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All Journal International Journal of Health and Pharmaceutical (IJHP)
Erlina Puspitaloka Mahadewi
Economic and Business Faculty, Universitas Esa Unggul, Jakarta Indonesia
Nursing Public Health

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An Overview in Adverse Selection: A Case Study in Indonesia Healthcare Insurance Dhimas Dita Rahadian; Monica Rizqi Yanuar Setyowati; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.343

Abstract

This study analyzes adverse selection in health insurance poses a significant challenge to the sustainability of insurance schemes, particularly in developing countries where enrolment is voluntary and insurance literacy is low. Information asymmetry between participants and insurers often results in higher-risk individuals dominating the pool, threatening the program’s financial stability. This study aims to synthesize findings from various studies on adverse selection in health insurance, identifying common patterns, causal factors, and mitigation strategies. A systematic literature review approach was used to examine about 40 selected articles published between 2012 and 2025 related to adverse selection in different types of health insurance schemes (public, private, and community-based). Literature was sourced from academic databases such as Google Scholar, PubMed, and others, using specific boolean keyword combinations. Adverse selection was found to be most prevalent in voluntary schemes in developing countries. In contrast, evidence from some developed nations indicated advantageous selection. Mitigation strategies such as premium subsidies, risk-based premium setting, risk pooling, and improving insurance literacy proved effective in reducing negative selection. Advanced technologies like big data and machine learning also showed promise in managing risk profiles. Addressing adverse selection requires a multi-dimensional approach involving public policy, financial incentives, and technological innovation. A combination of mandatory enrolment, risk adjustment, targeted subsidies, and improved literacy is essential for building a sustainable and inclusive health insurance system.
The Moral Hazard Phenomenon in Health Insurance: A Review of Driving Factors and Control Strategies Grace Christine; Ayu Anindhita Sekarsari; Budy Irawan; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.348

Abstract

Moral hazard in health insurance is a significant institutional issue that concerns the efficiency, sustainability, and equity of health funding systems. This study intends to comprehensively assess the different types of moral hazard, discern the root causes that contribute to it, and examine the regulatory strategies implemented at both national and international levels. This study employed a methodology characterized by a descriptive literature review, which involved a comprehensive analysis of 25 meticulously chosen peer-reviewed articles. The articles in question were published between the years 2014 and 2025, and they were obtained from reputable databases such as Scopus, PubMed, and Google Scholar. The results indicate that moral hazard presents itself in two main forms. Initially, this phenomenon arises among beneficiaries who may engage in excessive consumption and use of healthcare services lacking adequate medical justification. Secondly, it is apparent that healthcare providers may participate in administrative and clinical manipulation, which includes practices such as upcoding, unnecessary hospitalizations, and fraudulent claims. Several contributing factors to moral hazard can be identified, including deficiencies in the design of the INA-CBGs payment system, a lack of health insurance literacy among participants, and insufficient oversight and auditing mechanisms.The findings presented have considerable implications for policymakers, outlining the necessity to improve the national health insurance system. Structural reforms and the implementation of sustainable, multidisciplinary approaches.
Insurance Utilities in Indonesia: A Study for Future Opportunities Ingrid Green Nego; Dika Oktaviani Yustedjo; Hotmada Parlindungan; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.370

Abstract

This study analyzes Indonesia's path toward universal health coverage (UHC), which has been marked by the introduction of targeted schemes such as Askeskin and Jamkesmas, culminating in the comprehensive National Health Insurance (JKN) program. This literature review systematically synthesizes peer-reviewed empirical studies published between 2005 and March 2025, examining the impact of government-managed health insurance on healthcare utilization, financial protection, and equity across different population groups. The study conducted a structured narrative synthesis of studies retrieved from PubMed, Scopus, Web of Science, and Google Scholar, focusing on inpatient and outpatient services, maternal and dental care, and out-of-pocket expenditures. The findings indicate that insured individuals consistently demonstrate higher utilization rates and significant reductions in out-of-pocket spending, with notable benefits in maternal health and primary care in rural areas; however, geographic and socioeconomic disparities persist, particularly among the urban poor and remote communities. Secondary analysis revealed moral hazard effects and shifting private market dynamics, highlighting the need for cost-sharing mechanisms and regulatory oversight. Propose policy strategies to expand enrollment, adjust premium subsidies, integrate fragmented schemes, strengthen the community health center (Puskesmas) infrastructure, and enhance preventive care and health literacy. An integrated approach aligning financial, clinical, and regulatory reforms is essential to optimize equity, efficiency, and sustainability in Indonesia’s UHC journey.
The Dynamics Analysis of Development and Basic Principles of Health Insurance in Indonesia Sri Sulatriningsih; Didin Sunardi; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.372

Abstract

Healthcare insurance in Indonesia is mandated by the 1945 Constitution, Article 34 paragraph 2. The basic principles of health insurance in Indonesia are based on social justice and broad coverage and support the sustainability of an inclusive and equitable health service system. The health insurance system in Indonesia has transformed into Universal Health Coverage (UHC) through the National Health Insurance (JKN) program. Problems that are still obstacles to the effectiveness of the JKN system include slow payment of claims to health facilities, moral hazard, and gaps in the quality of services between health facilities in big cities and remote areas. This study aims to analyze the basic principles and dynamics of the development of the national health insurance system in Indonesia. The method used is a literature study of scientific sources, public policies, and official reports. The results of the study and review indicate that the principles of solidarity, equity, and sustainability are the main foundations in the implementation of JKN. Although coverage has expanded significantly, challenges such as gaps in access to services, imbalances in contributions and financing, and low public understanding of health insurance still need attention.
Managed Care In Healthcare Insurance: A Case Study In Indonesia For Review Kartika Destya Arini; Imas Nurhasanah; Mohammad Amnurokhim Malahade; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 2 (2025): May 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i2.375

Abstract

The process of goods and services procurement within the government environment still has vulnerabilities to fraud, which necessitates proper handling. This study aims to identify the factors that can influence efforts to prevent fraud in the procurement of goods and services using an e-procurement system. The data for this research was obtained through the distribution of questionnaires to employees at the Procurement Services Unit (ULP) and the Regional Financial and Asset Management Agency (BPKAD) Office of Dompu Regency. The sampling method used in this study is purposive sampling. Furthermore, the research data were tested using multiple regression analysis. This study demonstrates that the variables of technology utilization, e-procurement, internal control systems, organizational culture, employee ethics, and religiosity can influence the prevention of fraud in the procurement of goods and services. The research findings can serve as a reference for evaluating the use of information technology through e-procurement and the application of internal control systems for optimal results. Additionally, it is important to consider human resources, specifically employees, in maintaining organizational culture, good ethics, and religious values as a foundation for actions in the workplace to avoid various deviant or unlawful behaviors.
Analysis of Managed Care In Primary Health Care Services In Indonesian Health Insurance Management Elysia Widyadhari; Astri Nurlestari; Femy Dwi Muthashani; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.378

Abstract

This study aims analyzes and to evaluate the implementation of the National Health Insurance Program (JKN) in Indonesia, through the perspective of the managed care model. Managed care itself is an approach that combines financing mechanisms and health services in a single integrated system, with a focus on cost efficiency and improving service quality, as implemented by BPJS Kesehatan in Indonesia. This study used a systematic literature review method of 30 scientific articles published between 2016 and 2025. The results of the study indicate that the capitation payment system and INA-CBGs play a role in increasing spending efficiency and expanding access to health services. However, several challenges remain, such as infrastructure gaps, unequal distribution of health workers, and barriers in the referral system. This study also discusses various managed care models such as EPO, IDS, HMO, PPO, and POS, and the relevance of their implementation in the Indonesian context. The findings of the proposed improvement strategies include the use of digital health service technology, strengthening community-based public education, revising more adaptive capitation rates, and improving the monitoring system for service quality and costs. These steps are necessary to support the sustainability and equity of health services throughout Indonesia going forward, along with concrete solutions.
Healthcare Insurance Agreement Regarding Financing of Health Services by Insurance Companies Dewi Novia Laras; Hanna Yulita; Muhamad Ikhsan; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.424

Abstract

This study analyzes health insurance as a form of financial protection designed to reduce the burden of medical costs when a participant experiences a health problem. In practice, the relationship between the participant and the insurance provider is based on a legal agreement called an insurance contract. This contract is legally binding on both parties: the insurer (insurance company) and the insured (insurance participant), and includes rights and obligations that must be fulfilled during the coverage period. In Indonesia, public understanding of health insurance contracts remains relatively low. Many participants do not fully understand the content and implications of the agreement they sign, including the terms and conditions, guaranteed benefits, coverage limits, and claims procedures. This approach was chosen to gain a comprehensive understanding of the patterns, causal factors, and impacts of agreement health insurance reported in various cross-country studies and insurance schemes, both public, private, and community-based health insurance contracts, whether administered by social institutions like BPJS Kesehatan (Social Security Agency for Health), or by commercial insurance companies, have different structures and provisions. Problems gap arise when participants lack detailed knowledge of the scope and limitations of their insurance contracts, resulting in underutilization of available benefits. Furthermore, from the service provider's perspective, contract implementation often faces administrative and communication challenges, which can impact participant satisfaction and perceptions of service quality. The result of study is important to examine more deeply the content and implementation of health insurance contracts, as well as the extent to which participants understand their rights and obligations. A better understanding of insurance contracts will improve the effectiveness of health protection and strengthen public trust in the Indonesian health insurance system.
Management Analysis of The Implementation of The Utmost Good Faith Principle In Insurance Agreements Hanna Yulita; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.425

Abstract

This study analyzes insurance with an agreement between two parties, namely an insurance company called the insurer and a policyholder called the customer, where the insurance company promises to provide financial protection against risks such as accidents, illness, death and others while the customer makes premium payments periodically or all at once. One of the important principles in making an insurance agreement is Utmost Good Faith (Good Faith). In Indonesia, there are several examples of cases of violations of the principle of utmost good faith such as not disclosing previous illnesses, misuse of Health Insurance benefits, not providing clear information regarding the risks and benefits of insurance such as unit links. Therefore, insurance companies are challenged to be able to obtain honest information from customers and must convince customers, to provide information and claim reimbursement in accordance with the agreement made in the policy, both methodically and materially. This study uses a qualitative method. The source used is Google Scholar using search keywords are the principle of utmost good faith and insurance agreement. Research results: this study wants to know the implementation of the principle of utmost good faith in Insurance, problems, how to overcome and solutions in the future to benefit the Insurance business in Indonesia.
Analysis of Factors Contributing to Low Demand for Health Insurance in Indonesia Tumpak Benny Aurixon; Runggu Christine Saragih; Nurul Asri Baharsyah; Erlina Puspitaloka Mahadewi
International Journal of Health and Pharmaceutical (IJHP) Vol. 5 No. 3 (2025): August 2025
Publisher : CV. Inara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51601/ijhp.v5i3.437

Abstract

This study analyzes the demand for insurance products in Indonesia as developing countries remains relatively low despite the significant market potential. From an economic perspective, insurance is a method for reducing risk by transferring and combining the uncertainty of financial losses. Thus, insurance is a social tool that transfers personal risks to all members of a group by utilizing pooled funds to pay for losses incurred under agreed upon terms. The insurance business in Indonesia has recently grown rapidly, including the entry of foreign investors into insurance businesses, either through share ownership or majority ownership in national insurance companies, with the increasing need for risk protection in a dynamic socio-economic context, it is crucial to more comprehensively understand the factors that drive and hinder insurance demand in developing countries. This study aims to review existing literature that explores the factors influencing insurance demand in developing countries, including individual, social, economic, and institutional aspects. A systematic literature review method was employed to analyze scholarly articles published over the past two decades. The findings reveal that factors such as income, education level, trust in financial institutions, financial literacy, government regulations, and risk perception significantly influence individuals' decisions to purchase health insurance products. These findings provide insights for policymakers and insurance industry stakeholders to design strategies aimed at enhancing insurance literacy and penetration in developing countries. The study also identifies research gaps that could be addressed in future empirical investigations. Additionally, cultural factors and access to insurance in Indonesia services also play a crucial role.
Co-Authors Astri Nurlestari Ayu Anindhita Sekarsari Budy Irawan Dewi Novia Laras Dhimas Dita Rahadian Didin Sunardi Dika Oktaviani Yustedjo Elysia Widyadhari Femy Dwi Muthashani Grace Christine Hanna Yulita Hotmada Parlindungan Imas Nurhasanah Ingrid Green Nego Kartika Destya Arini Mohammad Amnurokhim Malahade Monica Rizqi Yanuar Setyowati Muhamad Ikhsan Nurul Asri Baharsyah Runggu Christine Saragih Sri Sulatriningsih Tumpak Benny Aurixon