91325
A STUDY ON THE IMPLEMENTATION OF
JAMPERSAL POLICY IN INDONESIA
DISCUSSION PAPER SEPTEMBER 2014
Endang L. Achadi
Anhari Achadi
Eko Pambudi
Puti Marzoeki
A STUDY ON THE IMPLEMENTATION OF
JAMPERSAL POLICY IN INDONESIA
Endang L. Achadi, Anhari Achadi, Eko Pambudi, Puti Marzoeki
September 2014
Health, Nutrition, and Population (HNP) Discussion Paper
This series is produced by the Health, Nutrition, and Population (HNP) Global Practice of the World
Bank Group. The papers in this series aim to provide a vehicle for publishing preliminary results on
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at mlutalo@worldbank.org or Erika Yanick at eyanick@worldbank.org.
© 2014 The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW Washington, DC 20433
All rights reserved.
ii
Health, Nutrition, and Population (HNP) Discussion Paper
A Study on the Implementation of Jampersal Policy in Indonesia
a a b b
Endang L Achadi, Anhari Achadi, Eko Pambudi, Puti Marzoeki
a
Center for Family Welfare, University of Indonesia
b
Health, Nutrition, and Population Global Practice, the World Bank Group, Jakarta Office, Indonesia
Paper prepared by the World Bank Group and supported by funding from the government of Japan
through the Japan–World Bank Partnership Program for Universal Health Coverage (P125669).
Abstract: Indonesia launched Jampersal in 2011, a nationwide program to accelerate the reduction
of maternal and newborn deaths. The program was financed by central government revenues and
provided free and comprehensive maternal and neonatal care with an emphasis on promoting
institutional deliveries. Jampersal providers were public and enlisted private facilities at the primary
and secondary levels. In 2013, the World Bank and the Center for Family Welfare, University of
Indonesia conducted a qualitative and quantitative study to assess the implementation and impact of
the program in Garut District and Depok Municipality in West Java Province. The study found that
Jampersal utilization was highest among women who were least educated, poor, and resided in rural
areas. Utilization was also high among women with delivery complications. The study showed
Jampersal only had an impact where institutional delivery coverage was still low such as in Garut
District. In this district, women were 2.4 times more likely to have institutional deliveries after
Jampersal. The finding suggests implementation of Jampersal policy may have to be adjusted
according to the utilization pattern for efficiency and effectiveness. The government discontinued
Jampersal with the launching of the National Health Insurance Program (JKN) on January 1, 2014.
The study’s findings indicate the merit in reevaluating the policy to terminate the program, given that
Jampersal helped increase institutional deliveries while voluntary participation in JKN remains low.
.
Keywords: Jampersal, comprehensive maternal and neonatal care, national health insurance
Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those
of the authors, and do not represent the views of the World Bank, its Executive Directors, or the
countries they represent.
Correspondence Details: Puti Marzoeki at pmarzoeki@worldbank.org.
iii
Table of Contents
Table of Contents .......................................................................................................................................... iv
ACKNOWLEDGMENTS ............................................................................................................................. vi
PREFACE ..................................................................................................................................................... vii
ACRONYMS AND GLOSSARY ................................................................................................................ viii
LIST OF FIGURES ..........................................................................................................................................x
LIST OF TABLES ...........................................................................................................................................xi
EXECUTIVE SUMMARY ............................................................................................................................... 1
PART 1: BACKGROUND .............................................................................................................................. 4
PART 2: OBJECTIVES .................................................................................................................................... 7
PART 3: JAMPERSAL PROGRAM DESCRIPTION ..................................................................................... 8
3.1. Program Target......................................................................................................................... 8
3.2. Benefit Package......................................................................................................................... 8
3.3. Financial Scheme .................................................................................................................... 10
3.4. Socialization ............................................................................................................................ 11
PART 4: STUDY FRAMEWORK ................................................................................................................. 12
PART 5: METHODOLOGY ......................................................................................................................... 14
5.1. Study Design .......................................................................................................................... 14
5.2. Population and Sample Size .................................................................................................. 14
5.3. Study Limitations ................................................................................................................... 14
PART 6: RESULTS ........................................................................................................................................ 15
6.1. DESCRIPTION OF THE STUDY AREAS ............................................................................. 15
6.2. Implementation of Jampersal Policy (Findings from the Qualitative Study) ..................... 16
6.2.1. Organizational Arrangement .............................................................................. 16
6.2.2. Financing .............................................................................................................. 17
6.2.3. Verification, Claim, and Reimbursement System.............................................. 18
6. 2. 3. 1. Primary Care Level ......................................................................... 18
6. 2. 3. 2. Hospital Level ................................................................................. 20
6.2.4. Provider Payment Scheme .................................................................................. 21
6. 2. 4. 1. Primary Care ................................................................................... 21
6. 2. 4. 2. Hospital Level ................................................................................. 21
6.2.5. Socialization ......................................................................................................... 22
6.2.6. Monitoring and Evaluation................................................................................. 23
6.2.7. Supply-Side Capacity .......................................................................................... 23
6. 2. 7. 1. Human Resources ........................................................................... 23
6. 2. 7. 2. Public Health Facilities ................................................................... 23
6. 2. 7. 3. Private Providers............................................................................. 24
6.2.8. Commitment to Jampersal .................................................................................. 25
6.2.9. Garut’s Dilemma in Implementing Jampersal Policy ....................................... 26
6.3. Results of the Household Survey .......................................................................................... 27
6. 3. 1 Respondent Characteristics................................................................................. 27
6. 3. 2 Community Understanding about Jampersal Program .................................... 28
6. 3. 3 Jampersal Utilization ........................................................................................... 30
6. 3. 4 Utilization of Maternal Health Services ............................................................. 31
1.3.4.1. Antenatal Care................................................................................. 31
1.3.4.2. Delivery ........................................................................................... 32
1.3.4.3. Cesarean Section ............................................................................. 34
1.3.4.4. Postnatal Care.................................................................................. 34
1.3.4.5. Family Planning .............................................................................. 35
1.3.4.6. Source of Payment for Last Delivery ............................................. 36
6. 3. 5 Impact of Jampersal............................................................................................. 37
6.3.5.1. Impact of Jampersal on Institutional Deliveries ............................ 37
6.3.5.2. Impact of Jampersal on Cesarian Section ...................................... 39
iv
PART 7: DISCUSSION ................................................................................................................................. 42
7.1. Breadth of the Coverage: Who Is Insured? .......................................................................... 43
7.2. Depth of the Coverage: the Benefit Package......................................................................... 44
7.3. The Height of the Coverage: Financial Protection ............................................................... 45
PART 8: CONCLUSION .............................................................................................................................. 46
8.1. Policy Formulation and Implementation.............................................................................. 46
8.2. Health Service Provision and Performance .......................................................................... 46
8.3. Community Acceptance to Jampersal Policy ....................................................................... 47
8.4. Impact of Jampersal on MCH Service Coverage .................................................................. 47
PART 9: RECOMMENDATIONS................................................................................................................ 48
REFERENCES ............................................................................................................................................... 50
ANNEX ......................................................................................................................................................... 53
v
ACKNOWLEDGMENTS
This report is published by the World Bank Office, Jakarta, as part of the Japan–World Bank
Partnership Program for Universal Health Coverage. Data management and analysis were
conducted by Anhari Achadi, Endang L. Achadi, Trisari Anggodowati, Kamaluddin Latief, Fitri
Nandiaty, Poppy Elvira, and Nurfitri Rachmadaniawati from the Center for Family Welfare, University
of Indonesia (CFW-UI), and by Eko Pambudi from the World Bank. Report writing was led by Puti
Marzoeki from the World Bank.
The team coordinated closely with, and benefited from, valuable inputs during consultations with the
following representatives of the Indonesian government: Usman Sumantri (P2JK/ Center for Health
Financing and Health Insurance, MoH) and Riskiyana Sukandi Putra (Dit Kesehatan Ibu/ Directorate
of Maternal Health, MoH).
Valuable comments on the draft report were received from Ajay Tandon, Senior Economist, World
Bank. The report was peer reviewed by Marjorie Koblinsky, International Maternal Health Expert, and
Karima Saleh, Senior Economist, World Bank
The paper was written under the overall guidance of Toomas Palu, Practice Manager, GHNDR.
The authors are grateful to the World Bank for publishing this report as an HNP Discussion Paper.
vi
PREFACE
In 2011, Japan celebrated the 50th anniversary of achieving universal health coverage (UHC). To
mark the occasion, the government of Japan and the World Bank conceived the idea of undertaking a
multicountry study to respond to this growing demand by sharing rich and varied country experiences
from countries at different stages of adopting and implementing strategies for UHC, including Japan
itself.
This led to the formation of a joint Japan–World Bank research team under the Japan–World Bank
Partnership Program for Universal Health Coverage. The program was set up as a two-year
multicountry study to help fill the gap in knowledge about the policy decisions and implementation
processes that countries undertake when they adopt the UHC goals. The program was funded
through the generous support of the government of Japan.
This country report on Indonesia is one of the 11 country studies on UHC that was commissioned
under the program. The other participating countries are Bangladesh, Brazil, Ethiopia, France, Ghana,
Japan, Peru, Thailand, Turkey, and Vietnam. A synthesis of these country reports is in the publication
“Universal Health Coverage for Inclusive and Sustainable Development: A Synthesis of 11 Country
Case Studies,” available at http://www.worldbank.org/en/topic/health/brief/uhc-japan.
These reports are intended to provide an overview of the country experiences and some key lessons
that may be shared with other countries aspiring to adopt, achieve, and sustain UHC. The goals of
UHC are to ensure that all people can access quality health services; to safeguard all people from
public health risks; and to protect all people from impoverishment due to illness, whether from out-of-
pocket payments or loss of income when a household member falls sick. Although the path to UHC is
specific to each country, it is hoped that countries can benefit from the experiences of others in
learning about different approaches and avoiding potential risks.
vii
ACRONYMS AND GLOSSARY
ANC Antenatal Care
APBD Anggaran Pendapatan dan Belanja Daerah/ Regional Government Budget
APBN Anggaran Pendapatan dan Belanja Negara/ State Budget
APN Asuhan Persalinan Normal/Normal delivery care
ARSADA Asosiasi Rumah Sakit Daerah Seluruh Indonesia/Indonesian District Hospital
Association
Askeb Asuhan Kebidanan/ Maternity Care Plan
Askeskin Asuransi Kesehatan Miskin/Insurance for the poor
Bappenas Badan Perencanaan dan Pembangunan Nasional/National Development
Planning Agency
BOR Bed occupancy rate
BPK Badan Pemeriksa Keuangan/ National Finance Audit Board
BPS Badan Pusat Statistik/ Central Bureau for Statistics
Bumil Ibu Hamil/Pregnant woman
Bupati Kepala Daerah/Head of district
DTP Dengan Tempat Perawatan/ Primary health center with in-patient care
Dinkes Kab Dinas Kesehatan Kabupaten/District health office
Dinkes Prop Dinas Kesehatan Propinsi/Provincial health office
EMAS Expanding maternal and newborn survival
FGD Diskusi Kelompok Terarah/Focus group discusion
GDON Gawat Darurat Obstetri Neonatal/Emergency Obstetric and Neonatal
HDI Indeks Pembangunan Manusia/Human Development Index
HRH Sumber Daya Kesehatan/Human resourches for health
IBI Ikatan Bidan Indonesia/Indonesia Midwives Association
ICU Intensive care unit
IGD Instalasi Gawat Darurat/Emergency room
INA-CBGs Indonesia case-based groups
IUD Intrauterine device
Jamkesda Jaminan Kesehatan Daerah/Local health insurance scheme
Jamkesmas Jaminan Kesehatan Masyarakat/National health insurance scheme
Jampersal Jaminan Persalinan/Universal delivery care
Jamsostek Jaminan Sosial Tenaga Kerja/Social insurance for private sector workers
JKN Jaminan Kesehatan Nasional/National Health Insurance Program
Juknis Petunjuk Teknis/Technical guidelines
KB Keluarga Berencana/Family planning
Kemenkes Kementerian Kesehatan/Ministry of Health
Kemendagri Kementerian Dalam Negri/Ministry of Home Affairs
Kemenkeu Kementerian Keuangan/Ministry of Finance
KK Kartu Keluarga/Family card
KPPN Kantor Pusat Perbendaharaan Negara/State Treasury Office
KTP Kartu Tanda Penduduk/Identity card
K1 Kunjungan ANC Pertama/ANC in first trimester
K4 Kunjungan ANC keempat/2nd ANC in third trimester
Linakes Persalinan oleh tenaga kesehatan/Delivery assisted by health professional
Linfaskes Persalinan di fasilitas kesehatan/Institutional delivery
MoU/SKK Surat Keterangan Kerjasama/Memorandum of understanding
MDGs Millennium Development Goals
Menkokesra Menteri Koordiantor Kesejahteraan Rakyat/Ministry of People’s Welfare
NICU Neonatal intensive care unit
Ob-gyn Spesialis Kebidanan/Obstetrics and gynecology
Perbup Peraturan Bupati/Head of district regulation
Perda Peraturan daerah/Local regulation
Permenkes Peraturan Menteri Kesehatan/ MoH regulation
PERSI Perhimpunan Rumah Sakit Seluruh Indonesia/Indonesian Hospital Association
Perwali Peraturan Walikota/Mayor regulation
PKH Program Keluarga Harapan/Conditional cash transfer program
PNC Postnatal care
viii
PNBP Penerimaan Negara Bukan Pajak/Nontax payment
PNPM-GSC Program Nasional Pemberdayaan Masyarakat — Generasi Sehat dan
Cerdas/The National Program for Community Empowerment (PNPM). Smart and
Health Generation
PNS Pegawai Negeri Sipil/Civil servant
PPH 21 Pajak Penghasilan/Personal income tax
PPM Bidan Praktek Swasta/Private practice midwife
Polindes Pos Bersalin Desa/Village delivery post
PONED/BEONC Pelayanan Obstetrik dan Neonatal Esensial Dasar/Basic essential obstetric and
neonatal care (BEONC)
PONEK/CEONC Pelayanan Obstetrik dan Neonatal Esensial Komprehensif/Comprehensive
essential obstetric and neonatal care (CEONC)
Posyandu Pos Pelayanan Terpadu/Integrated service post
PP Peraturan Pemerintah/Government regulation
PPS Probability Proportional to Size
PPK1 Pemberi Pelayanan Kesehatan — Tingkat 1/Primary health service
PTT Pegawai Tidak Tetap/Contracted worker (temporary civil service)
P2JK Pusat Pembiayaan dan Jaminan Kesehatan/Center for Health Financing and
Health insurance
Puskesmas Pusat Kesehatan Masyarakat/Primary health center
Pustu Puskesmas Pembantu/Satellite puskesmas
RB Rumah Bersalin/Maternity clinic
Riskesdas Riset Kesehatan Dasar/National Basic Health Research
RKA Rencana Kerja Anggaran/Budget work plan
SBA Persalinan oleh tenaga terlatih/ Skilled birth attendance
SC Sectio Cesarea (Operasi Sesar)/Cesarian section
SIP Surat Izin Praktek/License to practice
SK Surat Keputusan/Decree
SP2D Surat Perintah Pencairan Dana/Disbursement letter
TBA Dukun Bersalin/Traditional birth attendants
UNFPA United Nations Population Fund
Walikota Kepala Daerah/Mayor
WHO Organisasi Kesehatan Dunia/World Health Organization
ix
LIST OF FIGURES
Figure 1.1 Maternal Mortality Ratio in Indonesia................................................................................ 4
Figure 1.2 Jampersal Fund Channeling............................................................................................ 10
Figure 1.3 Conceptual Framework of Policy Implementation ............................................................ 12
Figure 1.4 Study Framework ........................................................................................................... 13
Figure 1.5 Claim and Reimbursment Mechanism at Primary Care Level .......................................... 19
Figure 1.6 Claim and Reimbursment Mechanism at the Hospital Level............................................. 21
Figure 1.7 Proportion of Women Who Have Heard of Jampersal ...................................................... 28
Figure 1.8 Source of Jampersal Information in Depok and Garut ..................................................... 28
Figure 1.9 Perception about Jampersal ........................................................................................... 29
Figure 1.10 ANC 1-1-2 Visit Pattern ................................................................................................ 31
Figure 1.11 Place of Delivery .......................................................................................................... 32
Figure 1.12 Skilled Birth Attendance before and after Jampersal ..................................................... 33
Figure 1.13 Percentage of Postnatal Care....................................................................................... 35
Figure 1.14 Percentage of Family Planning, before and after Jampersal, by Method ....................... 35
Figure 1.15 Three Dimentsions of Universal Health Coverage......................................................... 42
x
LIST OF TABLES
Table 1.1 Comparison between Jampersal and Other Social Insurance Programs in Indonesia prior
to January 2014................................................................................................................................. 5
Table 1.2 Comparison of 2011 and 2012 Jampersal Guidelines ......................................................... 9
Table 1.3 Facilities and Human Resources for Health in Garut and Depok, 2011 ............................ 15
Table 1.4 The Number of Health Facilities in Garut and Depok, 2010–2012 ..................................... 16
Table 1.5 Population and Recipients of Social Health Insurance in 2012 .......................................... 16
Table 1.6 Roles and Responsibilities of Actors under Jampersal ...................................................... 17
Table 1.7 Budget Allocation and Utilization of Jampersal in Garut, 2011–13 ..................................... 17
Table 1.8 Budget Allocation of Jampersal in Depok, 2011–13 .......................................................... 18
Table 1.9 Respondent Characteristics ............................................................................................. 27
Table 1.10 Utilization of Jampersal for the Last Delivery, by Respondents’ Characteristics, Depok and
Garut, Post-Jampersal (after 2011) ................................................................................................. 30
Table 1.11 Number of ANC Visits .................................................................................................... 31
Table 1.12 Place of Delivery by Time and by Women’s Characteristics, ........................................... 32
Table 1.13 Breakdown of Preferred Birth Delivery Facilities ............................................................ 33
Table 1.14 Skilled Birth Attendance before and after Jampersal, by Urban and Rural Areas, ............ 34
Table 1.15 Results of Bivariate Analysis on Association between Jampersal and Cesarian Sections 34
Table 1.16 Source of Payment for the Last Delivery ......................................................................... 36
Table 1.17 Type of Other Payments during Last Delivery, among Jampersal Users ......................... 37
Table 1.18 Association between Jampersal and Institutional Deliveries ............................................ 38
Table 1.19 Change in Institutional Deliveries by Mother’s Education, Socioeconomic Status,
Insurance Ownership, and Residence before and after Jampersal in Garut and Depok (%) .............. 38
Table 1.20 Change in Cesarian Sections by Women’s Characteristics before and after Jampersal in
Garut and Depok (%)....................................................................................................................... 39
Table 1.21 Association between Jampersal and Cesarian Sections ................................................. 40
Table 1.22 Results of Multivariate Analysis on Association between Wealth Quintiles and Cesarian
Section ............................................................................................................................................ 41
xi
EXECUTIVE SUMMARY
Indonesia has made progress in reducing maternal mortality in recent years. Despite this progress,
Indonesia’s maternal mortality ratio (MMR) level remains high relative to its income, to regional peers,
and for a country that has high utilization of maternal health services such as antenatal care (ANC)
and skilled birth attendance rates. In 2011, the government launched the Jampersal program to
accelerate the reduction of maternal and newborn deaths. The program was financed by central
government revenues, and provided free and comprehensive maternal and neonatal care with an
emphasis on promoting institutional deliveries. The beneficiaries were those without coverage from
existing social health insurance schemes such as Askes, Jamsostek, and Jamkesmas/Jamkesda.
Jampersal providers were public facilities and enlisted private facilities at the primary and secondary
levels. The government reimbursed providers for Jampersal services through fee claims. The tariff for
primary level services was set by the Ministry of Health (MoH), while the tariff for hospital services
followed the INA-CBG (Indonesia case-based groups).
The World Bank in collaboration with the Center for Family Welfare, University of Indonesia (CFW-UI)
conducted a study in 2013 to assess the implementation of Jampersal and the impact of the program
on the coverage of maternal and neonatal health services. At the subnational level, the study involved
Garut District and Depok Municipality in West Java Province. The study comprised qualitative and
quantitative components and was funded through the Japan–World Bank Partnership Program for
Universal Health Coverage.
Jampersal was implemented by the MoH and local governments, although other stakeholders such as
the Ministry of Finance, Bappenas (National Development Planning Agency,) Office of the Vice
President, Ministry of Home Affairs, and the coordinating Ministry of People’s Welfare were involved in
the policy formulation process. Awareness and socialization of Jampersal were lower than expected:
even in the third year of implementation: 30 percent of respondents (women of child-bearing age) in
both Garut and Depok were still unaware about Jampersal, in part due to limited involvement of other
sectors during implementation. Even among those respondents who knew about Jampersal, most
perceived Jampersal was a program that was limited to provision of free deliveries at puskesmas and
public hospitals. Respondents doubted that the services really were for free, and some perceived that
“free” meant lower service quality.
The percent of deliveries (last birth for each woman) financed by Jampersal in Garut and Depok were
28.1 percent and 10.3 percent, respectively. Jampersal utilization was highest among women who
were least educated, poor, and residents of rural areas. Jampersal use was also high among women
with delivery complications. Contrary to design, Jampersal use was higher among those who already
had health insurance coverage, including Jamkesmas/Jamkesda beneficiaries. Respondents who
knew about the program considered the requirements for using Jampersal services simple (identity
card and MCH [maternal and child health] book) and were aware that, unlike Jamkesmas, the choice
of providers at the primary level was not limited to public providers. Almost 60 percent of Jampersal
users in both Garut and Depok reported paying additional out-of-pocket (OOP) costs for delivery
services at health facilities, and about half of them could not explain the reason for the extra OOP
payments. Among those that provided explanations for OOP costs, 16 percent reported paying for
drugs and injections, even though these should have been covered by the program. In addition,
respondents noted that private midwives sometimes requested extra payments for long-term
contraceptives, as Jampersal fee reimbursement for family planning services was lower than the cost
of long-term contraceptives. Households also reported paying additional OOP costs for referral
transport.
Puskesmas was the main Jampersal provider at the primary level in Garut. In Depok, the private
sector was the dominant maternal and neonatal care provider. However, although 67 percent of
private practice midwives and all private hospitals have enlisted as Jampersal providers, their actual
participation in the program was minimal. The reluctance for involvement in Jampersal was mostly
due to dissatisfaction about service fees. Although the government increased the fees in the second
year, the amount was still considered much lower than the regular private sector fees. Moreover,
1
Jampersal reimbursement processes were considered cumbersome because verification
requirements and claim payments were often delayed. Private providers preferred non-Jampersal
clients who paid OOP directly.
The qualitative study revealed that Jampersal resulted in a reported workload increase among public
sector providers and that this affected the income of midwives, particularly those engaging in dual
practice. Jampersal negatively influenced those dual practice midwives who had a high number of
patients in their private practices before Jampersal. Conversely, private practice midwives with fewer
patients before Jampersal reported benefitting positively from the program.
In Garut District, the institutional delivery increase after Jampersal was 54.4 percent, and the increase
was statistically significant; women were 2.4 times more likely to have institutional deliveries after
Jampersal. However, around 30 percent of deliveries in Garut were still assisted by traditional birth
attendants (TBAs). Coverage of institutional deliveries in Depok was already high (92.3 percent) prior
to Jampersal, and after almost three years of program implementation, the coverage remained the
same. An interesting phenomenon was the slight shift of institutional deliveries in Depok from the
private to the public sector, and from private midwives to private clinics/obstetricians after Jampersal.
There was almost no change in antenatal care (ANC) and postnatal care (PNC) visits after Jampersal,
although the use of long-term contraceptives has increased. Delivery by Cesarean section (C-section)
increased by 26.4 percent, but the increase was not statistically significant, and the study could not
convincingly confirm that Cesarean sections were strictly for delivery complications. The odds of
having a C-section were higher in Depok than in Garut, suggesting higher access to C-section
services in Depok.
Recommendations
A program like Jampersal requires strong support from stakeholders beyond the health
sector. Jampersal encompassed horizontal (across sectors within the same level) and vertical
(between the central and local government) collaboration. Jampersal has brought sectors together
during policy formulation, but sector collaboration is important for building the momentum during
implementation as well. For example:
a. Given the decentralized system in Indonesia, the involvement of the Ministry of Home Affairs
(MoHA) could help build local government commitment to the program. A strong buy-in from
local governments may increase subdistrict and village government support in increasing
community awareness and potentially in removing other barriers to care.
b. Joint collaboration between MoH, MoHA, and Ministry of Finance (MoF) in reviewing existing
regulations would be helpful in finding ways to reduce the complexity of Jampersal (or other
insurance) fund management and the reimbursement process.
c. Multisector involvement is required in planning and implementing long-term investment for
improving road infrastructure, transportation, and health facilities in geographically difficult
areas, to improve access to institutional deliveries.
Jampersal could help to increase institutional deliveries while National Health Insurance
Program (Jaminan Kesehatan Nasional, JKN) voluntary participation is still low. The study has
shown the potential of Jampersal to increase institutional deliveries where coverage was low, as in
Garut. The government may want to consider this finding and reevaluate the policy to terminate
Jampersal implementation with the launching of the JKN on January 1, 2014. Nevertheless, before
continuing the implementation, it is important to review the cost-effectiveness of the program.
Addressing “nonservice” cost is important. The study reported families still pay additional OOP
cost for referral transport, which might be a barrier to accessing care. Building linkages with other
2
programs such as PNPM GSC1 might be an option for addressing this issue. Moreover, reducing
OOP would also require better understanding about the reason for the OOP; for example, whether it
is an issue of supply chain and drug shortages, an issue of exclusion of certain drugs from the basic
benefit package, or an issue of provider prescription behavior. For the latter, it will be useful to monitor
possible cream skimming.2
“Free” is not enough; service readiness and quality also matter. Women who experienced low
quality of care tended to stop using the care, or even dissuaded other women from using care
(Wairimu 2013). In Kenya, women’s refusal to use free maternity care was due to poor quality of
facilities and the rude attitude of health providers, among other factors. Continuous quality
improvements should follow any effort to improve access to health care. Complementary work shows
that maternal health supply-side readiness problems remain, especially in some parts of the country;
these issues could deter patients from utilizing care, despite the removal of financial barriers via
programs such as Jampersal.
Getting private providers on board requires a carefully designed provider payment system. In
areas where private providers are dominant and demand for private provision is high, buying services
from the private sector to improve access might be more efficient than expanding public sector
investment. Obviously, this would require reasonable fees and quality assurance of service provision.
The study also showed that the support from professional associations like the Indonesia Midwives
Association (Ikatan Bidan Indonesia, IBI) could facilitate private midwife participation in Jampersal.
There is a need to explore more options to improve human resources for health (HRH)
availability and distribution in remote areas. Skilled birth attendance in rural Garut increased after
Jampersal despite the low presence of midwives, suggesting adding more midwives could increase
skilled birth attendance even more if paying for service is not an issue. Experience shows that
monetary incentives are often not enough for deploying HRH to “difficult” areas. Other attractive
features, such as housing, children’s education, continuing education, and a clearly defined time
period of service need to be considered. In developing HRH policies, Indonesia would benefit from a
labor market analysis to understand labor market dynamics influencing HRH supply and demand.
In areas with difficult access to hospitals, the presence of basic emergency obstetric and
neonatal care (BEONC) is essential. Investment in BEONC should be followed by close monitoring
and consistent support to ensure continuity of care as well as by introducing policies that deter high
turnover of trained staff and increase utilization.
Implementation of Jampersal (or UHC) policy may have to be adjusted according to the
utilization pattern for efficiency and effectiveness. The household survey conducted under this
study showed Jampersal only had an impact in an area where institutional delivery coverage was still
low, such as Garut. Further assessment is needed to translate this finding into future policy changes.
1. PNPM GNC is the government’s community-driven development program, providing block grants to poor communities to
attain selected health and education targets.
2. Midwives working in dual practice may decide to ask patients to come to their private practice as they can use the whole
claim reimbursement for their own benefit, while in puskesmas they have to share with other staff.
3
PART 1: BACKGROUND
Indonesia has made progress in reducing maternal mortality. Although there is uncertainty about
Indonesia’s MMR level, all existing estimates show a decline of MMR during the last two decades with
a recent plateau or even increase (figure 1.1). Despite the decline, Indonesia MMR level is still high
for a country with good access to maternal health services.
Figure 1.1 Maternal Mortality Ratio in Indonesia
Maternal mortality ratio in Indonesia, 1990-2015
Maternal deaths per 100,000 live births
700 900
Joint WB-UN
2010 Census
500
DHS
300
IHME
MDG target
100
1990 1995 2000 2005 2010 2015
Year
Sources: Joint WB-UN estimates; Indonesia census
DHS; Institute of Health Metrics and Evaluation (IHME)
Note: Shaded area represents joint WB-UN estimation uncertainty
By 2012, delivery by a skilled provider was 83.1 percent, although 36 percent of deliveries were at
home, and 13.5 percent were assisted by traditional birth attendants (BPS et al. 2013). Many studies
reported that possible reasons for maternal deaths included unskilled attendant during delivery, lack
of knowledge of danger signs, and delayed referral. In addition, horizontal referrals have contributed
to the delay in proper management of birth delivery complications.
To achieve MDGs 4 (reduce child mortality) and 5 (improve maternal health), the government has
promoted institutional deliveries and improving the referral system, including access to referral
services. In 2011, the government launched the Jampersal program to provide free delivery
assistance to those who do not have insurance coverage for delivery services. Under this definition,
Jampersal is an expansion of Jamkesmas coverage for delivery services and aims at achieving
universal coverage for maternal and neonatal health services. Table 1.1 show the various social
insurance schemes implemented at the same time as Jampersal, as well as prior to the merger of
those programs under the National Health Insurance Program (JKN) on January 1, 2014.
4
Table 1.1 Comparison between Jampersal and Other Social Insurance Programs in Indonesia prior
to January 2014
Jampersal Jamkesmas3 (established Askes (established Jamsostek (established
(established 2011)* 2005)** 1960)*** 1992)***
Groups All women who were Poor and the near-poor Civil servants, Private employers with
mandated not covered by any retired civil >10 employees or pay
type of health servants, retired salary >Rp 1 million a
insurance military personnel, month
and veterans
Number n.a. 76.4 million 16.6 million 5.0 million
enrolled
Premium n.a. Rp 6,500 ($0.67) per capita 2% of basic + 1% 3% of salary for
per month government; no bachelors;
ceiling 6% of salary for
married employees;
ceiling Rp 1 million per
month (not changed
since 1993)
Contributor Government 100% Government 100% Employees 66%; Employers 100%
employer 34%
Carrier Ministry of Health Ministry of Health PT Askes (for profit) PT Jamsostek (for
profit)
Benefits Maternal and Comprehensive; drugs are Comprehensive, no Comprehensive; cancer
newborn health care covered if prescribed within specific exclusion; treatment, cardiac
formulary; no cost-sharing drugs are covered if surgery, hemodialysis,
prescribed within and congenital diseases
formulary; are excluded; 4 drugs
Cost-sharing are covered if
available when prescribed within
services fall outside formulary;
basic benefit no cost-sharing
package
Dependents n.a. All family members Spouse + 2 children Spouse + 3 children
under 21 years who under 21 years who are
are not working and not working and not
not married married
Providers All puskemas and All puskemas and public Mostly contracted Mixed: public and
public hospitals and hospitals and selected public health centers private providers
selected empanelled empanelled private and public hospitals
private clinics and hospitals
private hospitals
Provider Fee-for-service at Fee-for-service at Special fee schedules Fees are negotiated;
payment puskesmas; diagnosis- puskesmas; DRG for for civil servants; extra billing
mechanisms related group hospitals extra billing depending on
(DRG)/case-based depending on negotiated fees
group (CBG) for negotiated fees
hospitals
Source: *Indonesia, Ministry of Health 2011; **Indonesia, Ministry of Health 2012; *** Harimurti et al. 2013.
3. Health insurance for the poor was introduced as Askeskin in 2005, which was expanded and renamed Jamkesmas in 2007.
4. Starting in 2012, Jamsostek expanded the benefits package to cover catastrophic cases as well.
5
Jampersal benefit package includes antenatal, delivery, and postnatal services at the primary care
facilities, and referral services for maternal and neonatal complications at secondary and tertiary
hospitals. Table 1.2 in the next section explains the details of the benefit package. The primary care
facilities are public health centers (puskesmas) and their network, including the polindes (village
delivery post). Enlisted private providers include private midwives, private midwifery clinics, and
private hospitals. Referral/in-patient care is provided at class-3 hospital beds at public and enlisted
private hospitals.
6
PART 2: OBJECTIVES
This study examined the financing, payment, and organization policies of the Jampersal program.
Specific objectives of the study include the following: (i) a review of how Jampersal policy was
formulated at the central level and implemented at the local level; (ii) a review of service provider and
community response to the policy; and (iii) an assessment of the impact of Jampersal on the
coverage of maternal services, particularly the impact on institutional deliveries at the primary level
and Cesarean section (C-section) coverage at the secondary level (See annex 3 for study
methodology).
7
PART 3: JAMPERSAL PROGRAM DESCRIPTION
3.1. PROGRAM TARGET
Jampersal is a government-supported program for maternity care, specifically targeting pregnant
women who are not covered by any other health insurance scheme regardless of their socioeconomic
status. The government of Indonesia is committed to improving the country’s health system as stated
in the Ministry of Health Strategic Plan 2010–2014 and the government’s Roadmap to Accelerate the
Achievement of the MDGs in Indonesia. The commitments translate into the provision of social health
insurance for the poor, among others. Until the end of 2013, the main social health insurance for the
poor in Indonesia was Jamkesmas, previously known as Askeskin, financed by the central
government and targeting the poor and near-poor. Jamkesmas, which became operational in 2005,
was managed by the MoH, and provided beneficiaries with free health services in puskesmas and
hospitals. Another type of insurance for the poor is Jamkesda, which is funded by the subnational
government (province/district level), and finances health care for the poor who are not covered by
Jamkesmas. The aim of most social health insurance programs is to enable the poor and near-poor to
gain access to health services to reduce mortality, morbidity and inequality. Jampersal provides
comprehensive maternal health service coverage to those not covered by Jamkesmas, Jamkesda, or
any other health insurance scheme. The government terminated the implementation of Jampersal in
December 2013 with the launch of the National Health Insurance Program (JKN) on January 1, 2014.
3.2. BENEFIT PACKAGE
Jampersal covers pregnancy, delivery, and postpartum services including antenatal care, delivery
care, postpartum care for mother and newborn, and family planning. The coverage includes standard
drugs used in the national MCH program. Referral care is provided in hospital outpatient clinics and
class 3 hospital beds, regardless of the income level of the user. The Ministry of Health released the
Jampersal guidelines under Ministry of Health Regulation no.631/MENKES/PER/III/2011. This
regulation was revised by Ministry of Health Regulation no. 2562/MENKES/PER/XII/2011 in 2012, to
adjust the benefit package and the unit costs in response to findings from the evaluation of the first
year implementation, indicating dissatisfaction among health providers with the service fees. Table
1.2 compares Jampersal 2011 with 2012 guidelines on services, frequency, and fees.
8
Table 1.2 Comparison of 2011 and 2012 Jampersal Guidelines
Jampersal 2011 vs 2012
2011
2012
Type Benefit package (No.631/Menkes/PER/III/201
(No.2562/Menkes/PER/X11/2011)
1)
Rate ANC in basic
Antenatal care Rp 10,000/time Rp 20,000/time
service
Specifically for ANC with
complications, the claim can be
done according to the number of
Frequency 4 times only
ANC provided as long as it is
consistent with the standards
(ANC can be more than 4 times)
Fee for normal
Normal
delivery in primary Rp 350,000/time Rp 500,000/time
delivery
level
Limited to obstetric Obstetric and nonobstetric
Maternal Maternal complication complications (related to complications (heart and other life-
complication is covered pregnancy, delivery, and threatening pregnancy
postpartum) complications)
Rate for management
of hemorrhage, vaginal
delivery with basic Rp 500,000 Rp 650,000
emergency care in
BEONC facilities
In-patient services for
complications during Covered, rate based on standard
Not covered
pregnancy, postpartum rate for inpatient services
in BEONC facilities
In-patient services for Covered, rate based on standard
Not covered
sick newborns rate for inpatient services
Postpartum care, e.g.,
Separate at a rate of Rp 150,000
placenta removal Included in delivery package
Fee for PNC in
Postnatal care Rp 10,000/time Rp 20,000/time
primary level
4 times to achieve the target pof
KF1,KF2,KF3&KN1, KN 2, KN35
For PNC with complications,
Frequency 3 times only according to the number of services
given as long as consistent with
standards (PNC can be more than 4
times)
Separate:
Contraception services6 Included in PNC component a. IUD/implant Rp 60,000
b. Injection Rp 10,000
Complication of
contraception Not covered Rp 100,000/time
postdelivery
Transport Transport for referral Covered Covered
management of sick
Newborn Not covered Covered
newborn
Source: Indonesia, Ministry of Health 2011–12.
5. KF = Postpartum visit
KN = Neonatal visit
First visit for KF1 and KN1 (6 hours to 2nd day); second visit for KN2 (3rd to 7th days); third visit for KF2 and KN3 (8th to 28th
days); fourth visit for KF3 (29th to 42nd days
6. Although Jampersal also reimburses the use of short-term contraceptives, the guidelines emphasized prioritizing long-term
contraceptives.
9
3.3. FINANCIAL SCHEME
Jampersal is entirely financed through central government revenues. Figure 1.2 describes channeling
of the Jampersal fund from the central to the district level. The fund was channeled directly from the
State Treasury Office (Kantor Pusat Perbendaharaan Negara, KPPN Jakarta V) to the following:
The head of district/municipality health office (DHO) account. A Jamkesmas management team at the
DHO manages the fund for puskesmas and participating private health facilities/providers at the
primary level. The center makes the transfer periodically, three to four times a year. The amount is
based on the number of pregnant women projection for the district, and adjusted according to fund
utilization during the previous reporting period.
The hospital account for hospitals, which has a memorandum of understanding (MoU) with the DHO
for Jamkesmas/Jampersal program. The center transfers the amount in advance based on service
utilization in the hospital budget report.
As a measure to maintain continuity of care and equity among regions, P2JK (Pusat Pembiayaan dan
Jaminan Kesehatan, the Center for Health Financing and Health Insurance, MoH) has the authority to
reallocate funds among districts and municipalities according to district utilization and need, and
depending on the availability of funds at the national level.
Figure 1.2 Jampersal Fund Channeing
Feedbac
Ministry of
Health (P2JK)
Provincial
KPPN V Health Office
(State Treasury
Financial
Report
SP2 Financia
with INA-CBG’s l Report
Transfer Fund Transfer Fund
(Jamkesmas/Jamper (Jamkesmas/Jamper
sal) sal)
Hospital District
Health
CLAIM by Hospital
V ifi t
POA+CLAIM
Claim
Local Government
Coders & ADM
by Indenpendent Verificator
PH PH Hom
NOTE: C C
: Transfer Fund Clini
PH PP
: Claim M
C
: Financial
Report JAMPERS
: Feedback
Report
Source: Modified from Ministry of Health Jampersal Technical Guidelines 2012.
Payment for the puskesmas is done through a transfer from the district treasury, while primary level
private health providers receive payment directly from the DHO. The amount of payment is based on
claims. The DHO verifies claims from primary level providers, while P2JK assigns independent
verificators to verify hospital claims. Jampersal adopts the portability principle, allowing beneficiaries
to get services from any Jampersal participating facility; the facility can make claims to the DHO
10
where it is located. The DHO must return unused funds to KPPN V at the end of the year, and submit
the fund utilization report to MoH.
3.4. SOCIALIZATION
MoH invited DHOs and hospitals to the socialization workshops about Jampersal it held at each
provincial health office (PHO); Jampersal technical guidelines were distributed to all attendees.
11
PART 4: STUDY FRAMEWORK
Policy Implementation Theory lists five factors influencing the success of policy implementation. The
factors are content, context, commitment, client capacity, and coalition or the 5-C Protocol
(Najam 1995). According to Cheema and Rondinelli (1983), policy performance and impact in a
decentralized setting is affected by four variables as illustrated in figure 1.3 below:
Figure 1.3 Conceptual Framework of Policy Implementation
Relation between
organizations
Environment Characteristics Performa
condition & capability of nce &
institutions impact
Organizational
resources
Source: Cheema and Rondineli,1983.
The study adopted the 5-C Protocol and the above conceptual framework to comprehensively analyze
Jampersal implementation, focusing on the following:
Jampersal policy design at the national level: (a) policy formulation, (b) soliciting political support to
improve policy acceptance, (c) development of implementation guidelines, and (d) monitoring and
evaluation.
Jampersal implementation at the provincial and district levels: (a) policy implementation issues,
including analysis of barrier and facilitating factors; and (b) impact of the policy on continuum of care
and provider performance.
12
Figure 1.4 Study Framework
Jampersal policy formulation at central level
Involvement of related stakeholders in the design and formulation of the
policy, in its legitimation, development of implementation guidelines,
monitoring and evaluation
Jampersal policy
Implementation at Municipality/District level
Contextual factors (Population,
geographic, culture, revenue, Health Office’ capacity
Commitment, awareness, advocacy
t )
Local gov’t support & commitment
(Counter budget, local regulation,
etc)
Health services provision & Community’s
performance (hospital, health acceptance and
Stakeholder support &
center, doctors, midwife) use of services
commitment (awareness,
l t )
Continuum of care (by time and
place)
o % ANC
o Delivery:
% facility-based delivery
% Cesarean section
o % postnatal care
o % postpartum family
Source: Authors.
Jampersal policy is developed centrally and implemented by local governments to provide maternal
and newborn health services at public health service delivery points and private institutions enlisted
by the local government. Because of decentralization, implementation varied among the districts,
depending on local government commitment, health service, and community factors. This study
examined the implementation of Jampersal policy in Garut District (mostly a rural area) and Depok
Municipality (an urban area) in West Java Province, covering contextual factors (geography,
population, revenue, and cultural aspects); local government commitment and support; stakeholder
participation and support; and the capacity of the lead implementing unit (that is, district health office)
in implementing the policy. This study also looked at service provision by the responsible public and
private health service institutions at the primary and secondary levels; human resources, particularly
doctors and midwives working in the institutions, regarding their satisfaction toward Jampersal terms
and conditions and financial incentives; and Jampersal utilization by the community, including
involvement of the community leaders, client satisfaction, and reasons for not using Jampersal. The
study analyzed Jampersal program output at the community level, covering the level of antenatal
care, institutional delivery, Cesarean section, and postpartum family planning services.
In interpreting the impact of Jampersal, the study also identified other programs implemented at the
national, provincial, or district level in health and other sectors that may influence program outcomes.
13
PART 5: METHODOLOGY
5.1. STUDY DESIGN
The team implemented the study during May to August 2013 in Garut District and Depok Municipality
in West Java Province. The study applied qualitative and quantitative approaches. The study design
was cross-sectional with pre/post assessment. The qualitative approach provided information about
the financing, payment, and organizational policies of Jampersal and reviewed the impact of the
policies on HRH performance. The quantitative approach examined whether Jampersal has an impact
in improving the coverage of services, particularly institutional deliveries and Cesarean sections. The
sample size provided statistically representative data for each area.
5.2. POPULATION AND SAMPLE SIZE
The qualitative approach used in-depth interviews and focus group discussions at the central,
provincial, district/municipality, and community levels. A household survey measured the impact of
Jampersal on maternity care utilization. The respondents were women of childbearing age (15 to 49
years). Women who delivered two years (the two-year cut-off point was used to reduce recall bias)
before Jampersal implementation (2011) were the baseline/pre-Jampersal samples, and women who
delivered after Jampersal implementation were the endline/post-Jampersal samples. The required
minimum sample size was 453 households for each group (pre- and post-) in each study area. The
sample size was 906 samples in total for each area, or 1,812 samples in the two study areas. The
study collected information from 921 respondents in Depok and 918 respondents in Garut, or a total
of 1,839 respondents. The households were randomly selected using a two-stage random sampling
with Probability Proportional to Size (PPS) method. Inclusion criteria were mothers with a
child/children who have lived in the study area at least since 2009 (See annex 3 for the full study
methodology).
5.3. STUDY LIMITATIONS
The study may have been undertaken too early to evaluate the real impact of Jampersal. Further,
since it covered only two districts, the study cannot represent the real situation of Jampersal
implementation in the country.
14
PART 6: RESULTS
6.1. DESCRIPTION OF THE STUDY AREAS
The two study areas were widely different in factors influencing access to health care. The size of
Garut District was approximately 3,000 kilometers,² with a population of over 2.4 million residing in 42
subdistricts. The majority of the district is rural/remote areas consisting of 403 rural-villages and only
21 urban-villages. In contrast, Depok Municipality is an urban area, with no geographical constraints
2
and with a high availability of health care facilities. Depok encompasses an area of 200.2 kilometers
and has a population of approximately 1.8 million people. Depok is a rapidly growing city, located next
to Jakarta, Indonesia’s capital. According to the 2011 Human Development Index (HDI), 7 Depok had a
high HDI score (79.36), higher than the HDI of West Java Province (72.73). The HDI of Garut for the
same year was 71.70.
In 2012, 12 of the 65 puskesmas in Garut had no doctor. More than half of the midwives in two of the
sampled puskesmas in Garut were temporary midwives, who were paid a monthly honorarium by the
puskesmas. Around 52 percent of village midwives in Garut had completed Normal Delivery Care
(Asuhan Persalinan Normal, APN) training while only around 29 percent of them had attended
Obstetric and Neonatal Emergency Care training (Gawat Darurat Obstetrik Neonatal, GDON). In
Depok, almost 91 percent of the midwives had completed APN training, and around 63 percent had
attended GDON training.
The list of facilities and human resources for health at the beginning of the Jampersal program (2011)
in the two locations is shown in table 1.3 below.
Table 1.3 Facilities and Human Resources for Health in Garut and Depok, 2011
Depok
Garut District
Facilities Municipality
Number (*) Number (**)
Public hospitals 2 1
Public hospital beds 504 71
Military hospitals 1 1
Private hospitals 1 14
Puskesmas (with in-patient care) 15 1
Puskesmas (without in-patient care) 50 31
Pustu (satellite puskesmas) 136 5
Private maternity clinics 7 25
Private physicians 2 158
Private clinics 89 19
Posyandu (integrated services post) 3,558 974
Human resources
Specialist physicians 30 551
Obstetricians 5 35***
Anesthesia specialists 12 24
Physicians (general practitioners) 93 269
Midwives 586 377
Village midwives 431 —
Nurses 673 1827
Pharmacists 70 284
Source: *Garut District Health Profile 2011; **Depok Municipality Health Profile 2011;
***based on license.
7. Human Development Index is a composite of three indexes: life expectancy rate, education (based on illiteracy rate and
average school years), and decent living index.
15
In 2012, there were 15 BEONC facilities in Garut, or double the number of 2010. Garut DHO had
converted 14 Puskesmas in geographically difficult areas into BEONCs. There were far fewer BEONC
facilities in Depok: only one BEONC in 2010 and four in 2012 (table 1.4).
Table 1.4 The Number of Health Facilities in Garut and Depok, 2010–12
Data Garut District* Depok Municipality**
2010 2011 2012 2010 2011 2012
Puskesmas (PHC) 64 65 65 32 32 32
BEONC8 facilities 6 15 15 1 2 4
Midwives 930 1,074 1,074 108 109 109
CEONC9 (public) facilities 1 1 1 1 1 1
CEONC (private) facilities 0 0 0 15 15 15
Source: *Garut District Health Profile 2010–12; **Depok Municipality Health Profile, 2010-12.
Less than half of Garut’s population and around a quarter of Depok’s population were covered either
by Jamkesmas, Jamkesda, 10 or Askes. 11 In Garut, Jamkesmas, Jamkesda, and Askes covered
around 33 percent, 6 percent, and 2 percent of the population, respectively. In Depok, the coverage
was around 8 percent, 10 percent, and 6 percent, respectively (table 1.5).
Table 1.5 Population and Recipients of Social Health Insurance in 2012
Garut Depok
Total population* 2,485,130 1,813,612
Poor population** 969,924 321,012
Estimate number of pregnant women* 67,414 47,899
Estimate number of birth deliveries 64,701 45,722
Jamkesmas** (%) 33 8
Jamkesda** (%) 6 10
Askes** (%) 2 6
Source: *Health Profile of Garut District and Depok Municipality, District Health Office 2010–12;
** Provincial Health Office Estimates, 2012.
6.2. IMPLEMENTATION OF JAMPERSAL POLICY (FINDINGS FROM THE QUALITATIVE
STUDY)
6.2.1. Organizational Arrangement
There were six main actors in Jampersal implemention: MoF, MoHA, Bappenas, MoH, PHO/DHO,
and local government. In practice only the MoH and local governments were actively involved in
Jampersal implementation. Both Garut and Depok collaborated with the Indonesia Midwives
Association (IBI) to increase participation of private practice midwives.
8 BEONC is Puskesmas with ability to provide 24-hour Basic Emergency Obstetric and Neonatal Care (BEONC/PONED),
including management of preeclampsia/eclampsia, shoulder dystocia, vacuum extraction, post-partum hemorrhage, puerperal
infections, low birth weight, and other early neonatal conditions.
9 CEONC is hospital with ability to provide comprehensive emergency obstetric and neonatal care
10. Local government health insurance.
11. Health insurance for civil servants.
16
Table 1.6 Roles and Responsibilities of Actors under Jampersal
MoF MoHA Bappenas MoH PHO/D Local
HO govern
ment
Oversight scheme √
Financing scheme √ √ √
Benefit package determination √
Accreditation/empaneling providers √ √
Financial management/planning √ √ √ √
Setting reimbursement rates √
Claims processing/payment √ √ √
Outreach/social marketing √ √
Service delivery √ √
Monitoring local utilization √
Monitoring national utilization √
Customer service √ √
Source: Modified from the Joint Learning Network 2012.
6.2.2. Financing
Utilization of Jampersal and disbursement of the allocated money for Garut increased gradually (table
1.7). In 2011, the absorption of the Jampersal budget was 43.5 percent (Rp 7.0 billion from the
allocated Rp 16.2 billion), and increased to 57.0 percent in 2012 (Rp 15.2 billion from the allocated Rp
26.7 billion). By the end of the second quarter of 2013, the absorption was almost Rp 6.0 billion.
Table 1.7 Budget Allocation and Utilization of Jampersal in Garut, 2011–13
Jampersal budget tranches
Year
I II III IV Total
2011 Allocation 6,133,501,000 8,178,002,000 1.942,169,000 - 16,253,672,000
Utilization 7,076,388,000
2012 Allocation 8,017,686,000 10,690,248,000 - 8.017,686,000 26,725,620,000
Utilization 15,258,030,000
2013* Allocation 8,390,279,000 8,770.560,000 - - 17,160,839,000
Utilization 5,759,470,750
Source: Garut District Health Office 2011-–13,
*Second quarter.
In 2013, the fund allocation in Depok decreased significantly (table 1.8). This was because the DHO
reported utilization of Jampersal in 2012 was only around Rp 500 million, although not all services
had been claimed. The study could not gain access to the disbursement data. The low utilization in
Depok might be related to the high use of private providers for maternal care in Depok; many private
providers did not participate in Jampersal.
17
12
Table 1.8 Budget Allocation of Jampersal in Depok, 2011–13
Budget allocation tranches
Year
I II III IV Total
2011 Allocation n.a. n.a. — n.a. n.a.
2012 Allocation 3,377,336,000 4,503,114,000 — 3.377,336,000 11,257,786,000
2013 Allocation 875,700,000 — — — 875,700,000
Source: Depok District Health Office, Technical Implementing Unit (Unit Pelaksana Teknis, UPT) Jamkesda,
2011–13.
According to the revised 2012 guidelines, disbursement of Jampersal funds should comply with the
APBD (Anggaran Pendapatan dan Belanja Daerah, local government budget mechanism). The DHO
prepared an annual Jampersal budget work plan (RKA, Rencana Kerja Anggaran) based on the
yearly projection of the number of deliveries in the district. The amount had to be locally approved and
recorded in the APBD and would be the reference for the Jampersal money available to the district for
the year. The DHO could not pay for claims above the amount set in the APBD. If the total claim was
higher, as experienced by Garut, the DHO could not cover the whole claim and had to delay payment
until the subsequent budget year. The DHO must return any unused Jampersal funds to KPPN V, and
submit a fund utilization report to MoH at the end of the budget year.
6.2.3. Verification, Claim, and Reimbursement System
6. 2. 3. 1. Primary Care Level
Jampersal used verificators to check the completeness and validity of Jampersal claims. There were
seven verificators in the Garut DHO and five in the Depok DHO. In addition, at the puskesmas in
Garut, a team consisting of the head of the puskesmas, the Jampersal treasurer, and the midwife
coordinator verified the completeness of documents for services delivered through the puskesmas
network (including the polindes) before submitting the claims to the DHO. One puskesmas did spot--
checks to uncover any irregularities by conducting home visits to Jampersal users.
"I had an experience finding fictitious data. The woman turned out to be an elderly. Field
verification is meant to confirm the accuracy of the claim." (Puskesmas)
Staff involved in the verification process received some incentives from the local government. For
delivery complications, the Maternity Care Plan (Askeb, Asuhan Kebidanan) was added to the
requirements for service claims. The Garut DHO went further by introducing a local policy requiring
submission of the Maternity Care Plan for all deliveries as a way to improve discipline in
documentation of provided care. This local initiative was considered burdensome by the midwives,
who thought the partograph 13 was a sufficient tool for recording normal as well as complicated birth
delivery processes.
Puskesmas and private providers must submit the required documentation for fee claim processing at
the DHO.
“It took between two or three weeks until one or two months to finish (verification of
documents for Jampersal claims). There were so many...especially...when it has piled
up for several months. Maybe for private providers there are not as many ...around
two to three patients per month. But, for the puskesmas, there are tens up to
hundreds for every single month. So it takes a longer time.” (DHO)
12. The researcher did not get any fund utilization data from Depok DHO.
13. Partograph is a composite graphical record of key data (maternal and fetal) during labor, entered against time on a single
sheet of paper. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labor,
and vital signs.
18
Figure 1.5 Claim and Reimbursment Mechanism at Primary Care Level
Puskesmas and private providers
submit patients’ claim documents:
KTP/ID card, MCH book and
t h f h ti t
Documents submitted to
Verificator at DHO
Verification is conducted for each patient.
For referral cases with complication,
additional documents is needed:
midwifery care plan
After verification, the claim documents
are
submitted to APBN treasurer for
disbursement process
Private Practice Midwives
(PPM)
Puskesma
C
The amount of funds withdrawed by The funds withdrawed by APBN
APBN treasurer is in accordance with Treasurer (100% of the total
the local government decree funds) will be given to DHO
Treasurer
DHO Treasurer will make the
SP2D to withdraw the money
from the Local Government
Treasury
If the SP2D is approved, the cash can DHO Treasurer will give the
be withdrawn by DHO treasurer to be cash directly individual PPM
given to each puskesmas
Source: Authors.
The DHO verified Jampersal claims from the puskesmas and private providers (figure 1.5). Private
providers at the primary level could send claims directly to the DHO verificators.
Puskesmas in rural/remote areas of Garut submitted claims every two to three months instead of
monthly. On the other hand, urban puskesmas came frequently to the DHO for consultation during the
verification process.
In 2011, after completion of the verification process, the verficators sent the documents to the DHO
Jampersal management team leader for approval. The team leader forwarded the documents to the
DHO treasurer of Jamkesmas/Jampersal with the claim amount to be paid. The puskesmas would
receive payment in cash from the DHO verificators. In 2012, the center changed the puskesmas
claim mechanism to follow MoF regulation on district financial management. The verificators
submitted verified claims to the APBN treasurer, who had the authority to withdraw money from the
district APBN account. The APBN treasurer transferred the money to the local government treasury at
the DHO. Fund withdrawal from the local government treasury was based on a disbursement warrant
letter (Surat Perintah Pencairan Dana, SP2D). The DHO treasurer would transfer the claim payment
19
to the puskesmas, while primary level private providers obtained the payment directly from the DHO
treasurer (figure 1.5).
The deadline for the use of Jampersal funds in each calendar year was December 20. This was
because MoH must return unused funds at the end of the year as nontax payment (Penerimaan
Negara Bukan Pajak, PNBP) to the KPPN. Claims submitted after December 20 would be paid in the
following year. The balance in the DHO account should be zero at the end of the year when the BPK
(Badan Pemeriksa Keuangan, National Finance Audit Board) audits the DHO.
The DHO was also bound by Ministry of Home Affairs (MoHA) regulation no. 262/PMK.03/2010,
regarding income tax, applying 6 percent income tax (Pajak Penghasilan, PPH 21) to fees received by
civil servants level III and above. The tax would be deducted from the amount paid to the puskesmas.
6. 2. 3. 2. Hospital Level
P2JK assigned independent verificators to verify Jampersal and also Jamkesmas claims at the
hospital level. Each hospital may also assign its own staff to verify the documents before submission
to the independent verificator.
Hospital Jampersal claims were based on the INA-CBGs 14 tariff (figure 1.6). Required claim
documents included a copy of the medical record, including supporting examination results, family
card, the mother’s and the husband’s ID cards, and the mother’s MCH book.15 The hospital would
issue a statement letter for entering data into the INA-CBGs software and for verification by the
independent verificator. Problems in the verification process were related mainly to software changes
and broken computers.
14. Indonesia case-based groups or DRGs.
15. The MCH book records information from maternal services records (pregnancy, childbirth, and postpartum) and child
services records (immunization, growth monitoring) and provides relevant information about maternal and child health care.
20
Figure 1.6 Claim and Reimbursment Mechanism at the Hospital Level
The hospital prepare the documents for
jampersal user claim: Medical resume,
ID card, and MCH book
The documents will be verified by
Hospital Verificator to be inputed
into INA-CBGs software
All claim that has been inpjuted into the
software will be re-verified by Independent
Verificator from MoH
The claim that has been approved by
the independent verificator will be
inputed in a CD to be sent to P2JK
The funds that is already available in the
Hospital account can be
used/withdrawn by the hospital
without waiting for feedback from P2JK
Source: Authors.
Because MoH has transferred Jampersal money to the hospital in advance, the claim payment
process did not take long once the verification process was complete. So far, the amount transferred
by MoH to the hospitals was enough to cover the claim payments. If all Jampersal money in the
hospital account has been spent, the MoH would make another transfer to the hospital.
6.2.4. Provider Payment Scheme
6. 2. 4. 1. Primary Care
According to Jampersal guidelines, a minimum 75 percent of puskesmas claims were for service fees;
the remainder (25 percent) could be used by the DHO for operational costs, such as program
socialization, consumables, drugs, and monitoring and evaluation. Depok allocated only 15 percent
for DHO operational costs. 16 Private providers were reimbursed 100 percent of their claims.
The puskesmas has the flexibility to decide on the fee amount for the providers. In some puskesmas
in Garut, the amount received was shared by all puskesmas staff depending on the workload;
therefore, the amount received by the actual provider was quite small even though the government
had increased Jampersal service fees in 2012.
6. 2. 4. 2. Hospital Level
Payment to public and private hospitals was determined according to the same INA-CBG tariffs.
Public hospital management reported that the service fee for medical staff was a very small proportion
of the total claim per service. This was considered unfair, particularly for specialists who saw many
16. Depok Mayor Decree no. 903/99/KPTS/dinkes/Huk/2013.
21
hospital patients. One informant stated that the service fee received by a specialist from a public
hospital per patient was only 5 percent.
For private hospitals, the INA-CBG payment was considered far below the private hospital tariff, even
after the government increased the tariff. Cesarean section for third-class patients under INA-CBG
was Rp 1.4 million, while non-Jampersal patients in a private hospital paid Rp 8 million. A private
hospital informant stated 50 percent of the Jampersal payment was for the obstetrician, 30 percent for
the anesthesia specialist, and 20 percent for the pediatrician. Other clinical staff such as the
anesthesia assistant got Rp 50,000 to 100,000 per Jampersal patient from the hospital’s own budget.
Midwives and nurses in that private hospital were considered salaried workers and did not receive
anything from the Jampersal claims.
6.2.5. Socialization
The study found that the central level socialization workshop preceded the distribution of Jampersal
guidelines to the PHO/DHO and the health providers. The guidelines were available at the
implementation level around three months after the start of the implementation or mid-2011. There
were indications of some confusion at the beginning of program implementation, particularly regarding
implementation procedures and the benefits package.
The DHO conducted socialization for all Jampersal providers through monthly workshops, meetings,
and other activities. An informant from a private clinic stated there was no follow up from the DHO to
discuss agreement on the Jampersal program.
In puskesmas, participants of the socialization workshop were the head of the puskesmas, the
midwife coordinator as the technical implementer, and the treasurer of Jampersal. The DHO adjusted
the socialization material according to participants’ duties and responsibilities. Interviews during the
study revealed that the general nature of the guidelines may have undermined the wide variation of
implementation conditions.
“It is not suitable to the field condition. The technical guidelines are general, as if all
health facilities are the same: having a doctor, midwives, complete tools, and
infrastructure.” (Puskesmas)
The DHO reported that questions raised by the midwives indicated they did not have access to or had
not read the gudeilines.
“….. Many midwives still ask questions…whether pills can be claimed. In fact, the
answer is stated in the technical guidelines. Some midwives did not claim for family
planning services because they did not know that postpartum family planning was
covered.” (DHO)
Some midwives thought Jampersal information was clear except for information on payment to the
providers. They also questioned the use of the 25 percent operational costs by the DHO.
Puskesmas and village midwives conducted Jampersal socialization for the community through mini
workshop/meetings at the village office, posyandu, or puskesmas. In rural and remote areas, they
also used community activities such as religious gatherings as venues. Socialization for Jampersal
beneficiaries was done mostly by midwives for women seeking antenatal care.
Interviews with women and community leaders showed that community understanding about
Jampersal was inadequate. Many women did not know about Jampersal. Some informants perceived
that Jampersal only covered fees for birth delivery. Others thought that Jampersal required cost-
sharing and patients would have to pay half of the service costs. Some women did not want to use
Jampersal because they were not convinced that services were free, particularly for treatment of
complications in the hospital. Some perceived Jampersal provided lower quality of service.
22
"… Have heard of Jampersal, but I hesitated to use, I am afraid that I still have to
pay." (Mothers)
"I think the service is the same, but patient who pays get faster service, gets good
and expensive medicine.” (Mothers)
6.2.6. Monitoring and Evaluation
Jampersal monitoring and evaluation (monev) was conducted through a cascade process. The DHO
conducted visits and regular meetings with the puskesmas head and with the verificators to discuss
implementation issues, such as places eligible for birth delivery, claim schedule for puskesmas,
disbursement schedule of Jampersal funds, and coverage report. A DHO informant reported that
implementation of monev activities were not regular. At the puskesmas level, the discussion was
mostly about program coverage, barriers, and problems. Overall, information gathered during the
study seemed to indicate that the focus of monev was primarily on the utilization of Jampersal funds.
6.2.7. Supply-Side Capacity
6. 2. 7. 1. Human Resources
Unlike Depok, Garut had a serious shortfall in HRH numbers and distribution, especially for its rural
and remote areas. The local government relied mostly on support from the provincial and central
governments for HRH recruitment. However, most HRH sent by the province did not want to serve in
difficult areas.
Recruitment of Bidan Honorer in Garut has somewhat helped the puskesmas in solving the HRH
availability issue, but the compensation of Bidan Honorer has become a burden to the puskesmas. A
puskesmas reported that the monthly fee of a Bidan Honorer was only Rp 100,000 per month,
although they were eligible for receiving Jampersal service fees. The turnover of Bidan Honorer was
higher than that of civil servants. The DHO considered this problematic because the high turnover
affected puskesmas achievements.
"In puskesmas BEONC X, the PTT (contract) midwife has received BEONC training,
but the building was not ready. When the building is finished, the midwife has moved
out…the puskesmas recruit...volunteers…. In reality there are many Bidan Honorer in
the BEONC, but they do not have BEONC competencies." (DHO)
In the public hospitals, the increasing number of patients due to Jampersal was not followed by a
parallel increase in HRH. The hospital was lacking specialists and midwives for maternity care.
Although there were obstetric interns in the hospital, the workload of the obstetricians was quite high.
“Now there are eight patients, a patient has not given birth, another one came in. The
surgery has just finished; there is another one already in the waiting lists for the next
surgery. Honestly we really want to refuse patients, but it is not allowed…. It makes
us so tired….” (Hospital)
6. 2. 7. 2. Public Health Facilities
After Jampersal, all puskesmas in Garut were instructed to provide delivery services; while before
Jampersal, only puskesmas with in-patients provided the services. Despite improvements to the
puskesmas, for example by increasing the number of BEONC (basic essential obstetric and
neonatal care) facilities, puskesmas in the rural areas of Garut were only open from 7 am to 2 pm.
The midwives considered the presence of BEONC facilities in remote areas helpful, at least for
stabilizing patients with complications before referring them to the hospital. Dr. Slamet Public Hospital
in Garut could not fully function as a CEONC (comprehensive essential obstetric and neonatal care)
hospital because it did not have sufficient staff and facilities. The neonatal intensive care unit (NICU)
was available but not yet functioning.
23
"Referred obstetric patients go to emergency room where there is only one midwife
per shift, incomplete equipment, and lack of facilities. If there are three referred
patients ...will be a burden to the emergency room." (Hospital)
One clinical staff stated that even before the Jampersal program, the district hospital has always had
a high load of referred obstetric cases.
“What a pity …patients must be tired of waiting, and for us this did not make our
performance optimal. If the Cesarean section was delayed, we could not go home to
rest.... It was so tiring and make us angry.” (Obstetrician in a district hospital)
Both study areas faced problems in referring maternal complications. Depok has one public hospital
with very limited capacity to provide maternal and neonatal care; as a result, the hospital often
referred severe complications to other hospitals, including to public hospitals outside Depok and
sometimes to private hospitals. Garut has two public hospitals, but only one could fully function as a
referral hospital, causing a real burden to that hospital. The situation was exacerbated by
geographical constraints. The referral hospital was difficult to access from the southern part of Garut
with at least a three-hour travel time to reach the hospital.
6. 2. 7. 3. Private Providers
Private sector participation in Garut was low. Only 11 of 571 private practice midwives in Garut have
signed the Jampersal memorandum of understanding (MoU) with the DHO. Jampersal guidelines
stated services should be provided by competent staff. There is no accreditation process prior to
enrollment of the providers. Most private practice midwives in Garut engaged in dual practice as they
were public sector employees in the morning. In Depok, 67 percent of private practice midwives had
Jampersal MoU with the DHO. The Indonesia Midwives Association (IBI) was instrumental in
increasing the involvement of private practice midwives.
The acceptance of private practice midwives to Jampersal varies according to their perceived
benefits. Many private providers in the two locations were dissatisfied with the service fees; this was
the main reason for refusing to become Jampersal service providers. The regular tariff for delivery in
puskesmas according to Garut District regulation was Rp 75,000 to Rp 125,000, depending on the
type of the delivery provider. 17 Although the Jampersal tariff was already higher (Rp 500,000 for
normal delivery), it was still lower than the private provider tariff. In Depok, the fee for normal delivery
by a private provider was Rp 1 million, while in Garut it was Rp 850,000.
For midwives with a low visit rate or with a practice in areas where the majority of the community was
of low socioeconomic status, Jampersal increased the number of deliveries in their private practice. A
midwife who had few patients before Jampersal mentioned that Jampersal increased her income
because she saw more Jampersal patients. On the other hand, midwives with a high number of
patients paying out-of-pocket were reluctant to serve Jampersal patients. A private midwife with many
patients, who did not sign up for Jampersal, reported a reduced income because Jampersal shifted
some of her patients to the puskesmas or to other private practice Jampersal midwives. Other
midwives reported that the additional workload due to Jampersal was not comparable to the
compensation received.
Regardless of the midwife’s perception of Jampersal benefits, almost all midwives interviewed
consistently mentioned the problem of delayed reimbursement and troublesome claim processes.
One private midwife interviewed reported she stopped providing Jampersal services for those
reasons. Non-Jampersal clients paid directly out-of-pocket for services received, while in Jampersal,
private providers had to submit claims, and payment was often delayed.
Based on DHO information, no private clinic in Garut provided Jampersal services. One private clinic
owner stated the main reason for not joining Jampersal was the low reimbursement that did not cover
service fees and operational costs. The tariff rate set out by INA-CBGs was much lower than the
17. Garut Local Government regulation no. 821/Kep.0006.A/Dinkes/2013.
24
usual obstetrician fee rate. Private clinics were concerned that a low fee would result in low quality,
while service quality was the trademark of the private sector. Moreover, private clinics with low bed
occupancy rates (BORs) could not exercise cross-subsidy.
“It does not cover at all. I have to pay the wages for my staff, and in the private sector
the cost is borne by the patients.” (Private Clinic Owner)
“The specialist will get nothing…even the nurses will only receive 10 to 25 percent of
the usual service fee. In the end I fear that it will affect the service delivery
performance.” (Private Clinic Owner)
There was no private hospital in Garut. All private hospitals in Depok signed a Jampersal MoU, and
demanded that each private hospital get an equal share of Jampersal patients. In practice, many
private hospitals in Depok did not accept Jampersal patients, despite the MOU; or they limited the
number of patients. In addition, not all facilities adhered to Jampersal portability principles. Some
private hospitals rejected Jampersal patients from neighboring districts, while others refused referral
from private practice midwives and demanded a referral letter from a puskesmas or public hospital.
The main reason for low participation of the private hospitals was the low Jampersal reimbursement.
Another study found that the low involvement of private hospitals is due to unclear information about
the program itself, including about the criteria of cases covered by Jampersal, the payment system,
and the benefit package (Najib et al. 2012).
The DHO acknowledged difficulties in engaging the private sector to join Jampersal. There was
concern in the DHO that if private clinics provided Jampersal services, most patients would prefer
private clinics to public hospitals or puskesmas.
6.2.8. Commitment to Jampersal
Garut DHO acted to overcome some Jampersal implementation barriers, for example: (1) advocacy to
district government to increase the allocation for service fees to public providers at primary care level;
(2) advocacy to increase the ceiling of the Jampersal fund allocation in the APBD through a budget
amendment to ensure that all claims could be covered within the ongoing year; (3) speeding up the
verification process by providing incentives to the puskesmas verificators; (4) encouraging village
midwives and private practice midwives to improve the quality of their practice sites for eligibility as
Jampersal delivery facilities; and (5) developing a claim submission schedule for a puskesmas to
better organize the verification system and prevent delays.
Village government contribution to Jampersal included the following: (1) socializing Jampersal
information; (2) providing temporary ID cards or statement letters of domicile; (3) facilitating the
provision of a village ambulance by encouraging a Corporate Social Responsibility Program of the
private sector; (4) issuing village regulation on partnership between midwife and traditional birth
attendants (TBAs); and (5) approving the construction of a village polyclinic financed by PNPM 18 as
the village priority.
In 2013, the Depok DHO sought to improve Jampersal coverage by (1) adding a verificator at the
DHO to accelerate the verification and claim payment process; (2) requesting Jampersal providers to
send monthly claims to the verificator to avoid claim accumulation; (3) increasing the partnership with
private practice midwives in serving Jampersal patients by providing reimbursement for consumables
and drugs.
Low commitment of private hospitals to Jampersal in Depok compromised the effectiveness of the
Jampersal referral system. Some hospitals refused to admit referred Jampersal patients, and the
DHO often had to intervene and directly call the hospital to ensure that referred patients with
government insurance were accepted by the hospital.
18. PNPM (Program Nasional Pemberdayaan Masyarakat) is a national community empowerment program for poverty
reduction.
25
6.2.9. Garut’s Dilemma in Implementing Jampersal Policy
In response to the lack of delivery facilities in rural and remote areas, Garut allowed skilled birth
attendants to charge for home deliveries to Jampersal. This local policy was inconsistent with the
Jampersal guidelines.
“Deviation still occurs in the Southern region and mountainous areas, please note and
take this for input…. They give birth at home and still claim as Jampersal.” (DHO)
Another issue was that Garut had a decree from the DHO (No 821/Kep.0006.A/Dinkes/2013) for a
Service Fee Target for Local Revenues, meaning that all puskesmas had an annual target of service
fee earnings that would contribute to local government revenue. The fees were collected from in-
patient services, deliveries, medical treatment, laboratories, and ambulances. The fee target was
based on the number of villages, types of maternal care, and the number of pregnant women. The fee
for birth delivery was Rp 75,000 to Rp 125,000 per patient depending on the type of birth attendant
(midwife or doctor), and Rp 200,000 per patient for delivery in a BEONC facility.
The three puskesmas visited in the study had different fee targets for delivery care. The target for a
BEONC facility in an urban area was Rp 12,075,000; for a BEONC facility in a remote area, Rp
7,350,000; and for a puskesmas without in-patient care in a rural area, Rp 12,700,000 per year.
The local regulation was a dilemma for providers in rural and remote areas. Although Jampersal
patients did not pay for delivery services, a puskesmas still had the obligation to meet the district
government’s target.
Some puskesmas believed an unachieved target would be carried over to the next year and decided
to request a contribution from the midwives. Each puskesmas and village midwife contributed about
Rp 80,000 to Rp 150,000 per month. In contrast, puskesmas in urban areas with a high visit rate
could cover the target from other services.
“You can imagine, the target in my puskesmas is 9 million per year, and we only have
five midwives. Every month, how much do we have to contribute? There is Jampersal,
but we still have to pay….” (Puskesmas)
26
6.3. RESULTS OF THE HOUSEHOLD SURVEY
6. 3. 1 Respondent Characteristics
The household survey enrolled a total of 1,839 respondents, who are women of childbearing age (15
to 49 years): 921 sampled from Depok Municipality and 918 from Garut District. The sample size
difference between the two locations was due to the rounding of samples per census block. The
sample size per district for before and after Jampersal met the required minimum sample size.
Table 1.9 presents the respondent characteristics. The majority of the sample in both districts was in
the two age groups: 21-to-30 and 31-to-40 years. The proportion of respondents less than 20-years
old showed a different pattern: in Garut the percentage was much higher (3.9 percent among pre-
Jampersal samples and 15.6 percent among post-Jampersal samples) than in Depok (0.4 percent
and 3.0 percent, respectively).
Table 1.9 Respondent Characteristics
Characteristics Garut Depok
Before After Before After
(n=462) (n=456) (n=460) (n=461)
% % % %
Age ≤ 20 years 3.9 15.6 0.4 3.0
21–30 year 50.4 50.7 45.0 56.6
31–40 year 36.8 30.5 47.2 36.9
>40 year 8.9 3.3 7.4 3.5
Minimum (years) 18 17 20 14
Maximum (years) 49 49 45 45
Mean (years) 30.3 28.1 31.6 29.7
Pregnancy 2–3 times pregnancy 48.9 46.9 52.6 54.9
1 time pregnancy 31.6 35.3 35.2 32.3
> 3 time pregnancy 19.5 17.8 12.2 12.8
Minimum 1 1 1 1
Maximum 10 11 7 9
Mean 2.5 2.3 2.2 2.2
Completed No school/some primary 3.0 1.8 1.3 0.9
education Primary 46.5 43.4 14.3 12.6
Secondary 47.0 49.3 72.8 73.8
Academy/university 3.5 5.5 11.5 12.8
Occupation status Working 25.1 14.0 26.7 20.4
Not working 74.9 86.0 73.3 79.6
Urban-rural Urban 45.0 45.6 100.0 100.0
Rural 55.0 54.4 0.0 0.0
Health insurance No insurance 48.3 56.1 55.4 57.5
Insurance for the poor 46.5 38.4 15.9 14.3
Other insurance 5.2 5.5 28.7 28.2
Most before and after Jampersal implementation respondents in Depok and Garut had two to three
pregnancies. After Jampersal was initiated, the proportion of those with a first pregnancy was higher
in Garut, but lower in Depok. For women pregnant more than three times, the proportion after
Jampersal was lower in Garut, but was equal before and after Jampersal in Depok.
The educational background of respondents in the two locations was also different. In Depok, almost
75 percent of the respondents had completed secondary school and less than 15 percent attended
only primary school, while in Garut about the same proportions attended primary and secondary
schools. In both locations, only a quarter of respondents were working. By design, Depok Municipality
was selected to represent urban characteristics, while Garut Distrct was selected to represent rural
characteristics, although the district had some urban areas. The percentage of poor people in Garut
27
was higher than in Depok as indicated by the higher percentage of those having the insurance for the
poor in Garut.
6. 3. 2 Community Understanding about Jampersal Program
The study found a gap in women’s exposure to information about Jampersal as it entered its third
year of implementation. Approximately one-third (32 percent) and one-fourth (24 percent) of
respondents in Depok and Garut, respectively, stated that they had never heard of Jampersal (figure
1.7).
Figure 1.7 Proportion of Women Who Have Heard of Jampersal
Garut Depok "I have heard that,
but I did not pay
attention, free
No No delivery...to be
24% 32% honest...I don’t
know...I rarely go to
Yes the Posyandu."
Yes
76% 68% (Focus Group
Discussion Mothers,
Non-Jampersal
Among those who had heard of Jampersal, sources of information included health facilities and
personnel, nonhealth providers, and mass media. Different sources provided the information in Depok
and Garut. In Depok, a large proportion of women got Jampersal information from the health
providers (38.3 percent) and/or the health facilities (25.2 percent); while in Garut the majority of
women received information from nonhealth providers (60.3 percent), and only 8.3 percent and 17.4
percent got it from the health providers and the health facilities, respectively (figure 1.8).
Figure 1.8 Source of Jampersal Information in Depok and Garut
70,0%
60,0%
50,0%
40,0%
30,0%
20,0%
10,0%
0,0%
Garut Depok
Health facilities 17,4% 25,2%
Health provider 8,3% 38,3%
Non-health provider 60,3% 41,5%
Mass media 29,9% 21,4%
Community activities 0,5% 0,7%
For those who had heard of Jampersal, the study also measured their understanding about the
program. Most women who had heard of Jampersal mentioned the program provided free delivery
(mentioned by 81.8 percent of respondents in Depok, and 84.8 percent in Garut). The second most
frequently mentioned benefit was free antenatal care. Only a few women mentioned the other
benefits. Only 6.9 percent of women in Garut mentioned free Cesarean section as a Jampersal
28
benefit compared to 27.8 percent in Depok. Overall, the proportion of women who mentioned other
Jampersal benefits apart from free delivery was lower in Garut than in Depok (figure 1.9).
Figure 1.9 Perception about Jampersal
90
80
70
60
50
40
30
20
10
0
Free Free C- Free
Free Free Post Do Not
Free ANC Third Class Newborn Section w/ Contacepti
Delivery Natal Care Know
Care Indication ve Method
Garut 17 84.8 6.4 5.9 6.7 6.9 4.8 6.1
Depok 18.6 81.8 10.9 10.9 11.9 27.8 9.1 10.1
Women were asked about health facilities eligible for Jampersal services. In both districts, the main
response was public facilities. A small proportion of women mentioned that services at home were
also free of charge under Jampersal.
29
6. 3. 3 Jampersal Utilization
Jampersal utilization for the last delivery post-Jampersal was 28.1 percent in Garut and 10.3 percent
in Depok. Jampersal was used mostly by less-educated women (26.2 percent), who resided in rural
areas (33.5 percent), and who were in the lowest and second-lowest wealth quintile (21.8 and 23.1
percent, respectively). Jampersal use was also high among women with delivery complications (29.1
percent) (see table 1.10).
Table 1.10 Utilization of Jampersal for the Last Delivery, by Respondents’ Characteristics,
Depok and Garut, Post-Jampersal (after 2011)
Jampersal utilization for last delivery
Women's characteristics Garut Depok Garut and Depok
n % p-value n % p-value n % p-value
All 456 28.1 458 10.3 914 19.1
District/municipality
Garut 456 28.1
0.000
Depok 458 10.3
Women's age
20–34 years 325 27.4 352 10.2 677 18.5
<20 years 43 30.2 0.874 9 22.2 0.472 52 28.8 0.185
>=35 years 88 29.5 97 9.3 185 18.9
Women’s education level
completed
No school/primary 206 30.6 61 11.5 267 26.2
Secondary 225 25.3 0.434 338 11.2 0.176 563 16.9 0.001
Academy/univ 25 32 59 3.4 84 11.9
Women’s occupation status
Not working 392 28.6 365 11.2 757 20.2
0.555 0.175 0.072
Working 64 25 93 6.5 157 14
Number of pregnancies
2–3 pregnancies 214 27.6 251 10.4 465 18.3
First pregnancy 161 26.1 0.484 148 9.5 0.873 309 18.1 0.244
Multiple pregnancies 81 33.3 59 11.9 140 24.3
Antenatal care to health provider
No 9 0 2 0 11 0
0.058 0.632 0.104
Yes 447 28.6 456 10.3 903 19.4
Complication during delivery
No complication 367 22.1 286 6.3 653 15.2
0.000 0 0.000
Any complication 89 52.8 172 16.9 261 29.1
Residence
Urban 208 21.6 458 10.3 n.a. 666 13.8
0.005 0.000
Rural 248 33.5 248 33.5
Insurance
Other insurance 25 16 130 3.1 155 5.2
Insurance for the poor 175 32 0.180 65 13.8 0.006 240 27.1 0.000
No insurance 256 26.6 263 12.9 519 19.7
Wealth quintile (total)
Lowest 90 26.7 89 16.9 179 21.8
Second 90 33.3 92 13 182 23.1
Middle 96 24 0.002 89 9 0.084 185 16.8 0.007
Fourth 89 41.6 93 6.5 182 23.6
Highest 91 15.4 95 6.3 186 10.8
30
6. 3. 4 Utilization of Maternal Health Services
1.3.4.1. Antenatal Care
The total number of ANC visits and the MoH-recommended 1-1-2 visit pattern (at least one visit in the
first trimester, one visit in the second trimester, and two visits in the third trimester) were the same
before and after Jampersal implementation. This finding was consistent across the two study areas
(table 1.11 and figure 1.10).
Table 1.11 Number of ANC Visits
Number of ANC Garut Depok
Before After Before After
(n=462) (n=456) (n=460) (n=461)
4 times or more 93.7 93.9 97.4 96.3
3 times 2.8 2.4 1.3 1.5
1–2 times 2.2 1.8 0.4 1.8
No ANC 1.3 2.0 0.9 0.4
Figure 1.10 ANC 1-1-2 Visit Pattern
100%
13.40% 16.10%
90% 21.10% 20.40%
80%
70%
60%
50%
86.60%
40% 78.90% 79.60% 83.90%
30%
20%
10%
0%
BEFORE AFTER BEFORE AFTER
GARUT DEPOK
1-1-2- visits Not meeting 1-1-2 visits 1-1-2- visits Not meeting 1-1-2 visits
31
1.3.4.2. Delivery
After Jampersal, institutional deliveries increased by 8.4 percentage points or 13.7 percent compared
to before Jampersal (table 1.12).
Table 1.12 Place of Delivery by Time and by Women’s Characteristics,
Total Samples (Depok and Garut)
Variables Place of delivery Total p-value
Home Facility
n=633 n=1206 n=1839
Period
Pre-Jampersal 356 (38.6) 566 (61.4) 922 (100) 0.000
Post-Jampersal 277 (30.2) 640 (69.8) 917 (100)
Figure 1.11 shows that institutional deliveries in Garut increased 16.6 percentage points after
Jampersal, from 30.5 percent to 47.1 percent. In Depok, institutional deliveries before Jampersal were
already high (92.3 percent), and remained at relatively the same level after Jampersal (92.2 percent).
However, there was a slight shift of place of delivery in Depok from private to public facilities. The
change in choice of place of delivery before and after Jampersal was more apparent in Garut. Home
deliveries declined by 16.6 percentage points after Jampersal, while delivery at public and private
facilities increased by 5.2 percentage points and 11.4 percentage points, respectively.
Figure 1.11 Place of Delivery
Garut District
Before 9,7% 20,8% 69,5%
“Free delivery is
After 14,9% 32,2% 52,9%
only for delivery in
PHC, maybe it’s
0,0% 20,0% 40,0% 60,0% 80,0% 100,0%
called Jampersal”
Public Facility Private Facility Home
(FGD)
Depok Municipality
Before 14,3% 78,0% 7,6%
After 17,6% 74,6% 7,8%
0,0% 20,0% 40,0% 60,0% 80,0% 100,0%
Public Facility Private Facility Home
Respondents who delivered at home were asked the reason/s for choosing home delivery. The
reason most frequently mentioned was cost (34 percent), more convenient/more comfortable to
deliver at home (27 percent), and delivery process started before the mother could be transported to a
facility (20 percent). This pattern was the same for Garut and Depok, although in Garut a large
proportion of respondents (21 percent) also expressed transport and distance to facility as reasons for
choosing home delivery.
32
Table 1.13 shows the breakdown of preferred delivery facilities in the two study locations. In Garut,
delivery at midwife/nurse practice increased from 19.9 percent before Jampersal to 31.8 percent after
Jampersal. There was also an increase in delivery at a hospital from 8.0 percent to 11.2 percent. The
proportion of deliveries at the puskesmas in Garut was very low (2.2 percent) and only increased
slightly after Jampersal to 3.9 percent.
The preferred place of delivery in Depok before Jampersal was the midwife/nurse practice (43.9
percent) and hospital (36.1 percent). After Jampersal, birth delivery at midwife/nurse practice in
Depok decreased slightly (40.6 percent), while delivery at hospital increased slightly (37.5 percent).
Interestingly, delivery at private clinics/doctors/specialist practices in Depok after Jampersal increased
by almost 4 percentage points from 6.3 percent to 10.0 percent, while delivery at the puskesmas
declined from 6.1 percent to 4.1 percent.
Table 1.13 Breakdown of Preferred Birth Delivery Facilities
Garut Depok
Birth delivery facilities Before After Before After
% % % %
n=462 n=456 n=460 n=461
Home 69.3 52.9 7.6 7.8
Puskesmas 2.2 3.9 6.1 4.1
Midwife/nurse practice 19.9 31.8 43.9 40.6
Clinic/doctor/specialist practice 0.4 0.2 6.3 10.0
Hospital 8.0 11.2 36.1 37.5
Other 0.2 0.0 0.0 0.0
Figure 1.12 shows the proportion of deliveries by skilled birth attendants) in Depok and Garut. More
than 95 percent of deliveries in Depok were by skilled birth attendants before and after Jampersal. In
Garut the proportion of deliveries by SBAs was only around 60.0 percent before Jampersal, but
increased to 71.7 percent after Jampersal.
Figure 1.12 Skilled Birth Attendance before and after Jampersal
The increased proportion of deliveries by skilled birth attendants in Garut was higher in rural than in
urban areas. The increase in rural areas was around 14.5 percentage points, while in urban areas the
increase was only around 9.1 percentage points (table 1.14).
33
Table 1.14 Skilled Birth Attendance before and after Jampersal, by Urban and Rural
Areas, in Garut District
Before After
Urban n=208 n=208
(n=416)
69.7% 78.8%
Rural n=254 n=248
(n=502)
51.2% 65.7%
1.3.4.3. Cesarean Section
In Garut, the percentage of Cesarean sections more than doubled after Jampersal from 1.1 to 2.6
percent, although the increase is not statistically significant (p-value 0.092), and the level remains low.
In Depok, the percentage of Cesarean sections after Jampersal also increased from 20.2 to 24.1
percent, which is above the WHO standard for 5 to 15 percent, but as in Garut, the increase was not
statistically significant (p-value 0.159) (see table 1.15).
Table 1.15 Results of Bivariate Analysis on Association between Jampersal and Cesarean
Sections
Variables Garut Depok
Cesarian section p-value Cesarian section p-value
No Yes No Yes
n=901 n=17 n=717 n=204
Before Jampersal 457 (98.9) 5 (1.1) 0.092 367 (79.8) 93 (20.2) 0.159
After Jampersal 444 (97.4) 12 (2.6) 350 (75.9) 111 (24.1)
1.3.4.4. Postnatal Care
As with antenatal care, there was almost no change in the proportion of postnatal care before and
after Jampersal (figure 1.13). The coverage of postnatal care was low in both areas, but the coverage
in Garut was much lower (around 5 percent), while in Depok the coverage was around 22 percent. It
should be noted that those percentages reflect the coverage of four visits of postnatal care, according
to Jampersal guidelines introduced in 2012 (see table 1.1).
34
Figure 1.13 Percentage of Postnatal Care
Yes No Yes No
Before 5.5% 94.5% Before 22.2% 77.8%
Depok
Garut
After 5.3% 94.7% After 21.7% 78.3%
1.3.4.5. Family Planning
Family planning services endorsed by Jampersal were the long-term contraceptive methods (IUD,
19
implant, vasectomy, tubectomy ), although short-term methods were also eligible. Figure 1.14 below
shows low coverage of long-term contraceptive methods in both locations, although there was a
higher increase in Depok compared to Garut after Jampersal. The graphs also indicated that the
increase was due to substitution rather than to new contraceptive users. The focus group discussion
(FGD) with mothers revealed that they did not like long-term contraceptives because they were afraid
of the side effects.
Figure 1.14 Percentage of Family Planning, before and after Jampersal, by Method
Long Term Short Term Long Term Short Term
"…Most of the
people are still
afraid, especially
in using spiral
81.3% (IUD);” “…People
91.5% 89.4% 89.7%
are not free to
choose.”
18.7%
8.5% 10.6% 10.3% (FGD Mothers,
Before After Before After Non-Jampersal
Users)
Garut Depok
19. Vasectomy is a surgical procedure for male sterilization and/or permanent birth control. Tubectomy is a surgical procedure
for sterilization in which a woman's fallopian tubes are clamped and blocked, or severed and sealed; both method prevents
eggs from reaching the uterus for fertilization.
35
1.3.4.6. Source of Payment for Last Delivery
Table 1.16 Source of Payment for the Last Delivery
Source of payment for Garut (n=918) Depok (n=921)
delivery Before After Before After
n=462 n=456 n=460 n=461
Out-of-pocket 93.3 81.6 92.2 86.3
Company 0.6 1.5 11.7 13.4
Private insurance 0.4 0.4 2.2 2.4
Askes20 0.4 1.1 1.5 0.9
Jamsostek21 0.0 0.7 3.0 4.3
Jamkesmas22 8.2 3.1 0.9 1.3
Jamkesda23 1.3 0.7 1.1 1.5
Jampersal 0.0 28.1 0.0 10.2
Others 8.4 10.3 16.5 12.8
Respondents were asked if they made any payment during the last delivery. If they made payments,
they were asked to list all payment sources. Table 1.16 shows the percentage of out-of-pocket
payment for delivery decreased in Garut after Jampersal from 93.3 percent to 81.6 percent, while in
Depok the decline was from 92.2 percent to 86.3 percent. In Garut, the use of Jamkesda and
Jamkesmas declined after Jampersal. Payment by Jampersal was higher in Garut (28.1 percent) than
in Depok (10.2 percent).
Among respondents who used Jampersal, almost 60 percent reported additional out-of-pocket
payments. This proportion was almost the same in Garut and in Depok. From those spending
additional funds, more than 55 percent and around 30 percent of respondents in Garut and Depok,
respectively, could not give detailed information on the purpose of the additional payment (table 1.16).
Additional payment for drugs and injections was 13.5 percent in Garut and 22.2 percent in Depok,
while that for delivery services was 6.8 percent in Garut and 3.7 percent in Depok (table 1.17).
20. Askes is health insurance for civil servants and retired armed forces personnel. Active and retired civil servants, retired
military and police personnel, veterans, and national patriots, and their dependents are covered by this compulsory health
insurance scheme managed by PT Askes.
21. Jamsostek is social insurance for private sector workers, health insurance for formal workers and social insurance for
workers in large companies, providing four programs: employment injury, death, health insurance, and a provident fund–type
old-age benefit.
22. Jamkesmas is a national tax-funded health insurance plan that targets the poor and near-poor through a proxy means test
targeting method. The scheme provides beneficiaries with free health services in puskesmas and third-class wards in public
and designated private hospitals.
23. Jamkesda is social health insurance provided by provincial or district governments. Jamkesda typically targets people
identified by the local authorities as poor but not covered by Jamkesmas (because of mistargeting or because they recently
became poor due to illness, etc), with some provinces (such as Bali and Aceh) heading toward universal health insurance.
Schemes vary between provinces/districts, and benefits are normally only provided through health care providers in their
respective provinces.
36
Table 1.17 Type of Other Payments during Last Delivery, among Jampersal Users
Garut Depok Total
Utilities of payment for last delivery
% % %
n=74 n=27 n=101
Registration .0 3.7 1.0
Delivery service 6.8 3.7 5.9
Drug and injection 13.5 22.2 15.8
In-patient care 1.4 .0 1.0
Birth certificate 13.5 3.7 10.9
Volunteer 5.4 .0 4.0
Overall cost (could not be detailed) 55.4 29.6 48.5
Others (e.g., copying document) 5.4 25.9 10.9
6. 3. 5 Impact of Jampersal
The impact of Jampersal was estimated using logistic regression, controlling for other factors that may
contribute to increased institutional deliveries. The distribution of the potential contributing factors was
assessed before and after Jampersal in both locations to ensure that the two populations were
comparable. The logistic regression was conducted with the total samples from both locations, and for
the samples from each location.
6.3.5.1. Impact of Jampersal on Institutional Deliveries
Bivariate analysis of Garut showed significant association between Jampersal and institutional
deliveries. The result remained significant after controlling for other contributing factors. The adjusted
Odds Ratio (OR) was 2.40 (95% CI=1.74 – 3.33) (table 1.18 and annex 1). The result implied that
women who delivered after the introduction of Jampersal had a 2.4 times higher chance of giving birth
in health facilities compared to women who delivered before Jampersal. In other words, women who
gave birth after the introduction of Jampersal had 87.7 percent probability of giving birth in health
facilities.
For Garut, factors contributing to institutional deliveries other than Jampersal were delivery
complications and residence. Women with complications around delivery were 5.3 times more likely to
give birth in health facilities compared to those without complications. Furthermore, women living in
rural areas had 15 percent lower probability of giving birth in health facilities compared to those living
in urban areas.
For Depok, Jampersal introduction was not associated with institutional deliveries in bivariate as well
as in multivariate analysis. The adjusted OR was 0.93 (95% CI=0.55 – 1.57). After controlling for other
contributing factors, the strong predictor for institutional deliveries in Depok was a delivery
complication (OR 3.22, 95% CI=1.59 – 6.51) (see annex 1).
Women who had any complication around delivery had an approximately 3.2 times higher chance of
giving birth in health facilities as opposed to those who did not have any complication.
37
Table 1.18 Association between Jampersal and Institutional Deliveries
Garut District Depok Municipality
Variables Crude OR p- Adjusted p- Crude OR p- Adjusted p-
(95% CI) value OR value (95% CI) value OR value
(95% CI) (95% CI)
Time of delivery*
Pre-Jampersal Reference Reference Reference Reference
(2009/2010)
Post-Jampersal 2.03 0.000 2.404 0.000 0.97 0.909 0.93 0.788
(2011 to 2013) (1.55–2.66) (1.74–3.33) (0.60–1.58) (0.55–1.57)
* Adjusted by age, education level completed, occupation status, gravida, complication during delivery,
residence, insurance, and wealth quintile.
Results of the bivariate analysis also showed an increase in institutional deliveries in Garut after
Jampersal among women who were least educated, poor, and lived in rural areas; while in Depok
there was very little change in institutional deliveries before and after Jampersal across the same
variables (table 1.19).
Table 1.19 Change in Institutional Deliveries by Mother’s Education, Socioeconomic Status,
Insurance Ownership, and Residence before and after Jampersal in Garut and Depok
(percent)
Garut Depok
Women's characteristics Before After p- Before After
Change Change p-value
n=462 n=456 value n=460 n=461
Institutional delivery 30.5 47.1 54.4 0.000 92.4 92.2 -0.2 0.909
Women’s education level
completed
No school/primary 16.2 37.9 134.0 0.000 83.3 79.0 -5.2 0.525
Secondary 43.8 52.9 20.8 0.056 93.1 93.8 0.8 0.717
Academy/univ 56.3 72.0 27.9 0.303 100.0 96.6 -3.4
Residence
Urban 48.1 65.4 36.0 0.000 92.4 92.2 -0.2 0.909
Rural 16.1 31.9 98.1 0.000 n.a. n.a. n.a. n.a.
Insurance
Other insurance 37.5 84.0 124.0 0.002 95.5 98.5 3.1 0.177
Insurance for the
poor 28.4 41.7 46.8 0.006 84.9 83.3 -1.9 0.797
No insurance 31.8 47.3 48.7 0.001 92.9 91.3 -1.7 0.494
Wealth quintile (total)
Lowest 10.9 24.4 123.9 0.019 86.7 88.0 1.5 0.78
Second 19.4 34.4 77.3 0.023 89.4 91.3 2.1 0.655
Middle 31.9 53.1 66.5 0.004 96.7 95.5 -1.2 0.679
Fourth 38.3 57.3 49.6 0.011 95.9 93.5 -2.5 0.476
Highest 52.2 65.9 26.2 0.059 93.2 92.6 -0.6 0.885
In Garut, after Jampersal, institutional deliveries among women with elementary school education or
lower increased by 134 percent, or by more than five times compared to the increase among women
of other education levels. A very high increase (77.3 percent) was also observed among the second-
lowest wealth quintile (Q2). Although institutional deliveries in the lowest wealth quintile (Q1) also
increased by 123.9 percent, the increase was much lower than the increase in Q2. Institutional
deliveries in rural areas showed an increase by 98.1 percent compared to only 36.0 percent in urban
areas. Contrary to the purpose of Jampersal, although institutional deliveries among those without
38
insurance increased after Jampersal, the change was the lowest (48.7 percent) — compared to those
covered by insurance for the poor (46.8 percent) — and other insurance (124 percent).
6.3.5.2. Impact of Jampersal on Cesarian Section
Bivariate analysis for Garut showed the percentage of Cesarean sections more than doubled after
Jampersal implementation from 1.1 percent to 2.6 percent, but the increase was not statistically
significant (p-value 0.092) (table 1.20). Other contributing factors did not show association except for
education level and occupation status. Result of the multivariate analysis showed no significant
correlation among the variables (table 1.21). This might be due to the small number of Cesarean
sections in Garut.
Table 1.20 Change in Cesarean Sections by Women’s Characteristics before and after
Jampersal in Garut and Depok
(percent)
Garut Depok
p- p-
Women’s characteristics Before After Change Before After Change
value value
n=462 n=456 n=460 n=461
Cesarian section 1.1 2.6 136.4 0.092 20.2 24.1 19.3 0.159
Women's age
20–34 years 0.6 2.5 316.7 0.073 19.4 22.0 13.4 0.406
<20 years 0.0 0.0 n.a. n.a. — 11.1 n.a. n.a.
>=35 years 2.5 4.5 80.0 0.419 22.2 33.0 48.6 0.069
Women’s education
level completed
No school/primary 0.4 4.4 1000.0 0.027 6.9 16.1 133.3 0.102
Secondary 1.4 0.9 -35.7 0.627 19.7 22.1 12.2 0.451
Academy/univ 6.3 4.0 -36.5 0.746 41.5 44.1 6.3 0.785
Women’s occupation
status
Not working 0.3 3.1 933.3 0.022 19.3 21.3 10.4 0.781
Working 3.4 0.0 -100.0 n.a. 22.8 35.1 53.9 0.046
Gravida
2–3 gravida 0.4 2.8 600.0 0.085 18.2 23.3 28.0 0.160
Primigravida 0.7 1.9 171.4 0.383 23.5 24.2 3.0 0.884
Multigravida 3.3 3.7 12.1 0.895 19.6 27.1 38.3 0.346
Antenatal care to health
provider
No 0.0 0.0 n.a. n.a. 0.0 0.0 n.a. n.a.
Yes 1.1 2.7 145.5 0.089 20.4 24.2 18.6 0.169
Complication during
delivery
No complication 0.5 0.8 60.0 0.639 5.5 5.9 7.3 0.840
Any complication 3.4 10.1 197.1 0.094 50.0 54.3 8.6 0.435
Residence
Urban 1.9 3.4 78.9 0.365 20.2 24.1 19.3 0.159
Rural 0.4 2.0 400.0 0.133 n.a. n.a. n.a. n.a.
39
Insurance
Other insurance 4.2 4.0 -4.8 0.976 26.5 32.3 21.9 0.304
Insurance for the
poor 1.4 1.1 -21.4 0.826 13.7 24.2 76.6 0.115
No insurance 0.4 3.5 775.0 0.048 18.8 20.0 6.4 —
Wealth quintile (total)
Lowest 0.0 0.0 n.a. n.a. 16.7 13.0 -22.2 0.493
Second 1.1 5.6 409.1 0.127 16.0 27.2 70.0 0.065
Middle 0.0 3.1 n.a. n.a. 20.9 24.7 18.2 0.539
Fourth 2.1 3.4 61.9 0.609 15.5 34.4 121.9 0.003
Highest 2.2 1.1 -50.0 0.574 33.0 21.1 -36.1 0.071
Cesarean section percentage in Depok increased after Jampersal implementation from 20 to 24
percent, but as in Garut, the increase was not statistically significant (p-value 0.159) (table 1.20). For
the multivariate analysis, after controlling for other contributing factors, the result did not show
significant association between Jampersal implementation and Cesarean sections. The adjusted
Odds Ratio (OR) was 1.15 (95% CI=0.78 – 1.69), meaning the probability of delivery with Cesarean
section was not different before and after Jampersal implementation (table 1.21).
Table 1.21 Association between Jampersal and Cesarean Sections
Garut Depok
Variables Crude OR p- Adjusted p- Crude OR p- Adjusted OR p-
(95% CI) value OR value (95% CI) value (95% CI) value
(95% CI)
Period of delivery*
Pre-Jampersal Reference Reference Reference Reference
(2009/2010)
Post-Jampersal 2.470 0.092 2.45 - 1.252 0.159 1.15 0.479
(2011 s/d 2013) (0.863–7.069) (0.77–7.78) (0.916–1.710) (0.78–1.69)
* Adjusted by age, education level completed, occupation status, pregnancy, ANC, complication during delivery,
residence, insurance, and wealth quintile (see annex 2 for more detailed information).
Table 1.22 shows the result of multivariate analysis on association between wealth quintiles and
Cesarean section. Results from both locations did not show significant association between wealth
quintiles and Cesarean section. The difference among the wealth quintiles was also not significant.
However, the OR for the second quintile to the highest quintile was more than one, while the OR for
the lowest quintile was less than one. ta
40
Table 1.22 Results of Multivariate Analysis on Association between Wealth Quintiles and
Cesarean Section
Garut Depok
Variables Crude OR p- Adjust OR p- Crude OR p- Adjust OR p-
(95% CI) value (95% CI) value (95% CI) value (95% CI) value
Wealth
quintile
Lowest 0.000 0.995 0.000 0.995 0.495 0.008 0.524 0.043
(0.293–0.835) (0.280–0.980)
Second 1.676 0.484 2.854 0.175 0.795 0.353 1.179 0.589
(0.395–7.118) (0.627–12.992) (0.491–1.289) (0.648–2.148)
Middle 1.333 0.709 1.841 0.443 1.029 0.902 1.120 0.693
(0.294–6.043) (0.387–8.765) (0.655–1.616) (0.640–1.959)
Fourth 1.676 0.484 1.999 0.362 0.827 0.453 0.770 0.394
(0.395–7.118) (0.451– (0.504–1.357) (0.422–1.404)
8.854)
Highest Reference 0.959 Reference 0.761 Reference 0.055 Reference 0.080
* Adjusted by Jampersal period, age, education level completed, occupation status, pregnancy, ANC,
complication during delivery, residence, and insurance.
41
PART 7: DISCUSSION
Over the past few years, there has been a global movement to provide universal health coverage
(UHC) to reduce financial barriers to health care. In 2005, the 58th World Health Assembly
encouraged countries to plan health financing systems to achieve the goal of UHC such that “all
people have access to services and do not suffer financial hardship paying for them” (WHO 2010).
Indonesia started on the path to UHC in 2005 when Askeskin was introduced as a health insurance
for the poor. Two years later, Askeskin was expanded into Jamkesmas, covering not only the poor,
but also the near-poor (Harimurti et al. 2013). The local government contributed by providing
Jamkesda not long after Jamkesmas was introduced to increase the coverage of insurance protection
for the poor and near-poor. Substantial challenges in meeting MDGs 4 and 5 targets have led to the
initiation of Jampersal policy in 2011. The formulation of Jampersal policy started in 2010 involving
Bappenas (National Development Planning Agency), the Office of the Vice President, Ministry of
Health, Ministry of Finance, and Ministry of People’s Welfare. The policy was launched nationwide in
2011 and aimed to cover uninsured pregnant women and newborns, irrespective of their economic
strata. Thus by design, Jampersal could be considered universal coverage for maternal and newborn
care. The program ended in December 2013, and the National Health Insurance Program (JKN) was
launched in January 2014.
The Three Dimensions of Universal Health Coverage
The challenge for countries in moving toward universal health coverage is to expand the breadth,
depth, and height of coverage (figure 1.15). The first dimension highlights the importance to
progressively expand the coverage to include all uninsured populations, thus leading to equity across
wealth, education, age, place of residence, and other population attributes. The second dimension is
about expanding the range of essential health services to meet the health needs of the population,
taking into consideration demand and expectations. The last dimension points out that the health care
cost coverage should increase to reduce out-of-pocket copayment at service points (WHO 2010).
Figure 1.15 Three Dimentsions of Universal Health Coverage
Source: WHO 2010.
42
7.1. BREADTH OF THE COVERAGE: WHO IS INSURED?
Who benefits the most from Jampersal. Overall, Jampersal utilization was higher among
marginalized women — those with low education (26.2 percent of no school/primary school compared
to 11.9 percent of academy/university graduates), poor (around 22 percent and 23 percent of the
lowest and second-lowest wealth quintiles, respectively, compared to only around 11 percent of the
highest wealth quintile), and from rural areas (33.5 percent of rural respondents compared to 13.8
percent of urban rspondents). Furthermore, women experiencing complications during delivery were
more likely to use Jampersal. The study data show an inverse association between Jampersal use
and education, as well as between Jampesal use and socioeconomic status: Jampersal use
increased as the level of education decreased; similarly, the poorer the woman, the higher the
Jampersal utilization. This indicates the positive influence of Jampersal in alleviating barriers to care
for the most vulnerable group of women (table 1.19).
Complications during pregnancy appear to be a significant factor affecting the use of Jampersal, as
29 percent of those who reported complications used Jampersal, compared to 15 percent who did not
report any complication. This finding provides evidence of the positive influence of Jampersal in
improving access to complication management. Another study in West Java Province, including Garut
District, found perceived need was one reason for institutional delivery, meaning that women would
be transferred to health facilities only if they perceived they had problems (Titaley et al. 2010),
although it is not clear whether they were first told they had a complication, and hence were
transferred.
Jampersal targets uninsured deliveries estimated at 41.5 percent of total deliveries or, according to
MoH, around 2.8 million deliveries in 2011 and in 2012. An interesting finding was the higher use of
Jampersal among those who were covered by insurance for the poor, compared to uninsured women.
Among Jampersal users, approximately 32 percent already had other insurance protection, indicating
an overlap between Jampersal and other insurance schemes. In practice, health providers tended to
claim deliveries to Jampersal, perhaps because Jampersal was specifically covering deliveries. On
the demand side, Jampersal requirements were considered easy. Unlike Jamkesmas, women could
obtain services without any eligibility card. They only had to bring their ID card and the MCH book.
Jampersal also provided wider access to services, as benefiaries could obtain services not just from
public facilities, but also from any private providers/facilities that had signed an agreement with the
DHO to accept Jampersal clients. This finding was consistent with another study reporting that most
Jampersal users had previously been covered by another insurance scheme, such as Jamkesda, and
there was a tendency to charge Jampersal rather than Jamkesda for maternal care at
district/municipality level (Rachmawati et al. 2012).
The low awareness about Jampersal may have contributed to the relatively low utilization of
Jampersal for the last delivery after three years of program implementation. Results of the household
survey showed that around a third of women had not heard of Jampersal (32 percent in Depok and 24
percent in Garut). Most women who were aware of Jampersal did not understand the continuum of
care that is covered through Jampersal. Many only knew that Jampersal was for delivery. There was
also a gap in understanding about facilities providing Jampersal services. Women who did not use
Jampersal expressed they were concerned that the service was not really free. Some perceived that a
visit to the health facility might result in additional cost for examination or treatment. Another concern
was the notion that the Jampersal service would be of lesser quality than service to patients who pay.
Fear of coercion to use long-term contraception was also mentioned. Low awareness about
Jampersal may be due in part to the low participation of other nonhealth sectors in socializing
Jampersal during its implementation.
43
The qualitative study showed that most women who used Jampersal were pleased with the Jampersal
program, and this seemed due primarily to the free nature of the service. Some reported they
received less attention from health providers compared to non-Jampersal patients, but did not mind
because the service was free. Some were aware that Jampersal also covered Cesarean sections,
while others considered eligibility requirements for Jampersal were easy to meet.
An interesting finding was Garut local government’s decision to claim home deliveries to Jampersal in
areas with low availability of health workers and difficult access to delivery facilities as long as the
delivery was assisted by a skilled birth attendant. Another study reported similar findings and
suggested a special policy for districts with geographical challenges and limited facilities (Febriany et
al. 2011).
7.2. DEPTH OF THE COVERAGE: THE BENEFIT PACKAGE
The services covered within a health insurance scheme is fundamental to how the scheme affects
health outcomes and financial protection (Lagomarsino et al, 2012). The success of UHC requires
expansion of services, at least to meet essential care. Jampersal covers essential services within the
continuum of maternity and newborn care, that is, antenatal care, delivery care, postpartum and
postnatal care for mother and newborn, and family planning. MoH expanded Jampersal service
coverage further by (1) increasing antenatal and postpartum care frequency for complication cases to
more than the regular four times; (2) including treatment for nonobstetric, life-threatening maternal
complications; (3) covering in-patient care in BEONC facilities for pregnancies with complications; (4)
covering in-patient care for sick newborns; and (5) covering the management of sick newborns.
Service coverage may have been lower than expected because not all providers understood the
scope of Jampersal services, indicating the need to improve the clarity of the Jampersal guidelines
and to encourage the use of the guidelines as a reference point. Some health officers have a negative
perception of Jampersal and considered the program a threat to the success of family planning.
According to them the free services might encourage people to have more children.
Service availability. The capacity to deliver Jampersal primary and secondary health service in
Garut may have been constrained by the relatively low availability of delivery facilities and the fact that
only one hospital could provide comprehensive maternal health services. The situation in Depok was
entirely different, as the city had a large number of private providers, but they were unwilling to join
the Jampersal scheme. Nevertheless, the low private provider participation in Jampersal at primary
level did not affect the level of institutional delivery in Depok, which was already very high before
Jampersal — suggesting Jampersal did not have an impact in Depok. There were reports of
difficulties in gaining access to referral care in Depok because most hospitals in the city were private
and their participation in Jampersal was low, but since there were participating facilities in nearby
Jakarta, access to referral care appeared not to be an issue for Depok.
Coverage of MCH services. The household survey showed minimal change in the utilization of
antenatal and postpartum care in the two study areas before and after Jampersal implementation.
The minimal change in antenatal care coverage after Jampersal was not surprising as the coverage
was already high in both locations before Jampersal. The policy to have four instances of postpartum
care was relatively new, and this might explain the low coverage even after Jampersal (5.5 percent in
Garut and 22.2 percent in Depok). The use of long-term contraceptives, on the other hand, increased
after Jampersal in both locations, consistent with Jampersal endorsement for long-term contraceptive
use. The proportion of skilled birth attendants and institutional deliveries in Garut increased after
Jampersal, but there was relatively no change to both indicators in Depok. Despite the low number of
midwives in rural areas, the increase in use of SBAs was higher in rural than in urban areas,
suggesting Jampersal impoved access to skilled birth attendants in rural areas because the service
was free.
Despite Jampersal, around 30 percent of birth deliveries in Garut were still assisted by TBAs.
Alleviating the risks for adverse maternal outcome may require reducing deliveries by the TBAs,
among other efforts (Titaley et al. 2010). A study in West Java Province including Garut reported five
main factors influencing the preference for home delivery and having the TBA as the delivery
44
assistant: economic, trust and tradition, perceived need, access to service, and the community
member’s perception of the knowledge and skill of the care provider. The findings of the qualitative
study in Garut confirmed the five factors. Tradition, belief in the skill of the TBAs, previous experience,
fear of health care (for example, injection), difficulty in finding transportation, perception that a midwife
was only for emergencies, practicality and comfort of giving birth at home, and costs were the reasons
expressed by women. Jampersal may have removed the economic barrier, but there are behavioral
and cultural factors that are beyond Jampersal. Moreover, there has to be trust that the delivery is
really free of charge, and further that, although free, the quality of care is the same.
Institutional deliveries. The multivariate analysis confirmed the impact of Jampersal in Garut after
controlling for other contributing factors. The two-fold increase in institutional deliveries was
statistically significant (OR 2.4; 95 % CI=1.74–3.33). This finding was consistent with the evaluation of
the Delivery Fee Exemption Policy in Ghana, Senegal, and Nepal, although the latter two studies
used secondary data. A population-based survey in two regions in Ghana reported evidence of
institutional delivery increase by 11.9 and 5.0 percentage points after implementation of the fee
exemption policy. In Senegal, facility data showed an increase in institutional deliveries from 40 to 44
percent (p-value <0.001) after one year of implementation of the policy. Health facility registers in
Nepal showed a 19 percent increase of institutional deliveries after one year of implementing free
delivery (Penfold et al. 2007; Witter et al. 2008; Witter et al. 2011).
On the contrary, Jampersal did not have an impact on institutional deliveries in Depok (OR 0.93; 95%
CI=0.55–1.57). This was because even before Jampersal, institutional delivery in Depok was already
very high (92.4 percent). Nevertheless, it was interesting to find some shift of place of delivery from
the private to the public sector; and a shift from delivery with private practice midwives to a higher
level of care with hospitals and the private clinics/doctors/obstetricians. For policy makers, the
findings in Depok were important as they suggest in urban areas with high availability of and demand
for the private sector, introducing Jampersal might be irrelevant and inefficient. Many local
governments, including in cities like Depok, have responded to Jampersal policy by investing in public
health facilities. For example, despite the large number of hospitals in Depok, the city invested in
converting three puskesmas into BEONC facilities since the introduction of Jampersal, even though
there was little information on the use of these. Moreover, the shift to a higher level of care, like the
specialist clinics during the last two years in Depok, indicates that for the city, service cost was not a
barrier to accessing institutional delivery.
Cesarean section coverage. There was a slight increase in incidence of Cesarean sections in Garut
and Depok after Jampersal implementation, although the effect was not statistically significant (Garut
OR 2.45; 95% CI=0.77–7.78; Depok OR 1.15; 95%=CI 0.78–1.69). Interestingly, the odds of
Cesarean sections were much higher among women in Depok, compared to Garut (OR 11.257; 95%
CI=6.555-19.333), suggesting a higher access to Cesarean sections in Depok compared to Garut. It
should be noted that Cesarean sections in Depok were already high before Jampersal — 20 percent
of all deliveries — and increased to 24 percent after Jampersal. The study could not convincingly
confirm that all Cesarean sections were due to pregnancy or delivery complications, although most
respondents perceived their Cesarean section was due to a complication. The low use of Cesarean
sections in Garut may be related to the limited availability of Cesarean section services in the district.
Another explanation for limited impact is the short implementation period of the program.
7.3. THE HEIGHT OF THE COVERAGE: FINANCIAL PROTECTION
Almost 60 percent of respondents who used Jampersal in Garut and Depok reported paying for other
delivery-related costs. About half of those who paid additional out-of-pocket expenses could not
explain the reason for having to pay extra. Around 16 percent reported paying for drugs and
injections, and 11 percent reported paying for a birth certificate (birth certificates were not a part of the
benefit package). If the needed drug was not available in the health facility, the patient had to buy it
from outside the facility. Some hospitals charged the patient for blood transfusion. Private practice
midwives sometimes requested extra payment for long-term contraceptives because the price of the
contraceptives was higher than the Jampersal fees.
45
PART 8: CONCLUSION
8.1. POLICY FORMULATION AND IMPLEMENTATION
The formulation of Jampersal policy involved not only MoH but other sectors such as Bappenas,
Office of the Vice President, Ministry of Finance, and Ministry of People’s Welfare. During
implementation, MoH and the local governments implemented Jampersal with little engagement with
the other sectors. The study revealed that some local government regulations (Perda) were not
supportive of Jampersal implementation. Ministry of Home Affairs’ regulations regarding local
government planning and budgeting, for example, affected Jampersal implementation, as payment for
Jampersal claims could not exceed the amount allocated in the local government budget (APBD),
despite the notional amount allocated by the central government. This regulation has contributed to
delayed claim payments.
8.2. HEALTH SERVICE PROVISION AND PERFORMANCE
After more than two years of implementation, the supply side was not entirely ready to respond to an
increase in the demand for services. Limited facilities in rural and remote areas may have influenced
the coverage of institutional deliveries despite Jampersal. Their condition, for example, triggered the
Garut DHO policy to allow claiming home deliveries to Jampersal in areas with difficult access to birth
delivery facilities as long as there was an urgent need of assistance and the delivery was by a SBA.
Access to referral care in rural/remote areas was an issue in Garut because the district only had one
fully functioning hospital and the hospital’s workload increased after Jampersal. The number of private
facilities in Garut was very small, although most public sector midwives also had private practice office
hours (dual practice).
In an urban area like Depok, although there were many delivery facilities such as maternity clinics and
hospitals, most of them were run by the private sector, and they were reluctant to participate in
Jampersal. Although the government increased the amount of service fee in the second year of
implementation, the private providers were still dissatisfied with Jampersal fees. Low hospital
participation in Depok resulted in frequent referral to public hospitals outside Depok. The study noted
the number of BEONC facilities in Depok increased from one to four after Jampersal. There has been
no evaluation of the efficiency of investing in BEONCs compared to introducing financing policies to
increase private sector participation, which was dominating health care in Depok.
Other sources of provider dissatisfaction were the lengthy reimbursement process and confusion
about the benefit package, for example about family planning services and coverage of complications.
The issues found were not specific to this study as they were also reported in other studies conducted
during the earlier period of Jampersal. There seems little change to those issues after more than two
years of implementation.
Moreover, Jampersal has resulted in a workload increase for public sector providers, and this has
affected the income of midwives, particularly those doing dual practice. Jampersal has negatively
influenced dual practice midwives who had a high number of visits to their private practice before
Jampersal. On the other hand, private practice midwives with fewer patients before Jampersal have
positively benefited from the program.
Both Depok and Garut health offices were supportive of Jampersal implementation as indicated by
the provision of consumables and medicines for private practice midwives in Garut, and by the
increase in the share of provider fees from puskesmas’ claims from 75 to 90 percent, among other
factors.
46
8.3. COMMUNITY ACCEPTANCE TO JAMPERSAL POLICY
The community has not fully understood Jampersal. The study found that a third of women
respondents had not heard of Jampersal. Among women who knew about Jampersal, most perceived
Jampersal was only for free deliveries, and service was limited to puskesmas and public hospitals.
Utilization was affected by uncertainty that the services were indeed free. There was also perception
that “free” meant lower quality of service compared to that received by clients paying out-of-pocket.
Low awareness about Jampersal may be due in part to the low participation of other nonhealth
sectors in Jamperal implementation.
8.4. IMPACT OF JAMPERSAL ON MCH SERVICE COVERAGE
There has been no change in antenatal and pospartum care utilization in the two study areas before
and after Jampersal implementation. However, Jampersal resulted in a relative increase in the use of
long-term contraception.
The study observed increased use of skilled birth attendance (SBA) in Garut. The increase of SBA
was higher in rural than in urban areas of Garut. There was almost no change in SBA use in Depok.
However, the study found a shift of the type of preferred providers in Depok from the private to public
sector providers; and from lower to higher type of providers.
The study found Jampersal had a statistically significant impact in increasing institutional deliveries in
Garut but not in Depok. In Garut, there was approximately 2.4 times higher likelihood of institutional
deliveries after Jampersal. Nevertheless, in Garut the proportion of home deliveries was also higher
than in Depok. Women’s preference for home-based delivery in Garut was influenced by values,
practicality, and the comfort of home delivery, and geographical as well as transportation barriers in
reaching delivery facilities. There was the perception that free service meant lower quality service,
although others felt quality did not matter that much as long as the service was free.
Increase in deliveries by Cesarean section was not statistically significant. Nevertheless, the
likelihood to deliver by Cesarean section among women in Depok was higher than Garut (OR=11.257;
95% CI=6.555–19.333). This might be due to the easy access to hospitals in Depok.
Jampersal showed higher impact in areas with low coverage and greater challenges for accessing
institutional deliveries. The challenges shown in Garut were geographical and socioeconomic
constraints, low availability of health facilities, and low insurance coverage. In urban areas such as
Depok with easy access to health facilities — albeit private facilities — the impact of Jampersal was
minimal.
47
PART 9: RECOMMENDATIONS
A program like Jampersal requires strong support from stakeholders beyond the health
sector. Jampersal encompassed horizontal (across sectors within the same level) and vertical
(between the central and local government) collaboration. Jampersal has brought sectors together
during policy formulation, but sector collaboration is important for building the momentum during
implementation as well. For example:
Given the decentralized system in Indonesia, MoHA’s involvement could help in building local
government commitment to the program. A strong buy-in from local governments may increase
subdistrict and village government support in increasing community awareness and potentially in
removing other barriers to care.
Joint collaboration between MoH, MoHA, and MoF in reviewing existing regulations would be helpful
in finding ways to reduce the complexity of Jampersal (or other insurance) fund management and the
reimbursement process.
Multisector involvement is required in planning and implementing long-term investment for improving
road infrastructure, transportation, and health facilities in geographically difficult areas to improve
access to institutional deliveries.
Jampersal could help to increase institutional deliveries while JKN voluntary participation is
still low. The study has shown the potential of Jampersal in increasing institutional deliveries where
coverage was low, as in Garut. The government may want to consider this finding and reevaluate the
policy to terminate Jampersal implementation with the launching of the National Health Insurance
Program (JKN) on January 1, 2014. Nevertheless, before continuing the implementation, it is
important to analyze the cost-effectiveness of the program.
Addressing “nonservice” cost is important. The study reported families still pay additional OOP
costs for referral transport, and this might be a barrier to accessing care. Building linkages with other
programs such as PNPM GSC (he National Program for Community Empowerment, Smart and
Health Generation) might be an option for addressing this issue. Moreover, reducing OOP would also
require better understanding about the reason for the OOP; for example, whether it is an issue of
supply chain and drug shortages, an issue of exclusion of certain drugs from the basic benefits
package, or an issue of provider prescription behavior. Regarding provider behavior, it will also be
interesting to monitor the possibility of cream skimming.24
“Free” is not enough; service readiness and quality also matter. Women who experienced low
quality of care tended to stop using the care, or even dissuaded other women from using care
(Wairimu 2013). In Kenya, women’s refusal to use free maternity care was due to poor quality of the
facilities and the rude attitude of health providers, among other factors. Continuous quality
improvements should follow any effort to improve access to health care. Complementary work shows
that maternal health supply-side readiness problems remain, especially in some parts of the country,
and this could deter patients from utilizing care despite removal of financial barriers via programs
such as Jampersal.
Getting private providers on board requires a carefully designed provider payment system. In
areas where private providers are dominant and demand for private provision is high, buying services
from the private sector to improve access might be more efficient than expanding public sector
investment. Obviously, this would require reasonable fees and quality assurance of service provision.
The study also showed that support from professional associations like the Indonesia Midwives
Association (IBI) could facilitate private midwife participation in Jampersal.
24. Midwives working in dual practice may decide to ask patients to come to their private practice as they can use the whole
claim reimbursement for their own benefit, while in puskesmas they have to share with other staff.
48
There is a need to explore more options to improve human resources for health (HRH)
availability and distribution in remote areas. Skilled birth attendance in rural Garut increased after
Jampersal despite the low presence of midwives, suggesting adding more midwives could increase
skilled birth attendance even more if paying for service is not an issue. Experience shows that
monetary incentives are often not enough for deploying HRH to “difficult” areas. Other attractive
features such as housing, children’s education, continuing education, more definitive and specific
terms of services period need to be considered. In developing HRH policies, Indonesia will benefit
from a labor market analysis to understand labor market dynamics influencing HRH supply and
demand.
In areas with difficult access to hospitals, the presence of BEONC facilities is essential.
Investment in BEONCs should be followed by close monitoring and consistent support to ensure
continuity of care by avoiding high turnover of trained staff and by increasing utilization.
Implementation of Jampersal (or UHC) policy may have to be adjusted according to the
utilization pattern for efficiency and effectiveness. The household survey showed Jampersal only
had an impact in an area where institutional delivery coverage was still low, such as Garut. Further
assessment is needed to translate this finding into future policy changes.
49
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52
ANNEXES
ANNEX 1: ASSOCIATION BETWEEN JAMPERSAL AND
INSTITUTIONAL DELIVERIES
Table 1A.1 Association between Jampersal and Institutional Deliveries
Garut Depok
Adjusted p- CI 95% Adjusted p- CI 95%
OR value Lower Upper OR value Lower Upper
After Jampersal 2.40 0.000 1.74 3.33 0.93 0.788 0.55 1.57
Women's age
20–34 years Ref
<20 years 2.03 0.046 1.01 4.06 1.06 0.957 0.11 9.95
>=35 years 1.16 0.542 0.72 1.85 1.66 0.176 0.80 3.47
Women’s education level
completed
No school/primary Ref
Secondary 1.72 0.003 1.21 2.44 2.53 0.002 1.39 4.57
Academy/univ 2.83 0.015 1.22 6.54 5.92 0.027 1.22 28.64
Women’s occupation
status
Not working Ref
Working 1.00 0.983 0.66 1.51 0.86 0.657 0.44 1.67
Gravida
2–3 gravidas Ref
Primigravida 0.97 0.855 0.66 1.41 1.30 0.407 0.70 2.40
Multigravida 0.78 0.334 0.48 1.29 0.80 0.596 0.35 1.83
Complication during
delivery
No complication Ref
Any complication 5.34 0.000 3.54 8.04 3.22 0.001 1.59 6.51
Residence
Urban Ref
Rural 0.31 0.000 0.23 0.44 1.00 n.a. n.a. n.a.
Insurance
Other insurance Ref
Insurance for the poor 0.97 0.927 0.46 2.03 0.30 0.01 0.12 0.75
No insurance 0.79 0.513 0.38 1.61 0.53 0.125 0.24 1.19
Wealth quintile (total)
Lowest Ref
Second 1.36 0.287 0.77 2.38 0.98 0.946 0.48 1.98
Middle 2.01 0.013 1.16 3.48 2.20 0.091 0.88 5.52
Fourth 2.82 0.000 1.62 4.92 1.56 0.299 0.67 3.61
Highest 3.57 0.000 1.98 6.43 1.03 0.937 0.47 2.26
Obs 918 921
Pseudo R2 0.22 0.11
Source: Household Survey.
53
ANNEX 2: ASSOCIATION BETWEEN JAMPERSAL AND
CESAREAN SECTION
Table 2A.1 Association between Jampersal and Cesarean Section
Garut Depok
Adjusted p- Adjusted p-
OR value Lower Upper OR value Lower Upper
After Jampersal 2.45 0.128 0.77 7.78 1.15 0.479 0.78 1.69
Women's age
20–34 years Ref
<20 years 1.00 0.85 0.898 0.08 9.60
>=35 years 2.61 0.159 0.69 9.96 1.32 0.265 0.81 2.17
Women’s education level
completed
No school/primary Ref
Secondary 0.41 0.182 0.11 1.51 1.82 0.083 0.93 3.57
Academy/univ 2.08 0.517 0.23 19.11 3.92 0.002 1.66 9.29
Women’s occupation
status
Not working Ref
Working 1.17 0.826 0.30 4.56 1.22 0.413 0.75 1.99
Gravida
2–3 gravida Ref
Primigravida 1.01 0.990 0.26 3.98 1.00 0.993 0.64 1.55
Multigravida 1.34 0.682 0.33 5.43 1.00 0.990 0.52 1.91
Complication during
delivery
No complication Ref
Any complication 11.93 0.000 3.80 37.41 18.35 0.000 12.00 28.06
Residence
Urban Ref
Rural 0.46 0.193 0.14 1.49 1.00 n.a. n.a. n.a.
Insurance
Other insurance Ref
Insurance for the poor 0.22 0.139 0.03 1.64 0.85 0.627 0.44 1.65
No insurance 0.35 0.267 0.05 2.24 0.87 0.550 0.56 1.37
Wealth quintile (total)
Lowest n.a. n.a. n.a. n.a.
Second n.a. n.a. n.a. n.a. 1.97 0.043 1.02 3.80
Middle n.a. n.a. n.a. n.a. 1.44 0.273 0.75 2.78
Fourth n.a. n.a. n.a. n.a. 1.71 0.107 0.89 3.29
Highest n.a. n.a. n.a. n.a. 1.68 0.120 0.87 3.21
Obs 865.00 921.00
Pseudo-R2 0.26 0.30
Source: Household Survey.
54
ANNEX 3: METHODOLOGY
The study applied cross-sectional design with pre/post assessment, using both qualitative and
quantitative approaches. The qualitative approach provided information about the overall financing,
payment, and organizational policies of the Jampersal program, and specifically the impact of the
policies on HRH performance; while the quantitative approach examined whether Jampersal
implementation has impact on improving coverage of services, particularly on institutional deliveries
(primary level) and Cesarean section coverage (secondary level).
1. Qualitative Study
The qualitative approach used in-depth interviews and focus group discussions, collecting information
from central, provincial, district/municipality, and community levels. At each level stakeholders were
asked particular questions about the following aspects:
1. Central and provincial levels: role in policy formulation, implementation, and evaluation,
including analysis on the sustainability
2. District/municipality level: process of implementation, its barriers and enabling factors
3. Community: community leaders’ involvement; satisfaction, barriers, and enabling factors in
utilizing Jampersal
Table 3A.1 Informants in the Qualitative Study
Institution Method Informants Note
Central level
MoH In-depth interview • Directorate General for Nutrition and
MCH
• Directorate General for Health Effort,
include primary health and referral
• Center for Health Financing and
Insurance/P2JK
• Planning Bureau
• Board for Development and
Empowerment of Human Resources in
Health/BPPSDMK
MoHA • Directorate General for Regional
Autonomy/Ditjen Otoda
MoF • Ministry of Financing
Legislative Commission IX, which handles health
issues
Commission D, DPRD Garut
PHO In-depth interview • MCH Unit
• Unit for Health
Insurance/Administration Unit/Tata
Usaha
Garut District
DHO In-depth interview • MCH Unit
• Primary Health Care Unit
• Referral Health Care Unit
• Unit for Health
Insurance/Administration Unit/Tata
Usaha
Board for Regional In-depth interview Unit for Community Welfare
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Institution Method Informants Note
Development
Planning (Bappeda)
District hospitals In-depth interview • Vice Director/Head of Health Service
Unit
• Vice Director of Finance /Head of
Finance Unit
• Ob-Gyn
• Head of delivery room
Maternity clinic with In-depth interview • Ob-Gyn/ Owner of maternity clinic
Cesarean section
facility
Health center In-depth interview • Head of Health Center/Coordinator • Tarogong PHC
Midwife • Padaawas PHC
• Administration Unit/JKM Unit • Peundeuy PHC
Village midwives Focus Group Midwife who has worked for at least 2 • Tarogong PHC
Discussion years and currently still works as village • Padaawas PHC
midwife.
• Peundeuy PHC
Midwives will be formed to represent
urban-rural setting in Garut
Private midwife/dual In-depth interview Midwife who has practiced as private • Jati Village
practice practice midwife for at least 2 years and • Karyamekar Village
currently is still in practice.
This will cover pure private and dual
practice midwives.
Head of village, In-depth interview Lurah or TOMA per village • Jati Village
community leaders • Padaawas Village
(TOMA)
• Pangrumasan Village
Community (group of Focus Group • Mothers of at least 2 children who • Jati Village
mothers who gave Discussion born before and after Jampersal • Padaawas Village
birth after the
• Pangrumasan Village
implementation of
Jampersal) In-depth interview • Mothers of children born after • Jati Village
Jampersal and USED the Jampersal • Padaawas Village
scheme
• Pangrumasan Village
• Mothers of children born after
Jampersal and DID NOT USE the
Jampersal scheme
Depok Municipality
DHO In-depth interview • MCH Unit
• Primary Health Care Unit
• Referral Health Care Unit
• Unit for Health Insurance
• Financial Treasurer
Board for Regional In-depth interview Unit for Community Welfare
Development
Planning (Bappeda)
District hospitals In-depth interview • Vice Director/Head of Health Service
Unit
• Vice Director of Finance /Head of
Finance Unit
• Ob-Gyn
56
Institution Method Informants Note
• Head of delivery room
Private hospitals In-depth interview • Vice Director/Head of Health Service • Sentra Medika
Unit Hospital
• Vice Director/Head of Finance Unit • Hasanah Graha
• Ob-Gyn/ Head of Obstetric Ward Afiah (HGA)
Hospital
Health center In-depth interview • Head of Health Center/Coordinator • Sukmajaya PHC
Midwife • Duren Seribu PHC
• Administration Unit/JKM unit
Village midwives In-depth interview Midwife who has worked for at least 2 • Mekarjaya Village
years and currently still works as village
midwife.
Midwives will be formed to represent
urban-rural setting in Depok
Private midwife/dual In-depth interview Midwife who has practiced as Private • Mekarjaya Village
practice Practice Midwife for at least 2 years and
currently is still in practice.
This will cover pure private and dual
practice midwives.
Head of village, In-depth interview Lurah or TOMA per village • Mekarjaya Village
community leaders • Bojongsari Lama
(Tokoh Masyarakat — Village
TOMA)
Community (group of Focus group • Mothers of at least one of whom • Mekarjaya Village
mothers who gave discussion was born before and one after • Tirtajaya Village
birth after the Jampersal
• Bojongsari Lama
implementation of
Jampersal) Village
• Duren Seribu Village
In-depth interview • Mothers of children born after • Mekarjaya Village
Jampersal and USED the Jampersal • Bojongsari Lama
scheme Village
• Mothers of children born after
Jampersal and DID NOT USE the
Jampersal scheme
2. Quantitative Study
Sample Size
The population of this study were mothers and children as beneficiaries of the Jampersal package,
that is, antenatal, delivery, postnatal care, and family planning in the two areas. Women who
delivered two years before Jampersal implementation (this cut-off point is defined to reduce recall
bias) were considered part of the sample for the baseline/pre, and women who delivered after
Jampersal implementation will be considered as the sample for the endline/post. The sample size is
calculated using a sample size formula for hypothesis testing between two population proportions for
each group (Lemeshow et al. 1990).
Note: n = number of sample size
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Z1-α = Z-score for significance level of α in one-sided hypothesis testing
Z1-β = Z-score for 1-β power of statistical test
P = average of P1 and P2
p1 = estimated proportion at baseline survey
p2 = estimated proportion at evaluation survey
deff = design effect
Sample was selected using cluster sampling, instead of Simple Random Sampling (SRS), mainly due
to financial and time limitations. Thus, calculation of sample size uses correction of design effect. We
have anticipated that there is a wide variation of number of households per village within and between
study areas. Population size in Depok Municipality is around 1.7 million located in 63 villages; while
population in Garut District is approximately 2.4 million located in 424 villages. This condition results
in un-comparability between the study areas. Thus we used census block as the cluster. Census
block (CB) is the enumeration area developed by Indonesia Central Bureau of Statistics (BPS); the
latest was used for the 2010 national census. In average, each census block consists of 80 to 120
households. Since all main indicators are measured through the household survey, the sample size is
calculated for each main indicator to be assessed. The largest sample size was chosen.
Estimated proportion used in the sample size calculation is based on data from the 2010 National
Basic Health Research (Riskesdas) using data for West Java Province. Estimation of difference
coverage between pre-Jampesal and post-Jampersal implementation is 15 percent for all the main
indicators, except for Cesarean section, which is estimated at 10 percent. This assumption is based
on the increase of coverage data between the 2002–03 and 2007 IDHS (where no massive program
is implemented), inflated by estimation of increase due to Jampersal program.
Table 3A.2. Sample Size Calculation for Each Group (pre/post) for Each District
Indicators Estimated Estimat Sample size Total Total
% ed for group sample sample
at % at indicated with 10% size for
preinterve postinte under nonrespon women
ntion rvention “indicators” se rate with 10%
column* nonrespon
se rate
Delivery at facility 53.7 68.7 179 269 296
Skilled birth attendants 78.3 93.3 91 137 151
Cesarean section 15.1 25.1 274 411 453
Antenatal care according to the 67.2 82.2 142 213 235
standard**
Postnatal care 75.1 90.1 108 162 179
Source: Authors’ calculation.
*Significance level at 5 percent, one-side hypothesis testing; power of test 0.9; design effect=1.5.
**1 time during 1st trimester, 1 time during 2nd trimester, 2 times during last trimester.
According to the above sample size calculation, the highest sample size is 453 for each group (pre
and post) in each study area. In total there were 906 samples for each area, equal to 1,812 samples
in the two study areas. The study has collected 921 respondents in Depok and 918 respondents in
Garut, a total of 1,839 respondents.
Sampling Procedure
In each district, a number of census blocks/CBs (here, this refers to clusters) were selected randomly
as the Primary Sampling Units/PSUs. The sampling process was followed by selection of households
with the designated criteria (mothers of children born either before or after Jampersal
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implementation). The table below presents the estimated number of under-five children within each
CB (born either before or after Jampersal implementation).
Table 3A.3 Estimated Number of Eligible Population per Census Block
# of household per # of Estimated # of households
census block populationα with at least one U-5 in each
CB (assumption 30%)
80–120 320–480 30 (24–36)
Source: Authors’ calculation.
α
The number of population in each household is estimated at four per household.
Based on the above table, we expect that there will be at least 24 under-five children within each CB.
To control variation between CBs, the target is to enroll 18 samples in each CB.
The sample has been targeted in 61 CBs per districts. In situations where the number of eligible
population is the same as the needed sample size per block, all the population were enrolled as the
samples. When the number of eligible population is more than the designated sample size, random
selection was applied. If the eligible population is less than the sample size per cluster, additional
sample was taken from the neighboring census blocks (within the same village); thus, in such
situations more than 61 clusters were visited. Samples of the pre-Jampersal and post-Jampersal may
come from the same household, for example, a household with a child born before Jampersal and a
child born after Jampersal implementation.
In each CB, the study team listed all eligible population residing within the CB area. The listing
process used information from either cadres or head of the neighboring unit, who is most
knowledgeable and can help prepare a list of children in the area. The sample is mother with
child/children who has lived in the study area at least since 2009.
3. Data Collection
Qualitative Study
Qualitative data collections were conducted from May to August 2013 at district, province, and
national levels. All informants were successfully interviewed except two informants in Depok — the
regional representative council (DPRD) member and the Ob-Gyn of a private hospital. In Garut
District, since there is no private hospital, we have replaced informants from private hospital with
informants from a private maternity clinic that performed Cesarian sections.
Quantitative Study
Data collections for the quantitative survey were conducted from April 20, 2013, to May 25, 2013, in
Depok and Garut. There were 921 respondents in Depok and 918 respondents in Garut who were
interviewed. The study team visited 53 CBs in Garut and 52 CBs in Depok. The distribution of CBs in
Garut was 28 in rural areas, and 25 CBs in urban area; while in Depok, all CBs were in urban area.
Data collection processes of quantitative study were as follows:
1. In each district, the team consisted of a field coordinator, assistant coordinator, data
collectors (nine in Garut and eight in Depok), and two data entry personnel.
2. Before data collections were started, census blocks (CBs) were already selected. Field
coordinator and assistant coordinators worked on respondent sampling using household
listings. In each CB, 18 respondents were selected, consisting of 9 mothers with babies
born by year 2009 to year 2010, and 9 mothers with babies born by year 2011 until the
study time.
59
3. In conditions where the number of informants was not enough in one CB, the field
coordinator and assistant coordinator went to the nearest CB for the household listing.
4. In conditions where selected respondents were not available during home visits, a
second home visit was made by data collectors. If selected respondents were not
available on the second visit or refused the interview, data collectors replaced the
respondents with alternate respondents who had been identified prior to data collection.
5. Spot-checks to a sample of respondents (10 percent) were randomly conducted by the
field coordinator and assistant coordinator.
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Study Limitations
1. It is still too early in the program to evaluate and assess its impact.
2. The study is only conducted in two districts, so it is difficult to represent real conditions in
Indonesia.
4. Data Analysis
Qualitative Study
All in-depth interviews and FGDs were audio-recorded and transcripted. All transcripts were collated
into matrices to identify the main findings, which were then grouped based on the themes of interest.
Quantitative Study
Data were entered in the field on a daily basis: (1) to identify and correct any inconsistencies of data
and other problems; (2) to minimize the risk of losing data during data management. Data were
entered using EPI-Info program, and transferred to SPSS for further analysis.
Characteristics of the study participants were assessed to see whether the population of the
preintervention and of the postintervention were comparable. Furthermore, this study examined
factors and variables, either quantitatively or qualitatively, that may influence/confound the
relationship between Jampersal implementation and the outcomes assessed, such as access to
health services, urban-rural setting, sociodemographic characteristics of user, and existence of other
related programs. Socioeconomic status was assessed using the wealth index, developed based on
household assets ownership.
Quantitative analysis is aimed to assess the impact of Jampersal on the coverage of institutional
deliveries and Cesarean section, as well as other maternal services within the framework of the
continuum of care. Changes in the outcome were examined by comparing preintervention and
postintervention population. The changes were also examined by comparing Depok Municipality and
Garut District to explore whether there is difference on the impact of Jampersal between districts and
municipalities, in relation to urban and rural settings as well as policy implementation.
5. Data Quality
Initial Test and Revision of Questionnaire
Questionnaires were tested for format, wording, sequence, time needed for each questionnaire,
sensitive questions, difficult/unclear questions, flow of questions, use of local terms, and problems
with responses (unexpected answers, inconsistencies). Any modifications and corrections were
immediately applied to adjust the questionnaire for suitability for pilot testing.
Development of Manuals
Manuals were developed to assist the standardization of the data collection procedures in the field.
a. The General Manual consisted of the following:
• The background, purpose, and rationale of the study to make sure each member of the
study team had a good understanding about the study, including the questions in the
questionnaires.
• Explanation of the design of the study and sample selection.
61
• Organization and job description of each member of the study team, to help each
member understand his or her role and responsibility in the study, especially during
data collection.
• Guidelines for the interviewers in finding and approaching respondents, and a
description of the supervisory mechanism.
• Interview techniques (quantitative and qualitative) were also included in the manual.
The technique includes how to ask questions, including ethical considerations in how to
avoid bias and the like.
b. Questionnaires/Instrument Manual, which explains each question in the questionnaires.
Training
All field staff received training about the questionnaire and sampling procedures so they would have a
good understanding about the study being conducted. At the beginning, all field staff participated in
the general training covering all procedures of data collection in the field. Subsequently, all field staff
were trained in their specific duties on the basis of their skills, experience, and educational
background. The training took place over two days in classes that encompassed explanations on
questionnaires, guidelines, interview techniques, and one day for pilot testing in the field.
Pilot Test
The pilot test was conducted in the area identical to the main study area, with the following objectives:
a. To assess whether the sampling mechanism was working well, including the process of
finding the households, finding and selecting respondents, and understanding the pattern of
community activities.
b. To identify problems and find solutions, including in the process of administering the
questionnaires, and other logistical arrangements.
Supervision Mechanism during Data Collection:
a. Daily review of all questionnaires and reinterview of some selected respondents were done by
the supervisor to secure reliability of questions filled out by interviewers.
b. Regular meeting of the team took place in the base camp to check the consistency and the
completeness of the questionnaire, and to prepare activities for the next day. Any problem will
be identified and solved on a daily basis.
c. Spot-checking or supervision visit by supervisor.
Data Management
a. Testing of data entry template before and after pilot test, including data entry quality check.
b. Cross entry: 10 percent of sample data were reentered by different data entry staff.
Consistencies were checked against the two data entries, and compared with the filled-in
questionnaires.
c. Data cleaning.
6. Ethical Considerations
The research proposal and all related documents, including instruments, were submitted to the
Institutional Review Board (IRB) of Public Health Faculty, University of Indonesia for ethical approval
and clearance. Consent has been sought from selected institutions for qualitative study and from all
respondents of the household survey. All key informants have been provided with information about
the study. Names of key informants and respondents were kept confidential.
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Indonesia launched Jampersal in 2011, a nationwide program to accelerate the reduction of maternal and
newborn deaths. The program was financed by central government revenues and provided free and
comprehensive maternal and neonatal care with an emphasis on promoting institutional deliveries. Jampersal
providers were public and enlisted private facilities at the primary and secondary levels. In 2013, the World Bank
and the Center for Family Welfare, University of Indonesia conducted a qualitative and quantitative study to
assess the implementation and impact of the program in Garut District and Depok Municipality in West Java
Province. The study found that Jampersal utilization was highest among women who were least educated, poor,
and resided in rural areas. Utilization was also high among women with delivery complications. The study
showed Jampersal only had an impact where institutional delivery coverage was still low such as in Garut
District. In this district, women were 2.4 times more likely to have institutional deliveries after Jampersal. The
finding suggests implementation of Jampersal policy may have to be adjusted according to the utilization pattern
for efficiency and effectiveness. The government discontinued Jampersal with the launching of the National
Health Insurance Program (JKN) on January 1, 2014. The study’s findings indicate the merit in reevaluating the
policy to terminate the program, given that Jampersal helped increase institutional deliveries while voluntary
participation in JKN remains low.
ABOUT THIS SERIES:
This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The
papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage
discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely
those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated
organizations or to members of its Board of Executive Directors or the countries they represent. Citation and
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about the series and submissions should be made directly to the Editor Martin Lutalo (mlutalo@
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For more information, see also www.worldbank.org/hnppublications.
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