Mapping socioeconomic disincentives to public health insurance usage among informal sector workers: A case study on Lombok, Indonesia

Abstract: Indonesia faces large epidemiological and demographical challenges that make a functioning health system and social protection accessibility increasingly important. In line with UN Agenda 2030, inequality in health and healthcare access is a top priority among the country’s policy-makers. However, social protection coverage among low-middle income households is inadequate. Management of public programmes is hampered by decentralisation effects such as extensive bureaucracy and regulations. This study analyses underlying socioeconomic drivers of low registration and non-usage of Indonesia’s public health insurance scheme among informal sector workers. It builds on data collected through in-depth interviews conducted during eight consecutive weeks on the Indonesian island of Lombok. The informal sector employs some 70 per cent of Indonesians, yet social protection of this group is lacking which may, in turn, have broad socioeconomic consequences on both individual and national level in a potential crisis. This study shows that discriminatory treatment and lack of certain resources together with effects of decentralisation comprise the primary reasons among interviewees to remain unregistered or refrain from using public insurance. Amartya Sen’s capability approach combined with the concepts of social exclusion and unintended consequences are applied to explain the findings. User-evaluation of the public health insurance is limited, especially in regards to individuals in the informal sector as the characteristics of this sector make record-keeping difficult. The combined contribution of applied concepts and presented findings therefore complement existing research because it emphasises subjective accounts of former public insurance users employed in the informal sector.