Contributory Factors to the Inability of the Poor to Access National Health Protection: A Case Study in Waingapu, Sumba Timur District, Indonesia

Millions of poor Indonesians still need access to Indonesia's National Health Protection (NHP). The study investigated barriers making NHP inaccessible for the poor in Waingapu, Sumba Timur, Indonesia.  We used a qualitative approach to identify the contributing factors to why NHP was inaccessible for some populations. A total of 30 residents of Waingapu who attended healthcare in two hospitals and five Community Health Centers were recruited using convenience technic. Twenty residents participated in the semi-structured interview, while ten engaged in casual conversations. We also interviewed three heads of community groups and three health cadres for comparative information. Questions have been developed to guide the interviews and casual conversation. The interviews were audio-taped and transcribed while intensive note-taking was performed during the informal discussion or the conversation was narrated immediately after the talks ended. The information was inductive, analyzed, and coded to produce common information among the participants. The data analysis revealed the factors that contributed to the failure of the resident to enroll in the NHP, such as lack of information about the registration, poor socialization of the program, the ignorance of village officers, unaffordability, and confusion about the parties responsible for the registration. The study concluded that poor people were still vulnerable to access free coverage and healthcare from the NHP. The stakeholders of the NHP, especially the local management of NHP and local government, need to urgently and effectively educate the commoners about the mechanism, benefits, and contribution to the NHP to ensure equity and equality in accessing quality healthcare.

1. INTRODUCTION

The World Health Organization (WHO) campaigns for implementing Universal Health Coverage (UHC). The UHC aims to ensure the access of the whole population of a country to the full range of essential and quality healthcare needed and avoid financial catastrophe when seeking medication¹¹. UHC is the answer for people in Low-Income Countries (LICs) and Lower-Middle Developing Countries (LMICs) to access affordable and quality healthcare. The governments must provide free health protection and improve access to quality, equality, and equity healthcare²². Poverty is strongly associated with poor health, and medical costs draw the poor deeply to poverty^3–63456. Therefore, governments are responsible for reducing the gap betwee

n the poor and well-off populations in accessing quality health care.

In the Indonesian context, the progress of UHC is significant⁷⁷, especially when the NHP of Indonesia was officially introduced in 2014 as a measure to achieve UHC⁸⁸. The NHP is a substantial achievement of Indonesia in protecting the population⁹⁹, especially the low-income population. Currently, the BPJS-Kesehatan (the organizing management of NHP) claims that 247.7 out of 276 million people have been enrolled as members, and 151.7 out of 247.7 million are Non-Contributory Health Insurance (NCHI) subsidized by the government¹⁰¹⁰. The government pays for the monthly plan of the NCHI, while the rest of the population, the Contributory Health Insurance (CHI) population, is fully paid or partly subsidized by their employers.

Indonesia's poor and low-income groups reach 26.2 million (9.5%) of the country's total population¹¹¹¹. The coverage of NCHI in NHP is 5.8, which is five times bigger than the country's poor population. The figures reflect that all poor people have yet to enroll in the NCHI scheme and have access to healthcare. However, the extent to which the poor are fully registered in NCHI needs to be clarified. Validation of the poor is weak, making this population vulnerable to being cast away from the scheme. For example, the waste pickers in Surabaya, as the representation of the urban poor group counted as 20%, were left behind from the NCHI membership¹²¹². The Ministry of Human Research, Development, and Culture reports that 10.8 million impoverished people need access to the NCHI scheme¹³¹⁴. Furthermore, 28.3% of the urban poor are not covered by NHP¹⁴¹⁴.

The remaining question is why and what factors hinder people, especially poor groups, from accessing government health protection membership. The poor cannot access health protection due to the plan's cost, and free health protection does not reach the poor^15,161516. In the case of Indonesia, this study attempted to identify the contributing factors that make millions of people fail to enroll in the NHP. We chose Waingapu, the District of Sumba Timur, Nusa Tenggara Timur Province, as the research site based on some considerations, such as being classified as a poor district, limited access to social welfare benefits, and being geographically far from the center of government. The percentage of the poor population in the district was 31% from 252,704 people in 2017¹⁷¹⁷The NCHI paid through the Sumba Timur District's annual budgeting plan reached 44,429 people or 17.6% of the district's population¹⁸¹⁸. The statistics reflected the vulnerability of poor people in the district to access the NHP program.

Besides the district's financial capacity to enroll its residents in NHP, we argued that there must have been underlying factors that contributed to the inability of thousands of poor people in the district to access the social health plan. This study, therefore, investigated the factors that contributed to the failure of the poor residents of Sumba Timur to enroll in the NHP scheme. The study is vital for all stakeholders in the district to mitigate the factors and take necessary actions to improve the coverage of NHP for the poor in need.

2. MATERIALS AND METHODS

The study adopted a qualitative inquiry involving 30 Waingapu, Sumba Timur District residents. Using convenience procedures, we recruited the respondents who were attending healthcare centers in two hospitals and five community health centers. Three heads of community groups, including three health cadres, also participated in the interview. We collected data using semi-structured interviews and casual conversations. We approached potential respondents and explained who we were, the aim of the study, and the nature of their involvement. A plain language statement was provided, orally presented to the respondents, and their consent was requested as proof of participation. We convinced the respondents to protect their privacy and they only appeared in pseudonyms in any publication. We also asked permission to audio-tape the interviews while intensive note-taking was performed during casual conversation. The information was transcribed and narrated. We performed inductive analysis, coded, and determined the themes.

The project had passed the Ethical Clearance issued by the Research Ethics Commission of Poltekkes Kemenkes Surabaya, with project No: EA/828/KEPK-Poltekkes_Sby/V/2022, on 18 March 2022. Before the data collection, the researchers proposed and obtained permission from the Political and Community Protection Board of both NTT Province and the District of Sumba Timur to collect the data.

3. RESULTS

The qualitative data analysis identified some factors that made people, especially the poor, unable to enroll in the NHP program. Lack of information due to poor socialization of NHP, the