Background: To explore the situation of national health insurance coverage among informal workers and to identify the enrollment strategy for such workers.

Method: This is a qualitative research with a case study approach. Participants are eight palm sugar farmers and fifteen major and minor stakeholders of national health insurance in the district of Banyumas, Indonesia. This study includes semi-structured informant interview and open-ended questions. A thematic framework analysis is applied to guide the interpretation of the data. Data analysis is facilitated by using a qualitative data analysis software package MAXQDA 12.

Results: This study has highlighted several interesting issues regarding the efforts to extend health insurance coverage among palm sugar farmers. First, the nature of palm sugar cultivation possesses a higher risk of injury and work-associated diseases, including fall and seasonal diseases. Second, health insurance possession is crucial but the farmers face the problem of how to ensure the continuity of the premium payment amid the uncertainty of palm sugar business revenue. Third, multi-stakeholder initiatives, bringing together government, business and civil society will solve coverage expansion challenges among this such workers.

Conclusion: This study suggests extending health insurance coverage among informal workers need various and innovative approaches by considering their characteristics to maintain a sustainable membership. This study identifies an important role of cross-cutting collaboration between government with other stakeholders to assure informal workers coverage under national health insurance program, and further research is needed to explore alternative ways of maintaining sustainability of health insurance membership.

Keywords: Health insurance, Informal workers, Rural area, Qualitative approach, Indonesia