The Impact of Universal Healthcare Coverage_1Juli2013
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Transcript of The Impact of Universal Healthcare Coverage_1Juli2013
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The Impact of Universal Healthcare
Coverage (Jamsoskes)in South Sumatera
23rd Pacific Conference of The Regional Science Association International
(RSAI) & 4th Indonesian Regional Science Association (IRSA) Institute
Hotel Savoy Homan, Bandung, 2-4 July 2013
Institute for Economic and Social Research
Faculty of Economics University of Indonesia (LPEM FEUI )
Ari Kuncoro, Ifa Isfandiarni and Hengky Kurniawan
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Background
2
South Sumatera ranks in the bottom third life expectancy, infant and maternal mortality rates, and
malnourishment among children (UNDP, 2010).
In January 2009, the provincial government of South
Sumatera institutedJaminan Sosial Kesehatan (Jamsoskes) universal healthcare coverage
free basic health services to the 4 million citizens
excludesJamkesmas,ASKES, Jamsostek, etc.
eligible population constitutes about a half of the totalpopulation.
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Research Questions
3
DoesJamsoskes increase the number of inpatient, outpatient,and prenatal care visits?
Do families increase their utilization of all healthcare services?
Are levels of utilization different by age, education, and gender?
Is there any variation on utilization ofJamsoskes by urbanversus rural areas, and income group?
What are the effects on health outcomes (infant and adult)?
What are the effects on days of normal activity that was
disrupted due to illness?
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Region and Context
4
Area: 99,888.28 kmsq
11 districts and 4 cities,
district of Ogan Komering Ilir
(biggest area) and city of
Palembang (highest density) Border: Jambi, Bangka
Belitung, Bengkulu and
Lampung
Population: 7.4 millions
Main sector: mining and
services
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Evolution of Jamsoskes in South
Sumatera
2002: Askes Perdana, District ofMusi Banyuasin (Muba) (selectedpoors)
2003-2004: Gakin Muba (poors)
2005: Gakin Muba joined AskeskinNasional (poors)
2007: Mubas Jamkesda (universalhealth care)
2009: South Sumatera Provinces
Jamsoskes Covers more than half population
Cost shares between provincialgovt. and districts/cities govts (30-50% paid by districts/cities)
5
ASKES PNS
6%JAMSOSTEK
1%
JAMKESMAS39%
TNI/POLRI
1%JAMKES
SWASTA
1%
JAMSOSKESSUMSEL 52%
Proportion of Health Insurance by
Type (2012)
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Demand for Health and Health Care (1)
6
Health as capital (Grossman, 1974)
People invest when marginal benefit exceeds the marginal cost
Health insurances are rare in developing countries (Gertler and Gruber,2002)
Households face big portion of out-of-pocket expenditures Financial catastrophic endangers the familys ability to maintain its
standard of living (Berki, 1986)
There are varieties of catastrophic expenditures among countries (Xu et.al,2003)
Households spend less on food following a health shock (Wagstaff, 2007)
Health insurance increases the number of visits in health care center (Ekowati,
2009)
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Demand for Health and Health Care (2)
7
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Methodology (1)
8
Data Riskesdas 2007 & 2010, Susenas 2006 &2011, PODES 2008
Model to be estimated
edisturbanccomponent/error:v
Jamsoskes)afterand(beforedummyvariabel:D
puskesmas)hospital,(e.g.facilityhealthofchoice:F
rural)urban,(e.g.variablecontrol:C
sticcharacterihousehold:Xsticcharacteriindividual:I
estimatedbetoparameter:
indicatorhealthoroutcome:h
ik
ik
k
ik
ik
ikikkikkikikik
ikikkikik
vCDDFDXDIFCXIh
vDFCXIh
87654321
54321
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Methodology (2)
9
By adding other variables we get:
Interaction among the variables:
Above equations are estimated by maximum likelihood method
see annexes for detail tables of estimation results
jj'everyfor}{[
jj'everyfor}'{[:(j)facilitieshealthusingin(i)individualanof)(yProbabilit
'
ijijijijr
ijijrij
ij
euevP
uuPPP
ijkikkikijk DFCXIP 54321
ijkikkikkikikijk vCDDFDXDIFCXIP 87654321
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Results and Interpretation (1)
10
Multinomial Outpatient Choices - Basic regression
(government hospital as a base): The elder patient is more likely to visit government hospital compared
to other health facilities, while household income has mixed result Distance to hospital & percentage of paved road persistently affect the
choice of government hospital
Multinomial Outpatient Choices - Interactive terms
(government hospital as a base) The poor family tends to useJAMSOSKES to the utmost. The coefficients of all choices are negative and significant which means
there is a huge shift to government hospital for outpatient treatment Compared to Sumatra with no health care program; there is an increase
of demand for private doctor/polyclinic. People go to private doctor to get good diagnosis before joining free
health care despite having to pay fees.
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Results and Interpretation (2)
11
Multinomial Inpatient Choices Basic Regressions
(government hospital as a base) Age variable is the only significant for PUSKESMAS.
The negative coefficient suggests that as a person gets older the lesslikely he or she chooses PUSKESMAS relative to government hospital.
Education is not important in the choice. Richer family tends to use private relative to private hospital.
Multinomial Inpatient Choices Interacted Terms (governmenthospital as a base)
Urban people tend not choose PUSKESMAS but rather to go to government
hospital. In the choice of private health worker both urban dummy and its interaction
with time dummy are significant.
The coefficient sign indicates that after the program is introduced in 2009 more
urban dweller move away from private health worker to government hospital.
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Results and Interpretation (3)
12
Multinomial Choices of Birth Helper BasicRegressions (doctor as a base) The impact of age is uniform across all choices.
Higher household incomes prefer doctor for birth helper.
The introduction ofJAMSOSKES makes people less likely to choosemidwife and traditional midwife over doctor
As more and more midwife available locally paramedic and traditionalmidwife will no longer an attractive option.
Multinomial Choices of Birth Helper InteractiveTerms (doctor as a base)
The Jamkesmas benefit the poor family The urban people are also benefitting in the same sense that they are
moving to doctor as a birth helper and leaving out midwife, paramedic andtraditional midwife.
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Results and Interpretation (4)
13
Probability of Being Sick Impact ofJAMSOSKES is reducing the probability of being sick for all
cases considered.
The probability of being sick is related positively with age.
While higher education attainment tends to reduce the probability ofsickness.
But high household apparently does not prevent someone from beingsick.
Poisson Regression: South Sumatra Impacts on Daysof Illness
Older people seem to suffer longer than younger when they get ill. It suggests that marriage people tend to have fewer days of illness
None of the interactive terms is significant suggesting that the sicknessof this type does not prevent one from continuing to work.
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Conclusions
14
Increased demand for government hospital appears to
overburden
But Puskesmas as sorting system is working
Does not diminish the role of private doctor
In the inpatient case, non-doctor health worker is preferred.
In remote area, this reduce the number of visits in Puskesmas
In the case of woman in childbirth, medical doctor is preferred,
causing in reduction of other facilities
Good infrastructure plays an important role
Jamsoskes does not reduce normal activity that was disrupted
due to illness
Absorption of light illness
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Policy Implications
15
Health workers at remote areas should be improved as they serve as
a first stop before continuing to government hospital. This will reduce excess demand for government hospital at district level. PUSKESMAS should also add more staffs to anticipate the higher
utilization of this health facility by the expecting mothers.
In term of budgeting policy the local government could focus on
building and maintaining good roads while at the same time optimizingthe use of PUSKESMAS system by upgrading their capabilities and/orbuilding hospital. This is because PUSKESMAS are in effect in competition with each other
in attracting patient.
The socialization of staying at home if sick should be carried outmore frequent to all people so as to reduce spreading disease tofellow workers.
The role of modern trained midwife should be strengthened inreducing IMR among the poor.
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(1) (2) (3) (4)VARIABLES Private
Hospital PrivateDoctor/Polyclinic
PUSKESM
AS
/PUSTUPrivate
Health
WorkerAge 0.00404 -0.00931*** -0.0171*** -0.0132***
(0.930) (-3.321) (-6.361) (-4.811)H. school and
above0.332 -0.200 -0.838*** -0.841***
(1.427) (-1.246) (-5.123) (-5.058)Household
income 0.403** 0.250** -0.495*** -0.307***(2.339) (2.147) (-4.321) (-2.639)
Year 2011 -4.023** 0.568 3.129** 1.373(-2.270) (0.466) (2.572) (1.053)
% paved road -0.00341 -0.00192 -0.00595* -0.0112***(-0.721)
(-0.587)
(-1.908)
(-3.563)
Hilly region -0.0216** -0.000360 -0.00360 -0.00273
(-2.314) (-0.0966) (-0.993) (-0.749)N. of hospital 2.818** 1.199 -1.227 -0.00865
(2.029) (1.361) (-1.414) (-0.00946)N. of polyclinic -0.744 -0.132 0.468 -0.466
(-1.057) (-0.276) (0.987) (-0.962)N. of puskesmas 0.410 -0.905 -1.064* 0.528
(0.456) (-1.574) (-1.891) (0.896)Dist. to hospital -0.00182 0.0133** 0.00934* 0.0370***(-0.190) (2.277) (1.661) (6.640)Dist. to polyclinic 0.00714 -0.0177** 0.00303 -0.0149**
(0.649) (-2.429) (0.445) (-2.194)Dist. to
puskesmas 0.0217 -0.00587 0.00889 -0.0346**(1.028) (-0.344) (0.589) (-2.186)
Constant -6.810*** -2.015 9.752*** 5.797***(-2.753) (-1.204) (5.947) (3.487)
Observations 5,981 5,981 5,981 5,981
Table 1:
South Sumatra:
Multinomial Outpatient Choices
Basic Regressions
z-statistics in parentheses
*** p
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OutpatientChoices
VARIABLES PrivateHospital PrivateDoctor
/PolyclinicPUSKESM
AS
/PUSTUPrivate
Health
WorkerPoor Family
Poor Family 0.758** 0.473* 0.981*** 0.914***(2.038) (1.814) (4.121) (3.529)
2011 X Poor -1.143** -0.817*** -0.946*** -1.002***(-2.532) (-2.640) (-3.263) (-3.271)
MotherMother -0.555 0.530 0.396 0.638
(-0.494) (1.031) (0.817) (1.238)2011 X Mother -27.56 -0.567 -0.489 -0.170
(-4.18e-05) (-0.874) (-0.788) (-0.264)Children
under 5Age 5 and less 0.305 0.360 -0.00924 0.255
(0.561) (1.067) (-0.0293) (0.746)2011 X Age 5 or less -0.329 -0.0940 0.171 0.497
UrbanUrban -0.247 -0.383 -0.454* -2.138***
(-0.573) (-1.403) (-1.814) (-6.753)2011 X urban 0.904* 0.952*** 0.521* 1.424***(1.798) (2.958) (1.711) (3.831)
SumatraContext
South Sumatra 0.0815 -0.0604 0.151 -0.221**(0.498) (-0.551) (1.533) (-2.031)
2011 X South
Sumatra0.126 0.389*** -0.155 0.415***
(0.599) (2.780) (-1.182) (3.008)
Table 2:
South Sumatra Multinomial Choices of
Outpatient Interactive Terms
base: government hospital
The poor family tends to use
JAMSOSKESto the utmost.
The coefficients of all choices are
negative and significant which means
there is a huge shift to government
hospital for outpatient treatment
Compared to Sumatra with no health
care program; there is an increase of
demand for private doctor/polyclinic.
People go to private doctor to get good
diagnosis before joining free health
care despite having to pay fees.
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18
Inpatient ChoicesVARIABLES Private
Hospital PUSKESMAS/PUSTU Private HealthWorkerAge 0.00415 -0.0203*** -0.00994
(1.055) (-2.857) (-1.636)H. school and
above 0.159 -0.730 -0.535
(0.819) (-1.560) (-1.594)Household income 0.829*** -0.306 0.0862
(5.568) (-1.072) (0.372)Year 2011 1.778 -8.952** 8.807***
(1.010) (-2.126) (2.674)% road paved 0.000947 -0.0126** -0.0209***
(0.233) (-2.090) (-4.074)Hilly region -0.0468*** -0.00575 -0.0143
(-3.716) (-0.606) (-1.462)N. of hospital 0.695 9.733*** -1.419(0.596) (2.937) (-0.706)
N. of polyclinic -0.449 -0.177 0.185(-0.693) (-0.130) (0.193)
N. of puskesmas -0.948 -6.084*** -3.668***(-1.139) (-3.416) (-3.004)
Dist. to hospital -0.0124 0.0203** 0.0266***(-1.457) (2.087) (3.393)
Dist. to polyclinic 0.0114 -0.000942 -0.0402***(1.117) (-0.0858) (-3.194)
Dist. to puskesmas 0.00868 -0.0189 -0.0381(0.411) (-0.758) (-1.042)
Constant -12.12*** 4.321 -0.222(-5.548) (1.064) (-0.0667)
Observations 778 778 778
Table 3:
South Sumatra: Multinomial
Inpatient Choices Basic Regressions
z-statistics in parentheses
*** p
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19
Inpatient
ChoicesVARIABLES Private
Hospital PUSKESMAS/PUSTU PrivateHealthWorker/Poly
Poor FamilyPoor Family 0.508 -0.139 0.360
(1.192) (-0.233) (0.504)2011 X poor -0.521 0.155 -0.0660(-1.123) (0.221) (-0.0853)Mother
Mother 0.923 0.993 0.810(0.954) (0.886) (0.538)
2011 X mother -0.999 -33.40 -0.554(-0.904) (-4.78e-06) (-0.341)
Children under
5Age 5 and less -0.373 -0.478 -1.309
(-0.562) (-0.669) (-1.013)2011 X age 5 0.849 -0.109 0.978
(1.222) (-0.131) (0.739)Urban
Urban 0.710 -2.174** 1.956**(1.481) (-2.225) (2.422)
2011 X urban -0.545 0.458 -2.452***(-1.041) (0.365) (-2.735)Sumatra
ContextSouth Sumatra 0.129 -0.0207 -0.272
(0.724)
(-0.0783)
(-0.872)
2011 X S. Sumatra 0.0524 -0.830** 0.230(0.256) (-2.511) (0.665)
Table 4:
South Sumatra: Multinomial Inpatient
Choices Interacted Terms
z-statistics in parentheses
*** p
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(1) (2) (3) (4)VARIABLES Midwife Paramedic Dukun RelativeAge 0.0751** 0.352** 0.0859** 0.199*
(2.328) (2.362) (2.293) (1.768)Household income -0.694*** -0.839** -1.268*** -1.074***
(-8.565) (-2.122) (-12.73) (-3.389)Year 2011 -2.194* 15.70* -9.123*** -8.924
(-1.752) (1.769) (-5.129) (-1.509)% road paved 0.00143 -0.0228** -0.000639 0.0103
(0.628) (-2.487) (-0.253) (1.293)Hilly region 0.0133*** 0.0119 0.0173*** 0.0173**
(3.181) (0.969) (3.949) (2.218)N. of hospital -1.322* -14.95*** -0.239 2.422
(-1.873) (-2.824) (-0.238) (0.723)N.of maternity hosp. 0.976** 7.761* 1.140* -1.062
(2.016) (1.775) (1.783) (-0.520)N. of puskesmas 1.208** -0.861 3.118*** 3.474*
(2.479) (-0.233) (4.996) (1.651)N. of doctor -0.0400 0.559 -0.234* -1.558**
(-0.395) (0.479) (-1.714) (-2.149)N. of midwife -0.135 -3.043*** -0.488*** 0.745
(-1.199) (-3.199) (-3.519) (1.495)N. of polindes -0.122 -0.374 0.516** 0.497
(-0.609) (-0.418) (2.287) (0.758)Dist. to hospital 0.00633 0.0319 0.0178*** 0.0285**
(1.361) (1.515) (3.511) (2.398)Dist. to amaternity_hosp. 0.000412 -0.00323 0.00719 -0.00252
(0.101) (-0.161) (1.610) (-0.229)Dist. to puskesmas 0.00831 -0.0196 -0.0133 -0.0268
(0.609) (-0.376) (-0.936) (-0.870)Dist. to doctor 0.0178* -0.0800 0.0285*** 0.0176
(1.810) (-1.614) (2.813) (0.860)Dist to midwife -0.0183 0.0808* -0.00110 0.0273
(-1.540) (1.742) (-0.0902) (1.256)Dist. to polindes 0.00413 -0.0419 -0.00513 0.00547
(1.499) (-1.506) (-1.632) (0.686)Constant 11.35*** 11.35** 17.56*** 9.600**
(9.774) (2.055) (12.50) (2.168)Observations 6,577 6,577 6,577 6,577
Table 5:South Sumatra: Multinomial Choices of
Birth Helper Basic Regressions
z-statistics in parentheses*** p
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(1) (2) (3) (4)VARIABLES Midwife Paramedi
c Dukun Relative
Poor
FamilyPoor Family 0.523** 0.878 0.957*** 1.044*
(2.365) (1.463) (4.051) (1.836)Year 2011 X Poor -0.420* 0.175 -0.779*** -1.258*
(-1.706) (0.188) (-2.898) (-1.845)Urban
Urban 0.330 1.549 -0.391 -2.258*(1.334) (1.416) (-1.394) (-1.761)
Year 2011 X urban -0.475* -8.543*** -0.795** -1.050(-1.738) (-3.193) (-2.368) (-0.606)
Sumatra
ContextSouth Sumatra 0.0280 0.322 0.0778 -1.442***
(0.324) (1.210) (0.802) (-5.340)Year 2011 X South
Sumatra -0.01000 -0.881** -0.0519 0.544(-0.0968) (-2.000) (-0.437) (1.640)
Table 6:South Sumatra: Multinomial Choices of
Birth Helper Interacted Terms
z-statistics in parentheses*** p
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(1) (2) (3) (4)VARIABLES Days of illness Days of illness Days of illness Days of illness
Age 0.00276*** 0.00427*** 0.00290*** 0.00276***(11.40) (18.02) (17.07) (11.37)
Marriage -0.0285*** -0.0195** -0.0292***(-3.453) (-2.330) (-3.583)
High school -0.0687*** -0.0471*** -0.0643*** -0.0694***(-9.442) (-6.327) (-8.654) (-9.565)
Household
income 0.0390*** 0.0330*** 0.0326*** 0.0348***(4.082) (3.628) (3.652) (4.170)
Year 2011 0.536*** 0.536*** 0.532*** 0.552**(3.072) (3.050) (2.988) (2.296)
Poor Family 0.0500***(2.863)
2011 X poor -0.0245(-1.290)Age 5 and less 0.286***
(13.90)2011 X age 5 -0.0609***
(-0.636)Mother 0.238***
(11.32)2011 X mother -0.0468**
(-2.112)Urban -0.0337
(-0.808)2011 X urban -0.000171
(-0.00392)Geo-topography Yes Yes Yes Yes
Facility
availability Yes Yes Yes
Distance to
facility Yes Yes Yes Yes
Observations 73,171 73,171 73,171 73,171Wald-Chisq 365.68*** 1008.31*** 267.16*** 346.37***
Table 7:
South Sumatra: Probability of Being
Sick
Impact ofJAMSOSKES is reducing the
probability of being sick for all cases
considered.
The probability of being sick is
related positively with age.
While higher education attainment
tends to reduce the probability ofsickness.
But high household apparently does
not prevent someone from being sick.
(1) (2) (3) (4)
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(1) (2) (3) (4)VARIABLES Days of illness Days of illness Days of illness Days of illness
Age 0.00943*** 0.0104*** 0.00922*** 0.00942***(14.02) (14.81) (14.13) (13.91)
Marriage -0.0736** -0.0548* -0.0727**(-2.423) (-1.741) (-2.374)
High school -0.0426 -0.0207 -0.0433 -0.0441(-0.873) (-0.419) (-0.897) (-0.885)
ln_HH expenditure -0.0436 -0.0375 -0.0393 -0.0377(-1.404) (-1.273) (-1.327) (-1.308)
Year 2011 -0.407 -0.358 -0.396 -0.590(-1.031) (-0.929) (-1.018) (-1.450)
Poor Family -0.0589 -0.329(-1.034) (-0.919)
2011 X poor 0.0643(0.987)
Age 5 and less 0.174***(3.100)
2011 X age 5
-0.0396
(-0.636)Mother 0.00165
(0.0195)2011 X mother -0.000714
(-0.749)Urban -0.0436
(-0.474)2011 X urban 0.0735
(0.732)Geo-topography Yes Yes Yes Yes
Facility availability Yes Yes Yes YesDistance to facility Yes Yes Yes Yes
Constant 2.145*** 1.971*** 2.238*** 2.056***(4.955) (4.804) (5.550) (5.073)
Observations 9,248 9,248 9,248 9,248Wald-Chisq 269.69*** 305.88*** 267.16*** 246.00***
Table 8:
Poisson Regression: South Sumatra
Impacts on Days of Illness
Older people seem to sufferlonger than younger when they
get ill.
It suggests that marriage people
tend to have fewer days of
illness
None of the interactive terms is
significant suggesting that the
sickness of this type does not
prevent one from continuing to
work.