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


[1] Bitran R. Universal health coverage and the challenge of informal employment: lessons from developing countries. Washington, DC: International Bank for Reconstruction and Development, World Bank; 2014.

[2] Zen F, Dita A. Social protection systemin Indonesia: an assessment. In: Asher MG, Zen F, Dita A, editors. Social protection goals in East Asia: strategies and methods to generate fiscals pace. London: Routledge; 2018.p.98e132.

[3] Devadasan N, Criel B, Van Damme W, Manoharan S, Sarma PS, Vander Stuyft P. Community health insurance in Gudalur, India, increases access to hospital care. Health Pol Plann 2010;25(2):145e54.https://doi.org/10.1093/heapol/ czp044.

[4] Philip NE, Kannan S, Sarma SP. Utilization of comprehensive health insurance scheme, Kerala: a comparative study of insured and uninsured below-poverty-line households. Asia PacJPublHealth2016;28(1Suppl):77se85s.https://doi.org/ 10.1177/1010539515602306.

[5] Aji B, De Allegri M, Souares A, Sauerborn R. The impact of health insurance programs on out-of-pocket expenditures in Indonesia: an increase or a decrease? Int J Environ Res Publ Health 2013;10(7):2995e3013. https://doi.org/10.3390/ ijerph10072995.

[6] Aji B, Yamamoto SS, Sauerborn R. The economic impact of the insured patients with severe chronic and acute illnesses: a qualitative approach. Glob Health Action 2014;7:22526. https://doi.org/10.3402/gha.v7.22526.

[7] Aji B, Masfiah S, Harwanti S, Ulfah N, Minh HV. Social capital, health insurance, and community action: toward universal health coverage for informal workers. Adv Sci Lett 2017;23(4):3586e9.https://doi.org/10.1166/asl.2017.9187.

[8] Wijayanti DE, Hartono S, Darwanto DH. Relative efficiency of brown sugar agroindustry in kokap district, kulonprogo regency, D.I. Yogyakarta. Agro Ekon 2016;27(1):52e63. https://doi.org/10.22146/jae.30215.

[9] Abdullah WG, Rianse U, Muhidin Widayati W, Mihrad ES, Taridala SAA, et al. Farmer's motivation in aren sugar processing business. IOP Conf Ser Earth Environ Sci 2018;122: 012007.https://doi.org/10.1088/1755-1315/122/1/012007.

[10] Hidayat B, Mundiharno, Nemec J, Rabovskaja V, Rozanna CS, Spatz J. Financial sustainability of the national health insurance in Indonesia: a first year review. Jakarta: Social Protection Programme; 2015.

[11] Pisani E, Olivier Kok M, Nugroho K. Indonesia's road to universal health coverage: a political journey. Health Pol Plann 2017;32(2):267e76.https://doi.org/10.1093/heapol/czw120.

[12] Anindya K, Lee JT, McPake B, Wilopo SA, Millett C, Carvalho N. Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: a propensity score matched analysis. J Glob Health 2020;10(1): 010429.https://doi.org/10.7189/jogh.10.010429.

[13] Robyn PJ, Fink G, Sie A, Sauerborn R. Health insurance and health-seeking behavior: evidence from a randomized community-based insurance roll out in rural Burkina Faso. Soc Sci Med 2012;75(4):595e603. https://doi.org/10.1016/j.socscimed.2011.12.018.

[14] Aji B, Intiasari AD, Masfiah S. Insights in to urban informal workers in Indonesia: health insurance enrollment, adverse selection issue and access to health care. Indian J Public Health Res Dev 2019;10(3):722e4. https://doi.org/10.5958/ 0976-5506.2019.00587.4.

[15] Chomi EN, Mujinja PG, Enemark U, Hansen K, Kiwara AD. Health care seeking behaviour and utilization in a multiple health insurance system: does insurance affiliation matter? Int J Equity Health 2014;13:25.https://doi.org/10.1186/14759276-13-25.

[16] Bhattacharya J, Vogt WB. Employment and adverse selection in health insurance. Forum Health Econ Pol2014;17(1): 79e104.https://doi.org/10.1515/fhep-2013-0017.

[17] Ahmed S, Sarker AR, Sultana M, Chakrovorty S, Hasan MZ, Mirelman AJ, et al. Adverse selection in community-based health insurance among in formal workers in Bangladesh: an EQ-5D assessment. Int J Environ Res Publ Health 2018;15(2): 242.https://doi.org/10.3390/ijerph15020242.

[18] Priyanto D. Penderes gula kelapa di Desa pageraji kecamatan Cilongok kabupaten Banyumas. MajalahIlmiah Ekon 2010;13(4):130e62.

[19] Bonfert AT, Hennig J, Heymann M, Hussein K, Langenbrunner J. Closing the gap: the global experience providing health insurance coverage for in formal sector workers. Washington, DC: Joint Learning Network for Universal Health Coverage; 2015.

[20] Morestin F, Ridde V. How can the poor be better integrated into health insurance programs in Africa? An overview of possible strategies. Montreal, Canada: University of Montreal;2009.