Causal Factors Analysis of National Health Insurances Unpaid
Premium by Informal Workers in Baubau City
Habibi Zamuli, Retna Siwi Padmawati, Diah Ayu Puspandari
Department of Public Health, Faculty of Medicine, Universitas Gadjah Mada, Sleman, Yogyakarta, Indonesia
Keywords: Informal sectors, National Health Insurance’s, Unpaid premiums, City of Baubau.
Abstract: National Health Insurances (NHI) as informal sectors member are facing difficulties in paying the
contributions are vulnerable NHI participants to unpaid premiums. This problem is more common in the
informal sector workers and non-workers. The expanding aspect coverage of membership and contribution
sustainability, especially participants PBPU and BP is a major challenge that must be faced by BPJS
Kesehatan. Objective of this research is analysing the contributing factors for unpaid premiums of informal
workers participants in Baubau City. This research used mixed method, concurrent embedded design. Unit
analysis this study is that people who are in unpaid informal sector participants pay dues of NHI. The data
was collected by in-depth interviews and questionnaires. Results showed that there are seven factors that
causes PBPU participants unpaid premiums at Baubau City are socio-demographic categorization because
types of jobs that are not earning salary with earnings below UMR, forgot, dissatisfied with health services
provided, limited access to premium payment channels, healthy, class restrictions, health seeking behaviour
and knowledge. Conclusion from this research is unpaid premiums by JKN PBPU participants in Baubau
City are still high, therefore needed a breakthrough and right strategy to prevent and reduce to PBPU
participants who are unpaid premiums.
1 INTRODUCTION
In order to achieve UHC there are three dimensions
that must be a priority: the expansion of membership
(coverage), the extension of the benefit package
(benefit package) and the sustainability of the
contribution premium. Three years of the existence
of JKN, this program has a lot of problems and
challenges that must be experienced, one of which is
the collection function of the premium (revenue
collection) that is the coverage of membership and
the continuity of payment of premium by the
participants. This problem occurs mostly in the
informal sector (PBPU) and Non-Workers (BP).
The aspect of extending the coverage and
continuity of premium, especially the participants of
PBPU and BP is a big challenge to be faced by BPJS
Kesehatan, based on data BPJS Kesehatan report
that there are about 47.33% or 9 million participants
PBPU delinquent contribution by August 20161.In
order to maintain the balance and sustainability of
JKN financing, efforts to improve compliance and
sustainability of contributions by participants are as
important as increasing the coverage of membership
(Mundiharno & Thabrany, 2012). Informal sector
participants have the greatest possibility of
delinquent paying premiums because the main
characteristics of these workers are non-permanent
income and in many cases (especially in agriculture
and plantation sectors) depending on the season,
unlike the formal sector that the premium is
universally administered by the institutions or
organizations where they work and automatically
deducted from their salary while informal sector
workers have to manage their own premiums.
2 METHODS
This research used descriptive method, with mixed
method research design: concurrent embedded (case
study). Qualitative sampling technique using
purposive sampling and quantitative sampling using
cluster random sampling. The unit of analysis in this
82
Zamuli, H., Padmawati, R. and Puspandari, D.
Causal Factors Analysis of National Health Insurances Unpaid Premium by Informal Workers in Baubau City.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 82-87
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved

research is the community of participant of JKN
independent PBPU in arrears paying the premium.
Data collection was done with in-depth interviews as
well as questionnaires.
3 RESULT
This research used descriptive method, with mixed
method research design: concurrent embedded (case
study). Qualitative sampling technique using
purposive sampling and quantitative sampling using
cluster random sampling. The unit of
3.1 Socio-demographic Characteristics
of Respondents
The socio-demographic condition of PBPU
participants has an important role in influencing the
high rate of premium payment arrears to the
participants of JKN PBPU, the result of in-depth
interview analysis describes the work and income
become the dominant factors causing the PBPU
participants in arrears premium. The age of 31-50
years has a tendency of delinquent pay dues
compared to other ages, about 6 informants and
43.86% respondents, men are more likely to
delinquent pay premiums than women,
approximately 5 informants and 61.40% respondents
and PBPU participants with higher education tend to
be dominant in delinquent from other informants
about 6 informants and 70.67% of each respondents
are in arrears premium for ≤ 6 months. Work and
income have a significant relationship with the
premium arrears of participants JKN PBPU, for
instance farmers with income IDR. 150,000. - IDR.
500,000 are in delinquent premium for> 6 months
about 3 informants, artisans (motorcycle taxi, stones
and wood) who have income IDR.500.000 -
Rp.900.000 are in arrears premium for ≤ 6 months as
many as 4 informants, while other jobs (apprentices,
mall servants and retired civil servants) with revenue
from IDR. 100,000 - IDR. 2,000,000 in arrears
premium for ≤ 6 months about 3 informants.
Informants with entrepreneurial occupation with
income IDR. 2,500,000 are in arrears for ≤ 6
months.
In general, in many informants and respondents
who earn below the UMR (≤ IDR 1,850,000) as
many as 8 informants and 74.38% respondents are in
arrears premium for ≤ 6 months, the number of
family members>4 people tend to be lower in
delinquent pay premium if compared with the
number of family members ≤ 4 people around 5
informants and 73.64% participants are in arrears
paying premium for ≤ 6 months.
3.2 Causes Arrears of Premium
Payments
The premium payer is over ≤ 6 months more than
the informant who is in arrears of premium for> 6
months each of 10 informants and 6 informants
respectively. Here are the reasons why participants
of JKN PBPU are in delinquent of paying premiums:
3.2.1 Type of work
The type of informant work with low and uncertain
income leads to premiums arrears, along with in-
depth interview quotes with informants:
“Ehh honestly sir, ah hence mi we are unpaid
because of the obstacle of money also not exist and
income effects as well because our income as
farmers is not fixed”. (Informant_1)
3.2.2 Health status and history of chronic
illness
Two reasons participants enrolled JKN PBPU that
healthy condition (7 informants and 35.96%) as
anticipation to get health insurance when sick and
financial protection. Ill condition (9 informants and
64.04%) due to need of health services in the near
future, get free health service and self-esteem and
advice from medical officer, besides the reason the
participants registered for JKN PBPU when healthy
is as a worship charity for saving in the next life and
ethics-related awareness is also a trigger for the
society to register to be a participant JKN PBPU so
they are not comfortable if directly use the BPJS
Kesehatan card when in a state of illness. But these
conditions still affect the payment of premium
payments, PBPU JKN participants who are healthy
do not comply again pay a premium because they do
not need any more BPJSK and it is useless if they do
not use BPJS Kesehatan although they know that the
obligation to pay premiums is in every month and
rarely use it.
Regular utilization of health services so that the
ownership of JKN PBPU becomes important
because the absence of close families and relatives
that can be relied on to help alleviate health
financing and previous family experience when
treatment requires high costs are the reasons
participants register JKN PBPU, the presence of
chronic diseases should be able to improve
Causal Factors Analysis of National Health Insurances Unpaid Premium by Informal Workers in Baubau City
83

compliance participants of JKN PBPU paid a
premium due to the high frequency of use of health
services, about 9 informants and 35.09% of
respondents had chronic illness. The findings of this
study illustrate that the participants of JKN PBPU
who chronically ill choose surrender with the disease
and switch to traditional treatment which more
affordable and cheap so they do not want to pay
BPJS Health premium again.
3.2.3 Membership Class
Class 3 is more dominant than other classes because
of the cheap and affordable premium of about 8
informants and 64% of respondents. About 7
informants and 33.33% of respondents chose grade 2
because of the quality of health services despite their
financial capacity due to poor quality experience of
3rd grade health services and class restrictions. The
restriction of membership class 1 and 2 by the
BPJSK officer becomes the participant's expense so
that the premium paid is expensive and unreachable.
Class 3 is more dominant than the other classes
because of the low and affordable premium about 8
informants and 62.28% respondents, about 6
informants and 35.96% respondents choose class 2.
Because of the quality of health care despite the
ability of their financial capacity around 2
informants and surrounding class restrictions 3
informants, restriction of membership class 1 and 2
by unscrupulous officer BPJSK become the burden
of participants so that premiums paid expensive and
not affordable finally delinquent in premiums.
3.2.4 Knowledge
In general, in many informants it is found that
knowledge of informants related to rights as
participants of JKN PBPU is high enough to get
quality health service, to pay medical expenses when
experiencing illness or even free. Related to his
obligations as a participant JKN PBPU informants
have enough knowledge on monthly fee obligations,
nominal and sanctions in arrears paying premiums
and payment due. Informant's knowledge related to
paying the premium on time is high enough about 9
out of 16 informants paid premiums on time, but
some informants, 7 of the 16 informants in paying
premium have low knowledge about the deadline
payment so that affecting compliance of payment,
forget and use health services infrequently. The
consequences of PBPU JKN participants in arrears
in paying premiums are the inactivity of membership
and penalties, 11 out of 16 informants had high
knowledge related to sanctions and penalties when
delinquent paying premium, however about 5 of the
informants had low knowledge related to sanctions
and fines when delinquent paying premium.
Informants with initials ES related how to use and
treatment procedures using BPJS Kesehatan card
does not know. This is because informant has never
used the BPJS Kesehatan card on the ground of still
healthy
3.2.5 Access Premium Payment Channels
Approximately 13 informants and 71.05% of
respondents made payments through banks because
of the ease, although there are also difficulties such
as queue, but a small number of participants feel
bored and lazy because the old queue, about 10
informants and 86.84% respondents travelled ≤ 10
kilometres, easy access by having a motorcycle so
that it is easy to reach becomes the reason the
participants are not burdened with distance, but in a
small part the participants feel burdened by the
distance. The reason is difficult to reach because
they have no a motorcycle. Approximately 14
informants and 98.25% respondents took ≤ 60
minutes to the payment site, most informants were
not burdened with time because it was close and
short, but in small numbers of informants felt
burdened because they had no time and busy.
Approximately 11 informants and 55.26%
respondents spent ≤ IDR. 10,000 for transportation
costs, most informants are not burdened with the
cost because they have a motorcycle so it is cheap
and practical, but a few informants feel burdened
because it is expensive. Limitation of access to
premium payment services is also a contributing
factor to JKN PBPU participant’s delinquent paying
premiums, long distance payment places that
requires long travel time, expensive transportation
costs and disruption payment system through auto-
debit make some participants of JKN PBPU choose
delinquent pay premium.
3.2.6 Experience of Health Service Access
Utilization
About 15 informants and 96.49% respondents had
used health services, around 8 informants most often
use health services in Public Health Services
(Puskesmas) are those who suffer from sickness that
could be handled by Public Health Services
(Puskemas). Approximately 7 out of 16 informants
using health facilities in hospitals are those who
have high-cost diseases, require comprehensive and
high-tech health services, most of the participants
are satisfied with the quality of the health service
INAHEA 2017 - 4th Annual Meeting of the Indonesian Health Economics Association
84

they get, however in some cases the experiences of
JKN PBPU participants related to poor service
quality and additional costs when getting treatment
are some of the reasons participants delinquent pay
premiums.
4 DISCUSSION
The results of this quantitative study show that
around 25.33% of PBPU participants are no longer
active in paying premiums or not paying health
insurance premiums more than six months, the
average of those who are in arrears of premiums is
to have informal sector jobs with income below
UMR due to uncertain income and not routine.
Employment in the informal sector is an important
determinant of participation in the NHIF program,
our findings suggest that more efforts are needed to
integrate informal sector workers into NHIF
3
.
Previous research has shown that in many African
countries one of the obstacles to efforts to
implement comprehensive social health insurance is
the difficulty of accumulating contributions due to
the high proportion of the population in the informal
sector
4
. A large number of household members are
preventing people from enrolling in health insurance
schemes because they cannot pay the premiums of
their entire family members. Revenues are one of the
main causes of PBPU participants delinquent paying
contributions for ≤ 6 months and > 6 six months
(inactive) are those with uncertain income, non-
regular income and income below the Minimum
Wage of Municipalities.
Most of the participants who signed up to
participate in PBPU were those with ill health
conditions because they needed health services in
the near future so that were forced to enroll JKN
with the hope of obtaining free healthcare, those
who participated in PBPU mostly worked in the
informal sector where the work had non- routine
income, uncertain and still below the UMR so
reasonable if they are delinquent to pay premiums.
The tendency of participants to register when the
illness is the impact of the social health insurance
policy, as it is known that social insurance does not
have underwriting as in commercial insurance, so
this situation becomes a weakness of social
insurance, high adverse selection on PBPU
participants is the impact from the discontinuity of
premiums or high burden of BPJS Kesehatan
premiums because participants pay only premiums
when ill
6
. The health status of the participants at the
time of registering to BPJS Kesehatan affected the
arrear of premium payment, the PBPU participants
who enrolled in the ill condition 1, 3 times the risk
of delinquent paying premiums than the PBPU
participants who enrol in healthy condition
7
. Quite a
few participants who registered as JKN Mandiri
participants suffered from illnesses requiring care
and costly medical treatment (Nopiyani, et al, 2015).
This research is in line with Nopiyani and Pujiyanti's
research in 2015, indicating that most participants
enrolling to be PBPU participants are those with ill
health conditions so they need financing and health
care insurance in the near future. Quantitative
findings about 3.33% of PBPU participants due to
delinquent premiums are healthy so feel no longer
need to pay per month if not using health services
and it's just a waste of money only.
The behaviour of the health seeking pattern by
the people also influences the compliance of the
public paying the premium, a small percentage of
the participants with chronic health disorder tend to
choose traditional treatment either by themselves or
with the help of others such as masseuse or shaman,
so no wonder if there are still a small number of
PBPU delinquent paying premiums JKN despite
having a history of chronic diseases because of the
high trust of PBPU participants to the traditional
medicine which effective and cheap and because the
payment process is voluntary depending on the
economic capacity of the people. But distinguish the
results of research conducted by Dong et al, (2009)
found that continuous utilization of health services
due to certain diseases will encourage people to
register themselves as participants of JKN Non-PBI
Mandiri and encourage people to obediently pay
JKN contributions. The risk of noncompliance
decreases with the increasing number of visits to
FKTP and FKTL because participants who suffer
from illness or health problems should receive
services at health facilities will be more diligent to
pay premium so they can continue to utilize JKN to
access services Health at no charge
9
. A household
with one family member who has a chronic illness or
has had a disruption in routine activity over the past
three months has a significant relationship to
registering to become a CBHI member rather than a
household without chronic disease (Alkenbrack, et al,
2013). There is an influence of the history of chronic
diseases on the participation of the informal sector
community as a participant of health insurance.
The high number of PBPU 3
rd
graders who are in
arrears paying the premiums is a description that the
group is risky or easy to get into the category of
poor, unpredictable jobs and income, making them
at risk for delinquent paying JKN premiums. Several
cases in the study also found that PBPU participants
generally chose grade 3 because the premiums were
cheap so they could be reached and the willingness
of the premium payer that is the child for those
participants paid by others. The high number of
Causal Factors Analysis of National Health Insurances Unpaid Premium by Informal Workers in Baubau City
85

PBPU class 3 participants in arrears of premium
compared to other classes illustrates that PBPU class
3 is a group that is still vulnerable or easy to go in
the category/poor category also found in Pujiyanti et
al research on PBPU participants in 10 Provinces of
Indonesia 2015.
Class 1 and 2 restrictions by unscrupulous
officers of health BPJS become a burden for PBPU
participants because they have no choice but to be
inconsistent with the income and financial condition
of the family causing them to default in paying the
premium. Their main reason for purchasing class
fees is higher than their capacity because their
previous experience of showing 3
rd
class health
services is less satisfactory, such as less friendly
healthcare workers and less comfortable treatment
rooms were also found in Pujiyanti's et al research
on PBPU participants in 10 provinces of Indonesia
by 2015
.
Access to limited premium payment channels
such as limited payment places and payment system
disruptions, travelled distance to payment access is
far due to the difficulty of transportation to premium
payers, long travel time so that participants do not
have time because busy with work in the informal
sector so forget, long travelled distance, time
consuming and using public transportation such as
motorcycle taxis and city transportation, causing
expensive transportation costs because their income
below the UMR is the cause of PBPU participants
are not obedient to pay premiums.
In some cases in this study found that
participants PBPU delinquent premiums because
they do not know and forget the due date of
premium payments this is due to the length of time
they do not use health facilities either in the FKTP
and FKTL because their health conditions are good
and healthy are they educated and less
knowledgeable. Not knowing sanctions when
delinquent premium is a factor supporting the
payment of premium not timely. Knowledge of
premium dates and sanctions when late paying
contributions is significantly related to the incidents
of participants in the 2-6 months unemployment
rate, therefore, it is necessary to innovate and
improve the reminder/notification system due date
and the late payment premium. Since both variables
are factors that influence the delinquent premium,
BPJS Kesehatan should be able to innovate in
utilizing technology in order reminder mechanism
more efficient for example through SMS gateway
also found in research conducted by Pujiyanti et al in
2015. In contrast to the research of Mebratie et al.,
2015 that the high understanding and knowledge of
health insurance especially health insurance CBHI is
significantly related to the low number of CBHI
members out of the CBHI insurance scheme in
Ethiopia because they realize that CBHI insurance is
not just for sick people only but healthy people also
need, they also realize that it is not a savings scheme
and their premium will not be returned
.
Poor quality of health care is also one of the
factors causing delinquent paying of premiums such
as long registration booth queues, lack of stock of
drugs resulting in additional costs when using health
care facilities, the finding is in line with previous
findings that factors affecting compliance of pay
premium (in arrears compliance) namely education,
sex, health status, occupation, place of payment,
travelled time and transportation costs and related
knowledge maturity and sanctions when not paying
on.
5 CONCLUSIONS
There are seven factors that cause PBPU participants
in arrears in paying premiums in Baubau City are
socio-demographic categorization because the types
of jobs that are not earning salary with earnings
below the UMR, forgot, dissatisfied with the health
services provided, limited access to premium
payment channels, better health status (Healthy),
class restrictions, health seeking behaviour and
knowledge are the causes of PBPU participants
delinquent paying premiums.
Unpaid-premiums for PBPU participants with
earnings below UMR should be reviewed, the
determination of premiums as mandated in the JKN
roadmap, the government contributes by providing
premium subsidies or PBPU participants who cannot
afford the premiums transferred to participants of
JKN PBI. Premium collectability is enhanced by
various ways such as payment by adjusting the
characteristics of PBPU participants. Socialization
and education need to include stakeholder, cross
sector of program including from community and
private segment
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