Abstract
Healthcare financing plays role in improving the quality of health services, with an aim to examine the effect of family socioeconomic status on the patterns and methods of ability to purchase health services. A quantitative study with a survey approach used in this research that connects exogenous (family socioeconomic status) and endogenous variables (financing patterns and methods, ability to purchase health services), with total sample of 770 households. The technique used an accidental sampling in western and eastern regions of Jambi, with questionnaire instrument and analysis PLS-SEM’s second order. Based from this research, family socioeconomic status has a direct influence on the ability to purchase health services showing as the first hypothesis. The second hypothesis also proved direct influence on the ability to purchase health services. The third hypothesis was also proved like the first and second hypotheses. Methods of health financing mediated the correlation between family socioeconomic status and ability to purchase health services was accepted of fourth and fifth hypotheses. Therefore, the family’s socioeconomic status, patterns and methods of health financing have a direct influence on the ability to purchase health services. Meanwhile, there was an indirect effect of family socioeconomic status on the ability to purchase health services through health financing patterns and methods.
Background
The function of all parties is required in health financing which plays an important role in improving the quality of health services. WHO (2010) in Supriyanto and Ernawati (2018), recommended six patterns and seven methods of health financing to measure the purchasing of health services. Therefore, this study aims to examine the effect of family socioeconomic status on the patterns and methods of health financing on the ability to purchase health services in Jambi Province.
Literature Review
The size of the socioeconomic status grouping is determined based on the measure of wealth, which includes power (Soekanto, 2007), jobs, education, income Sumardi (2004), number of dependents, and asset ownership. According to Rahman (2002), the status also includes the condition of the size and location/position of the house, and the area of residences such as elite or slum areas. Meanwhile, Warner classified these categories into upper, lower, upper-middle and middle, lower upper, and class (Sunarto, 2004).
There are six categories of health financing patterns that are currently being developed. These include (a) direct government financing which is the responsibility of government to citizens, (b) health insurance, which is a financing system prepared by families when in a healthy state, (c) financing from the community, which is managed and agreed by deliberation in a particular community, (d) financing from the patient after using health care facilities, (e) funding from government organizations and external cooperation which is the assistance from donor agencies or WHO, specifically on certain diseases, and (f) financing from the private sector and asset ownership.
Furthermore, there are seven health financing methods in healthcare facilities, namely (a) payment based on disease diagnosis, which is common in referral service facilities, (b) payment based on daily rates, (c) advance payment based on a definite number of people being served, (d) payments based on the total budget (Trisnantoro, 2016), (e) payment based on monthly salary (Supriyanto & Ernawati, 2018) (f) direct payment of fees after service, and (g) reimbursement of prepayments.
The ability to pay showed a family head’s capacity to access health services by optimizing socioeconomic status through income. According to Steven Russel, the ability to pay is influenced by (a) the nature of the disease, the frequency, the length of illness, and the costs required, (b) the various resources available in the household such as assets, cash, education, investment, the ability to organize resources effectively, and accounts receivable, and (c) family response, namely the decision to organize resources effectively and efficiently. Moreover, the hypotheses are as follows: In Jambi Province, (a) the socioeconomic status of the family has a direct effect on the ability to purchase health services, (b) the pattern of health financing has a direct effect on the ability to purchase health services, (c) the method of health financing has a direct effect on the ability to purchase services health, (d) the socioeconomic status of the family has an indirect effect on the ability to purchase health services through the pattern of health financing, and (e) the socioeconomic status of the family has an indirect effect on the ability to purchase health services through the health financing method.
Research Methodology
This study used a quantitative design with a survey approach. The study was conducted in the western region (Bungo, Sungai Penuh City, and Merangin) and the eastern region (Jambi City, Batang Hari, and Tanjab Barat), within 7 months. The population of family visits to health facilities was 1,115,465, while the number of samples used was 770 people. Furthermore, an accidental random sampling technique was used and data sources include primary (questionnaires) and secondary (annual reports/official profile documents of government agencies). The instrument of the questionnaire includes data collection and processing, while the data were analyzed using SEM-PLS second-order analysis.
Result and Discussion
Analysis of the Characteristics of the Respondents
The respondents’ results are based on the characteristics as shown in Table 1:
Distribution of Respondents Based on Age, Gender, Education, and Profession in 2020.
Based on the results, respondents aged 19–64 years old are the dominants with approximately 94.8%. Furthermore, the education level of the majority is high school with approximately 44.2%, employment such as self-employed/entrepreneurial has 31.7%. The socioeconomic status of the family was measured by indicators, namely the income level of the family head, the level of population density, and the number of family members. These results related to the income of the family head were categorized into four, which are dominated by low and moderate income. Out of the total income level, the average is IDR 3,144,155 per month and is greater than the average income (UMP) of Jambi Province which is IDR 2,630,162 (BPS Provinsi Jambi, 2020).
Other factors that are related to the strength of the family in the fulfilment of daily needs are reviewed from the number of family members. The result showed that respondents with a total of 4–6 people were 63.8%. This indicated that more than half of the number of children have 3–4 people, including a father and mother. The detail is shown in Table 2.
Distribution of Respondents by Income and Number of Family Members in 2020.
The detail of the average distribution of the results is shown in Table 3.
Distribution of the Average Respondent’s Answers for Each Variable in 2020.
SEM PLS Analysis
During the outer model measurement, a validity test is carried out, with the condition that the indicator is valid when the loading factor value is above 0.70 (Sarwono, 2012). The results showed that 7 indicators were invalid and were excluded from the model, which led to a structural equation model with 84 valid indicators as follows (Figure 1).
In the reliability test, the instrument is reliable when the Cronbach’s alpha value is >0.6, the composite reliability value is >0.8, and the AVE value is >0.5, as shown in Table 4.
Reliability of Research Indicators (Cronbach’s Alpha, Composite Reliability and Average Variance Extracted/AVE).
Based on the result of the validity and reliability test, the instrument is declared valid and reliable. Subsequently, the inner model measurement is carried out by conducting a hypothesis test based on t-statistics > 1.96 or p-value < 0.05, as shown in Table 5.
Results of Bootstrapping Direct and Indirect Influence.
The results of the estimation test showed that hypothesis 1 obtained a t-statistical value of 25.023 and a p-value of 0.004. This indicated that the direct effect of family socioeconomic status on the ability to purchase health services in Jambi Province is accepted. Meanwhile, hypothesis 2 obtained a t-statistical value of 687.514 and a p-value of 0.000, which showed that the direct effect of health financing patterns on the ability to purchase health services in Jambi Province is accepted. Furthermore, hypothesis 3 obtained a t-statistics value of 34.772 and a p-value of 0.000, showing that the direct effect of the health financing method on the ability to purchase health services in Jambi Province is accepted. Hypothesis 4 obtained a t-statistical value of 21.301 and a p-value of 0.017, which also indicated that the indirect effect of the socioeconomic status of the family on the ability to purchase health services through the pattern of health financing as an intervening variable is accepted. Hypothesis 5 obtained a t-statistical value of 24.919 and a p-value of 0.000, indicating that the direct effect of the socioeconomic status of the family on the ability to purchase health services in Jambi Province through the health financing method as an intervening variable is accepted.
Discussion
The socioeconomic status of a family influences the ability to purchase health services. Based on the family socioeconomic status, Jambi Province with an average income of IDR 3,144,155 per month generate more than 2020 revenue (Regency/City Minimum Wage) which was IDR 2,630,162. Therefore, there is the ability to purchase health services as shown by 62.55% of respondents that can afford health costs. However, almost 19.3% of jobs such as freelance daily labour needs more attention, including jobs in the informal sector with an average income of IDR 1,729,194.
The ability to purchase health services is shown by the indicator statement which stated that the income the family head needs to pay for the health services for all the family members, regardless of the type of health service facilities, both public and private. This is supported by government policies that seek to provide health services regardless of the status of the facilities (Kementerian Kesehatan RI, 2013; Peraturan Presiden, 2018). Similarly, this is also in line with a statement related to income which stated that each family generates an additional half of the basic monthly income. However, there are also claims that an additional amount of income with an uncertain amount is generated. The ability of the family head to pay the cost of health services has been programmed by the government through Universal Health Coverage (UHC) with a target of 95% by 2020. In Jambi Province, it has only reached 86.32% since people can pay independently according to the criteria. This is because the government cannot afford the provision of subsidized assistance to pay for health services (Kementerian Kesehatan RI, 2017). Similarly, education is also a strong factor that supports the ability to purchase health services because 73% of the people have senior high school education. This is also supported by the readiness of the number and types of health professionals in all lines of districts/cities in Jambi Province with the ratio of health workers, especially doctors, at position 1:31 (National Standard 1:43), and nurses at 1:193 (National Standard 1:185). Furthermore, there is support for health service facilities at first-level health facilities (puskesmas) with 217 units in remote areas and 37 units at the referral level (hospitals) in the district or provincial capitals (Dinas Kesehatan Provinsi Jambi, 2020).
In 2013, a similar study conducted by Nguyen Thi in Vietnam stated that households with better economic growth are more optimized in the use of health services (Thoa et al., 2013).
The effect of health financing patterns on the ability to purchase health services had the highest average distribution value of 62.97%, on community-sourced finance. This showed that the community still needs to manage funding with the principle of cooperation. However, this only fulfilled financing in a supportive nature or a non-chronic disease, since public financing is limited to service units in a small scope or services (Dewi & Mukti, 2018). Meanwhile, a statement of the respondent showed a willingness to have deliberation in financing the family by forming an arisan (regular social gathering for the purpose of conducting a lottery). Health costs in the neighbourhood is also supported by the statement to provide input to a place or health service unit, when members are sick.
Moreover, the most preferred pattern by respondents after public financing is direct government financing with an average distribution of 55.30%. This showed that the government has carried out necessary obligations to guarantee the rights of every citizen in health services. Also, several sustainable program efforts oriented towards health financing are targeted at vulnerable, poor, informal groups, and people in need of social assistance. One of the efforts with the National Health Insurance for Indonesia Healthy Card (JKN–KIS) program is to collect data as recipients of contribution assistance (PBI) and non-contribution recipients (Non-PBI). This is supported by the respondents in the indicator statement which stated that the ease to obtain direct costs from the government to use all health service costs is borne by the government.
A similar program was launched for the private sector engaged in manpower through wage and non-wage earner assistance programs for employees or company workers (BPJS Ketenagakerjaan, 2020). Furthermore, efforts were made to support the government through Law Number 40 of 2004 which stated that the government guarantees financing through the National Guarantee System (Kementerian Kesehatan RI, 2004). The National Security System is referred to through health, old age, and education insurance, pension and death benefits, as well as other social security. It is also supported by 52.21% of the respondents that showed concern about the importance of the health insurance concept. Meanwhile, this program is strengthened through the family head and their members that are always obedient to pay BPJS health dues every month and the ease to a health BPJS card according to the stipulated requirements during the use of health care facilities.
Health insurance still focuses on social/compulsory insurance, with the average being borne by the government or independents that can afford it. Therefore, there is a need to support other financing patterns through financing from government organizations and foreign cooperation. According to this financing pattern, it is focused on certain cases or diseases that have become different trends in a region or country for both endemic and pandemic. The statement showed approximately 49.20% of the importance of financing from government organizations and foreign cooperation. This is supported by the statement that there is financial assistance for families waiting at health service facilities for supporting examinations, recovery, and family care costs after their return, which is supported by the private sector. Although it is a complement to compulsory/social insurance coverage, it also has an impact on the system of financing patterns.
The smallest pattern of financing is direct financing from the patient’s pocket (44.00%), related to income. This is supported by the statement that there are objections to paying for health services in cash because the costs of using health service facilities cannot be ascertained.
Moreover, the results showed that among the various health financing patterns launched by the Jambi Provincial Government, funding from the community is the most popular. This is because the service management is in line with the agreement of the community that is members of a (small) group due to the similarities, while disease characteristics are almost similar (Dewi & Mukti, 2018). Although there is no perfect pattern of health financing, each of them has advantages and disadvantages in its implementation. In Indonesia, the most ideal pattern to be implemented is health insurance that guaranteed every citizen with purchasing ability to access health services. However, for citizens that cannot afford them, subsidies are given through contribution assistance recipients, including wage earners which are being managed by BPJS Kesehatan and BPJS Ketenagakerjaan. The principle of assisting is also supported by direct financing through a pattern of direct funding from the government.
This is supported by Murauskiene and Karanikolos (2017) in Lithuania and Achoki and Lesego (2016) studies on the Universal Health Coverage of the private and government sectors. Moreover, a study by Ryan et al. (2009) in Ireland, stated that in the health care system, the health financing system depends on the pattern of health financing. The tendency to use the health insurance system such as NHS and SHI has been chosen by several countries. This is in line with a study by Cavagnero (2008) which stated that government insurance is very beneficial for the poor.
The effect of health financing methods on the ability to purchase health services is divided into two categories, namely the method of payment before or after service which is incorporated in the seven indicators. Based on disease diagnosis, financing indicators had the highest average distribution of 52.86%. This indicated that the method is often chosen by the community for clarity in health financing as shown by the indicator statement. From the statement, the respondent and their family are served by a diverse team of medical officers through the systematic use of the Interpol or inter-unit information system by optimizing services using good information systems and techniques.
The capitation system of health financing method ranks second with 52.63% agreeing to its use. It is supported by the respondent’s statement in the indicator, which stated that families and their members have information on the importance of prevention efforts before getting sick when they come to health service facilities. Also, there is family support to pay fees at the beginning of each month and the monthly salary of health workers is also part of the health financing method. Therefore, almost half of the respondents (50.52%) stated that this method was chosen, with the certainty of income. This makes it possible to benefit from the service directly based on the indicator which stated that the services provided were only routine by health workers, however, they are still served with good cooperation.
Based on the respondent’s statement on the method of health financing, the after-services consisted of direct financing. After service and replacement of prepayments showed unfavourable results with 43.92% agreeing to use fees for services which allows the availability of costs in each family. Service fee is very attractive to health workers, considering in concept and theory, there is a direct payment after health workers provide services to patients, however, many patients and families do not make this option. This is supported by the statement in the indicator that families are served optimally with a customer satisfaction orientation and their opinions after using health services are usually requested.
With direct financing after service and reimbursement of prepayments, only 46.55% of respondents were willing, while 53.45% refused to use this system. This is supported by the statement contained in the indicator that the family head and their members need to contact the insurance company immediately on the cost of health services, even though at first they have paid part of the costs in advance, to submit a claim to a third party/insurance agency.
It has been shown that nothing is perfect in the selection of health financing methods, however, each has advantages and disadvantages in its implementation. In Indonesia, the most ideal method to be implemented is capitation (advance payment based on the number of people served), considering the number of people served in a certain area by health workers in accessing health services. With this capitation method, efforts are made to implement a healthy lifestyle through a healthy paradigm, namely, prevention is better than cure. Meanwhile, the health financing method with direct payments needs to be prepared by the community or the family head to complement the funding from the capitation system. This direct payment is related to the income of each head of the family for the family members to access health service facilities. Moreover, the proportion of direct payments in several countries is commonly greater among poor or developing countries compared to the developed ones, even though there are different resources.
A study by Feng et al. (2020) in China showed support for the payment method of health care costs, through cost-sharing. Similarly, a previous study by Cuadros-Meñaca (2020) from the University of Arkansas Colombia also stated the need for cost-sharing in efforts to finance health, especially for groups of informal workers that are not fully identified by the government. In the United States, Angrisani et al. (2018) showed the importance of Medicare financing which is better patterned when compared to the risk of uncertainty about the occurrence of illness. Furthermore, a study by DeLeire et al. (2017) in the United States, stated that the Affordable Care Act (ACA) assists low-income communities through premium subsidies and reduced cost-sharing (CSR).
The family’s socioeconomic status influences the ability to purchase health services through the health financing pattern. In 2020, the socioeconomic status of the respondent’s family with an average income of IDR 3,144,155 per month was more than the provincial minimum wage income (UMP) in Jambi Province which was IDR 2,630,162. This showed that there is an ability to purchase health services as indicated by an income of more than 2 million of 63.9%. When compared with the UMP for each district/city of the study location, there are four districts (Batanghari, Bungo, Merangin, and Sungai Penuh City) with the same value as the UMP Jambi Province of IDR 2,630,162. However, two districts are above the provincial minimum wage, namely West Tanjab Regency with IDR 2,865,000 and Jambi City with IDR 2,900,000.
Based on work, 19.3% need attention with the work of casual daily labourers, or income engaged in the informal sector with an average monthly income of IDR 1,729,194. This includes work in agriculture, forestry, and fisheries (IDR 1,508,698), mining and quarrying (IDR 2,485,594), industry and processing (IDR 2,411,289), procurement of waste, water, and waste recycling (IDR 2,088,111), while the construction sector (IDR 2,199,968) (BPS, 2021). These results showed that among the various health financing patterns launched by the Jambi Provincial Government, this variable (collaboration with six variables) mediated the relationship between family socioeconomic status and the ability to purchase health services. This is supported by the results of Thakur et al. (2018) in India, Thoa et al. (2013) in Vietnam, and Ku et al. (2019) in Taipei Taiwan.
The family’s socioeconomic status affects the ability to purchase health services through the health financing method. In 2020, the socioeconomic status of the respondent’s family with an average income of IDR 3,144,155 per month was more than the provincial minimum wage (UMP) of IDR 2,630,162 in Jambi Province. Therefore, there is the ability to purchase health services as shown by an income of more than 2 million of 63.9%. When compared with the size of the UMK (City/Regency Minimum Wage) for each district/city of the study location, there are four districts (Batanghari, Bungo, Merangin, and Sungai Penuh) with the same UMK value as UMP Jambi Province of IDR 2,630,162. Meanwhile, two districts that have different values above the Provincial Minimum Wage include West Tanjab Regency IDR 2,865,000 and Jambi City IDR 2,900,000. When related to the job, 19.3% need attention with freelance day jobs or incomes engaged in the informal sector with an average monthly income of IDR 1,729,194. This includes agricultural, forestry, and fishery work (IDR 1,508,698), mining and quarrying (IDR 2,485,594), industrial and processing (IDR 2,411,289), waste procurement, water, and recycled waste (IDR 2,088,111), and construction sector (IDR 2,199,968) (BPS, 2021).
These results showed that among the various health financing methods that have been implemented by the Jambi Provincial Government, the method with seven variables, namely five before service and two after service mediated the relationship between family socioeconomic status and the purchasing ability of health services. This is in line with previous studies conducted by Hsiao (2007), Raeesi et al. (2018) in Iran, and Schieber et al. (2007).
Conclusion
Based on the results, it is concluded that (a) the socioeconomic status of the family has a direct effect on the ability to purchase health services, (b) the pattern of health financing has a direct effect on the ability to purchase health services, (c) the method of health financing has a direct effect on the ability to purchase health services, (d) socioeconomic status of the family has an indirect effect on the ability to purchase health services through the health financing pattern, and (e) the socioeconomic status of the family has an indirect effect on the ability to purchase health services through the health financing method.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.