16(1), p. 167. Available at: https://doi.org/10.1186/s12978-019-0829-z.
Wulandari, R.D. et al. (2022) ‘Hospital utilization in Indonesia in 2018: do urban–rural disparities exist?', BMC Health Services Research, 22(1), p. 491. Available at: https://doi.org/10.1186/s12913-022-07896-5.
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