The JKN policy did not increase the use of overall contraception methods, but the JKN policy could increase LACs use. The influence of health insurance ownership, socio-economic status, and geography factor, on the use of overall contraception method and LACs use, indicated some contrary results. A negative correlation between socio-economic status and the use of overall contraception method was found, while in LACs use was a positive correlation. There was a tendency to increase the use of overall contraception method in rural areas after the implementation of the JKN. On the contrary, LACs use increased more in urban areas than in rural areas after the implementation of the JKN. The results of this research showed that the JKN did not increase CPR at the national level, and it also did not increase equity in family planning use among regions, especially the eastern areas of Indonesia.
This research had some limitations, which need to be considered when interpreting the results. First, not all the variables that should be considered exist in the secondary data. Some variables that could have influenced CPR and LACs use are not available in SUSENAS data, such as availability of health facilities and contraceptives, and the distance of health facilities from the locality of residence. We only identified four determinants that contribute to the use of overall contraception method or CPR and LACs use. Second, we only used a before-after approach with a cross-sectional design to measure equity of family planning utilization. It is one of the standard methods used in health impact assessment. Third, this study only measured equity in utilization of the use of overall contraception method and LACs use. Equity in health financing could not be measured because of data limitations.
Even though our study has some limitations, data with large samples in 2012-2016 were able to measure the change of equity every year and the change of socio-economic determinants and the geography factor that influence the use of overall contraception method or CPR and LACs use.
One of the objectives of the national health insurance implementation is to ensure all people get access to health services. Reducing the financial barriers to access health services will increase health services utilization. The JKN has not increased the use of overall contraception method that are included in the benefit package in JKN. Moreover, there was a decreasing trend of the use of overall contraception method who have health insurance after the implementation of the JKN. Research by Teplitskaya et al. supports this finding . After 2002, CPR tended to decrease in the decentralization era because of the reduction in funding of family planning and the diminishing role of BKKBN as the leading service provider . The problem continues after implementation of the JKN since there are now multiple agencies that have a lack of coordination. BKKBN, the Ministry of Health (MOH), the National Health Insurance Agency (Badan Pelaksanan Jaminan Sosial-Kesehatan or BPJS-K), local government are agencies that have a role in the family planning program. In other words, there is fragmentation among multiple agencies .
The central and local governments provide drugs and contraception, while BKKBN has the role in fulfilling and distributing it in health service centers. BPJS finances the tariff of family planning services in health service centers based on the laws of the Indonesian Health Ministry [12,13,19–21]. Besides the lack of coordination among multiple agencies, the reducing trend of CPR after the implementation of the JKN can occur because of the weak regulations. Some regulations related to family planning programs in JKN must be evaluated. Some of them are Non-capitation tariff for IUD and sterilization is assumed too low, no limitation to births, no claim for IUD in hospital, and no guarantee for sterilization after delivery . When the government implemented childbirth insurance, called Jaminan Persalinan-Jampersal, in 2011, there were some provisions to encourage the participants enrolled in Jampersal to join in post-partum family planning. This law did not continue in the JKN era .
The JKN policy did not increase equity in contraceptive use among regions. The achievement of CPR in the eastern areas of Indonesia was still lower than in the western areas of Indonesia. However, LACs coverage in the eastern areas of Indonesia increased more than in the western areas of Indonesia. The new policy that encourages LACs use coverage in eastern Indonesia can be a solution to increase CPR in the eastern areas of Indonesia. To achieve it, the government must strengthen the quality and equitable distribution of the supply side. Gaps in infrastructure, health facilities, and health workers between the western and eastern areas of Indonesia have already been observed in the first year of the implementation of the JKN . This problem continued to occur after the implementation of the JKN.
Some countries that had implemented maternal health insurance for deliveries and mothers’ postpartum care through universal health coverage agenda showed different results. Mauritania had implemented the obstetrical risk insurance scheme (ORI) in 2002, but the effects of the ORI exhibited decreasing use of family planning . The implementation of universal health coverage (UHC) in Latin America showed that m-CPR has continued to increase in the majority of Latin America Countries. However, disparities remain, especially for marginalized groups . In the United States (US), the implementation of Affordable Care Act (ACA) indicated a significant result in increasing of use of overall contraceptive, in the use of Long-Acting Reversible Contraceptives (LARCs), in decreasing of the births, in reducing of the proportion of births from unwanted pregnancies, and in reducing an inequality among insured women [6,26–35].
Not only health insurance ownership but also socio-economic status and the geography factor contributed to the use of overall contraception method. Household economic status showed a significant result, but the association was a negative correlation. It means the higher household economic status, the less contraceptive use. These results contrast with the prior research that used the 2002-2003 and 2007 of Indonesia Demographic and Health Survey (IDHS) Indonesia and some other studies. The 2002-2003 and 2007 of IDHS indicated that better-off women were more likely to use family planning than were the poor women [9,10]. The conflicting results in two periods, between 2002-2007 and 2012-2016, indicated that there is a significant transformation in the society. We assumed that there is a shift of values in the society in Indonesia, but this assumption must be proved through further qualitative research. The same results were shown by studies in Bangladesh and Cameroon [36–38]. However, the studies in North Ethiopia and Malawi showed that education contributes significantly to the use of overall contraception method [39,40]. The gap between urban and rural areas in use of overall contraception method decreased after the implementation of the JKN. Moreover, in 2016, the result showed that married women in rural areas were more likely to the use of overall contraception method than were married women in urban areas. In other words, the JKN contributed to decreasing inequity in use of overall contraception method between urban and rural areas. However, an inequity gap between provinces in the western areas and the eastern areas of Indonesia has remained.
On the contrary with determinants of the use of overall contraception method, the influence of health insurance ownership, socio-economic status, and geography factor, on LACs use indicated significant results, which were a positive correlation. The JKN policy could increase LACs use, especially in the group who has subsidized health insurance and the Nusa-Maluku-Papua region, but an inequity has remained between urban and rural areas. Most studies indicated that health insurance had made a significant contribution to increasing of LACs use [6,26–30,32–35,41–46]. The contribution of LACs use in the success of the family planning program is very crucial, but until 2016, LACs use coverage in Indonesia was only 18.72%. To increase contraceptive use, especially LACs use, the Indonesian government must evaluate the prior policies related to family planning policies.
Health system improvement related to family planning programs must be prioritized. Some specific actions must be done. First, the government must strengthen the quality and equitable distribution of the supply side for the family planning program, especially in the rural and eastern areas of Indonesia. Second, strengthening of the role and coordination among multiple agencies in the family planning program must be implemented. Third, improving regulations is needed related to family planning programs in the JKN, for example, increasing of non-capitation tariff for IUD and sterilization; providing of IUD service in hospital; and encouraging of family planning after post-partum. Some studies had also suggested increasing family planning among postpartum women [47,48]. Besides improving the health system, the shift of values in the Indonesian society that encourages acceptance of family planning must be evaluated. The social approaches based on values and norms in the society are needed to increase contraceptive use, especially LACs use.
The married women between 15 and 49 years of age who are covered by National Health Insurance (NHI) must be ensured to get the optimal services of family planning. Therefore, the supply-side of family planning programs, ability to manage by multiple agencies in family planning programs and the regulations related to family planning in NHI must be properly prepared before and during the implementation of NHI. Every kind of health service that is included in the NHI package has a unique problem in its implementation. As a result, every health service must have appropriate regulations that are suitable to overcome the problem.