National Health Insurance Scheme: Internal and External Barriers in the Use of Reproductive Health Services among Women

Evi Martha, Herna Lestari, Resvi Siti Zulfa, Yoslien Sopamena


Lack of familiarity among the community, medical workers, and administrative staff regarding reproductive health services covered by Badan Penyelenggara Jaminan Sosial (BPJS) or the National Health Insurance (NHI) in Indonesia remained a problem. Therefore, this resulted in sub-optimal use of the medical services, as shown by surveys from the Women's Health Foundation for three consecutive years (2015-2017). This qualitative study was conducted with a Rapid Assessment Procedure design in three cities within Indonesia: Padang Pariaman, Manado, and Kupang. Data were collected through IDIs (n = 47informants) and 6 FGDs (7 persons/group). Participants also consisted of NHI RHS users (mothers and young women), administrative officers at health facilities, medical services providers, and officials related to the NHI assistance. Data were managed using NVivo version 2.0 software, accompanied by thematic analysis. The internal barriers in NHI use included inadequate knowledge of RHS covered by NHI, and a culture of shame in informants. External barriers included additional costs for medicines not covered by NHI, the dissatisfaction of health services provided by medical workers, busy work and household activities, and lack of women's role in decision-making within families, which related to reproductive wellness.


National Health Insurance, reproductive health, the Social Security Administrative Body for Health, women

Full Text:



 1. United Nations General Assembly. Principle 1 and principle 4, respectively, of the ICPD programme of action, uphold human rights and gender equality and equity and women’s empowerment. In: Report of the International Conference on Population and Development A/94/10/18 Programme of Action. New York: UnitedNations. 1995. p. 11–2.

 2. Plesons M, Cole CB, Hainsworth G, Avila R, Va Eceéce Biaukula K, Husain S, et al. Forward, together: a collaborative path to comprehensive adolescent sexual and reproductive health and rights in our time. Journal of Adolescent Health. 2019; 65 (6): S51–62.

 3. Ravindran TKS, Govender V. Sexual and reproductive health services in universal health coverage: a review of recent evidence from low-and middle-income countries. Sex Reprod Heal Matters. 2020; 28 (2).

 4. Kieny MP, Evans DB. Universal health coverage. Eastern Mediterranean Health Journal. 2013; 19 (4): 305–6.

 5. Hasstedt K, Desai S, Ansari-Thomas Z. Immigrant women’s access to sexual and reproductive health coverage and care in the United States. Issue Brief (Commonw Fund). 2018. p. 1–10.

 6. Yayasan Kesehatan Perempuan. Laporan studi pelaksanaan skema jaminan kesehatan nasional (JKN) dalam kaitannya dengan kebutuhan perempuan dan pelayanan kesehatan reproduksi dan seksual; 2017.

 7. Peters SAE, Woodward M, Jha V, Kennedy S, Norton R. Women’s health: a new global agenda. BMJ Global Health. 2016; 1 (3): 1–8.

 8. Manze MG, Romero DR, Sumberg A, Gagnon M, Roberts L, Jones H. Women’s perspectives on reproductive health services in primary care. Family Medicine. 2020; 52 (2): 112–9.

 9. Mozumdar A, Aruldas K, Jain A, Reichenbach L. Understanding the use of India’s national health insurance scheme for family planning and reproductive health services in Uttar Pradesh. International Journal of Health Planning and Management. 2018; 33 (4): 823–35.

 10. Scrimshaw Nevin S and Gleason Gary R. Rapid assessment procedures: qualitative methodologies for planning and evaluation of health related programmes (international nutrition foundation for developing countries- INFDC). Scrimshaw Nevin S and Gleason GaryR., editor. Boston, Ma.: Library of Congress Cataloging-in-Publication-Data. 1996. p. 588.

 11. Din N. Manajemen penerapan perilaku hidup bersih dan sehat (PHBS) tatanan rumah tangga di Kelurahan Kurao Pagang Kota Padang tahun 2016. J Endur. 2016; 1.

 12. Zamawe FC. The implication of using NVivo software in qualitative data analysis: evidence-based reflections. Malawi Medical Journal.2015; 27 (1): 13–5.

 13. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. International Journal of Qualitative Methods. 2017; 16 (1): 1–13.

 14. Boyatzis RE. Transforming qualitative information: thematic analysis and code development. Thousand Oaks, California: Sage Publications, Inc.; 1998.

 15. Stuckey H. The second step in data analysis: coding qualitative research data. Journal of Social Health and Diabetes. 2015; 03 (01):007–10.

 16. Allcock SH, Young EH, Sandhu MS. Sociodemographic patterns of health insurance coverage in Namibia. International Journal for Equityin Health. 2019; 18 (1): 1–11.

 17. Nguyen TD, Wilson A. Coverage of health insurance among the near-poor in rural Vietnam and associated factors. International Journal of Public Health. 2017; 62 (s1): 63–73.

 18. Mustapha Kurfi M, Hussaini Aliero I, Author C. A study on clients’ satisfaction on the national health insurance scheme among staff of Usmanu Danfodiyo University Sokoto. IOSR Journal of Economics and Finance. 2017; 8 (5): 44–52.

 19. Adetona TO, Kio JO. Determinants of national health insurance scheme utilization among heads of households in selected communities in Ogun State, Nigeria. International Journal of Academic Research in Business, Arts & Science. 2020; 7354: 142–54.

 20. Yusuf HO, Kanma-Okafor OJ, Ladi-Akinyemi TW, Eze UT, Egwuonwu CC, Osibogun AO. Health insurance knowledge, attitude and the uptake of community-based health insurance scheme among residents of a suburb in Lagos, Nigeria. West African Journal of Medicine. 2019; 36 (2): 103–11.

 21. Negash W, Dessalegn M, Yitayew B, Demsie M, Wagnew M, Nyagero J. Reproductive health service utilization and associated factors: the case of North Shewa zone youth, Amhara region, Ethiopia. Pan African Medical Journal. 2016; 25 (Supp 2): 3.

 22. Smith KT, Monti D, Mir N, Peters E, Tipirneni R, Politi MC. Access is necessary but not sufficient: factors influencing delay and avoidance of health care services. MDM Policy & Practice. 2018; 3(1):238146831876029.

 23. Yakong VN, Rush KL, Bassett-Smith J, Bottorff JL, Robinson C. Women’s experiences of seeking reproductive health care in rural Ghana: challenges for maternal health service utilization. Journal of Advanced Nursing. 2010; 66 (11): 2431–41.

 24. Åkerman E, Östergren P, Essén B, Fernbrant C, Westerling R. Knowledge and utilization of sexual and reproductive health care services among Thai immigrant women in Sweden. BMC International Health and Human Rights. 2016; 1–14.

 25. Tlaye KG, Belete MA, Demelew TM, Getu MA, Astawesegn FH. Reproductive health services utilization and its associated factors among adolescents in Debre Berhan town, Central Ethiopia: a community-based cross-sectional study. Reprod Health. 2018; 15 (1):1–11.

 26. Schwarz N, Bohner G. The construction of attitudes. Blackwell Handbook of Social Psychology; 2001.

 27. Chaiklin H. Attitudes, behavior, and social practice. The Journal of Sociology and & Social Welfare. 2011; 38 (1).

 28. Kyilleh JM, Tabong PTN, Konlaan BB. Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana. BMC International Health and Human Rights. 2018;18 (1): 1–12.

 29. Andoh-Adjei FX, Cornelissen D, Asante FA, Spaan E, Van Der VeldenK. Does capitation payment under national health insurance affect subscribers’ trust in their primary care provider? a cross-sectional survey of insurance subscribers in Ghana. BMC Health Services Research. 2016; 16 (1): 1–10.

 30. Campbell P, Owoka O, Odugbemi T. National health insurance scheme: are the artisans benefitting in Lagos state, Nigeria?. Journal of Clinical Sciences. 2016; 13( 3): 122.

 31. Ansha MG, Bosho CJ, Jaleta FT. Reproductive health services utilization and associated factors among adolescents in Anchar District, East Ethiopia. Journal of Family & Reproductive Health. 2017; 11 (2): 110–8.

 32. Badan Penyelenggara Jaminan Sosial Kesehatan. Peraturan Badan Penyelenggara Jaminan Sosial Kesehatan nomor 1 tahun 2014 tentang penyelenggaraan jaminan kesehatan. Jakarta; 2013.

 33. Gyimah SO, Takyi BK, Addai I. Challenges to the reproductive-health needs of African women: on religion and maternal health utilization inGhana. Social Science & Medicine. 2006; 62 (12): 2930–44.

 34. Gobah FK, Zhang L. The national health insurance scheme in Ghana: prospects and challenges: a cross-sectional evidence. Global Journal of Health Science. 2011; 3 (2): 90–101.

 35.Mensah J, Oppong JR, Schmidt CM. Ghana’s national health insurance scheme in the context of the health MDGs: an empirical evaluation using propensity score matching. Health Economics. 2010; 19 (Suppl.1): 95–106.

 36. Dalinjong PA, Laar AS. The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Health Econ Rev. 2012; 2 (1): 1–13.

 37. Gan-Yadam A, Shinohara R, Sugisawa Y, Tanaka E, Watanabe T, Hirano M, et al. Factors associated with health service utilization in Ulaanbaatar, Mongolia: a population-based survey. Journal of Epidemiology. 2013; 23 (5): 320–8.

 38. Wang Z, Li X, Chen M, Si L. Social health insurance, health care utilization, and costs in middle-aged and elderly community-dwelling adults in China. International Journal for Equity in Health. 2018; 17(1): 1–13.

 39. Kumi-Kyereme A, Amu H, Darteh EKM. Barriers and motivations for health insurance subscription in Cape Coast, Ghana: a qualitative study. ARC Journal of Public Health and Community Medicine. 2017;75 (1): 1–10.

 40. Haque SE, Rahman M, Mostofa MG, Zahan MS. Reproductive healthcare utilization among young mothers in Bangladesh: does autonomy matter?. Women’s Health Issues. 2012; 22 (2): e171–80.

 41. Ganle JK, Obeng B, Segbefia AY, Mwinyuri V, Yeboah JY, BaatiemaL. How intra-familial decision-making affects women’s access to, and use of maternal healthcare services in Ghana: a qualitative study. BMC Pregnancy Childbirth. 2015; 15 (1): 1–17.

 42. Jalu MT, Ahmed A, Hashi A, Tekilu A. Exploring barriers to reproductive, maternal, child and neonatal (RMNCH) health-seeking behaviors in Somali region, Ethiopia. PLoS One. 2019; 14 (3): 1–15.



  • There are currently no refbacks.