Factors associated with skilled birth attendance in 37 low-income and middle-income countries: a secondary analysis of nationally representative, individual-level data.

BACKGROUND: Progress on skilled birth attendance (SBA) has been very uneven across low-income and middle-income countries (LMICs). There is scant empirical evidence on the role of fundamental development processes in explaining differences in SBA outcomes across world regions over time in these settings. We therefore aimed to estimate how these processes have contributed to observed changes in SBA across Latin America and the Caribbean, South Asia, Southeast Asia, and sub-Saharan Africa. METHODS: We pooled all available Demographic and Health Survey (DHS) rounds that contained detailed birth attendance information. The compiled data covers about 1·1 million births (1·1 million female individuals) from 103 DHS rounds in 37 countries. We estimated the determinants of SBA using multivariable regression techniques and Oaxaca-Blinder decompositions for different world regions and time periods (1990s, 2000s, and 2010s). FINDINGS: We show that progress in SBA is associated with improvements in terms of household-level wealth, mothers' education, urbanisation, contraceptive knowledge, and proxies of female empowerment. Furthermore, we show that changes in the underlying relationship between SBA and specific development indicators (wealth, education, and rural residence status) have further contributed to the observed rise in SBA across LMICs. Our findings further suggest that certain determinants of improvements in SBA are region-specific (eg, importance of rural residence status in sub-Saharan Africa), whereas some of the studied processes (eg, poverty, maternal education, and urbanisation) have become less predictive for the uptake of SBA over time. INTERPRETATION: Although substantial progress has been made in increasing SBA rates over the past three decades across LMICs, further efforts for continued progress are still needed to achieve international targets on SBA as part of the Sustainable Development Goals, the Every Newborn Action Plan, and the Ending Preventable Maternal Mortality initiative. According to our findings, these efforts can include general policies (eg, female empowerment) and region-specific policies (eg, poverty reduction programmes in Southeast Asia). FUNDING: Bernhard Nocht Institute for Tropical Medicine. TRANSLATIONS: For the French and Indonesian translations of the abstract see Supplementary Materials section.

Multidimensional energy poverty: A study of its measurement, decomposition, and determinants in Indonesia.

This study estimated Indonesian households' Multidimensional Energy Poverty Index (MEPI) using Alkire-Foster's multidimensional poverty concept to capture the incidence, intensity, decomposition, and changes over time. The study used monetary and non-monetary variables to identify the availability, accessibility, affordability, consumption, and deprivation of modern energy services; and compared existing affordability indicators. Redundancy, robustness, and sensitivity tests were conducted with three weighting schemes and deprivation cut-offs. The study decomposed and determined household-head (HH) socio-economic, demographic, and geographic factors for MEP using the Logit, Probit, Tobit, and Heckman Selection models. The results show that the low-income and high cost (LIHC) was the most robust affordability indicator, followed by the ten percent rule (TPR). The complement-frequency weighting scheme gave the smallest and most robust MEPI compared to equal and principal component analysis (PCA) weighting. Three alternative deprivation cut-offs can show households as "vulnerable," "moderately," or "severely" energy poor. The MEP incidence decreased, but its intensity remained high and increased. Energy-poor households were averagely deprived of 55-60 % of all weighted indicators. The lack of modern cooking services was the primary cause. MEPI differed by geographical location and HH gender, education, business field, and employment status. Policies that boost education levels, raise household income, and increase the availability, accessibility, and affordability of modern cooking technology in the rural, hinterland, or non-coastal forested locations in the eastern islands of Indonesia may minimize the number of households experiencing MEP.

The role of the 30% threshold for Islamic parties: A fast-growing middle class and religion-based political preferences in Indonesia.

Recently, Indonesia's middle-class Muslims have come under suspicion for strengthening the religious foundation of their political preferences. However, while this suspicion has been triggered by their increasingly confident expressions of Islamic identity in political, social and economic spheres, these public expressions do not consistently translate into electoral outcomes. Despite the significant growth of the middle class, the proportion of votes cast for Islamic parties, encompassing both pro-shari'a or Islamist and Islam-inclusive parties, has declined from 37% in 1999 to 30% in 2019. Utilising panel data from 397 districts and cities spanning three recent general elections (2009, 2014 and 2019), this study examines the association between the middle class's proportion of the total population and the vote share of Islamic parties. Our fixed-effect estimations validate an inverted U-curve relationship between the middle class's share and the vote share of pro-shari'a or Islamist parties, with the turning point occurring at approximately 29% of the middle class's total population. In regions with a lower percentage of the middle class, the vote share of Islamist parties rises in parallel with middle-class growth. Conversely, at a higher level, a growing middle class curtails the vote share of Islamist parties. This suggests that Indonesia's contemporary social structure is undergoing desecularisation in various ways, contingent on levels of modernisation. Notably, this desecularisation process does not imply a movement towards establishing an Islamic state. Indonesia's Muslims are moderate and more inclined to support secular, national or Pancasila-based parties, which tend to be inclusive and secular in their approach.

Relieving or aggravating the burden: Non-communicable diseases of dual users of electronic and conventional cigarette in Indonesia.

INTRODUCTION: Conventional (tobacco) and e-cigarette smoking prevalence is a growing concern in Indonesia. It has worsened as e-cigarettes complement conventional cigarettes, resulting in dual users, potentially causing an additional burden in terms of health. METHODS: Our study is a secondary data analysis of the 2018 National Basic Health (Riskesdas) Survey. The sample is limited to respondents aged 15-64 years who either only used e-cigarettes (e-cigarette single users), only used conventional cigarettes (conventional cigarette single users) or used both e-cigarettes and conventional cigarettes (dual users) in the last month. The sample size of the data was 174917 individuals. Our analysis utilized the logit and negative binomial regression to test whether the type of smoking behavior was associated with reporting to have a non-communicable diseases (NCDs) and multimorbidity, respectively. RESULTS: We found that: 1) dual users are positively associated to report having NCDs, such as liver failure (AOR=2.38; 95% CI: 2.32-2.44), diabetes (AOR=1.53; 95% CI: 1.50-1.57), hypertension (AOR=1.49; 95% CI: 1.48-1.51), and gum diseases (AOR=1.74; 95% CI: 1.73-1.74) compared to single users; and 2) e-cigarette single users are positively associated with reporting to have NCDs such as asthma (AOR=3.11; 95% CI: 3.01-3.22) and diabetes (AOR=16.01; 95% CI: 14.57-17.59), and dental problems such as broken teeth (AOR=1.04; 95% CI: 1.03-1.06), and they have disease multimorbidity compared to conventional cigarette single users. CONCLUSIONS: Simultaneous control of the consumption of e-cigarettes and conventional cigarettes is essential. In addition, it is important to promote policies to increase the price of e-cigarettes and conventional cigarettes to reduce smoking prevalence and prevent dual users. Moreover, as there are negative health consequences for conventional and e-cigarette single users or dual users, the most effective alternative is to stop smoking, not switching products.

Retailer's Density and Single Stick Cigarette's Accessibility among School-Age Children in Indonesia.

OBJECTIVE: The density of single-stick cigarette sales is related to the increase in tobacco epidemic-related diseases. This study aims to provide evidence of retailers' density and radius around the school location, accessibility of single-stick cigarette selling among school-age children, and retailers' response regarding the restriction policy options in urban areas in Indonesia. METHODS: It is a cross-sectional study. The retailers' spatial density and the radius around schools in Daerah Khusus Ibukota (DKI) Jakarta Province were investigated using Google Maps and Google Street View (GSV). The coordinates of retailers and schools were geo-coded to Kernel Density Map. The accessibility of single-stick cigarettes among children and restriction policy options for cigarette selling were derived from random sampling using surveys of 64 retailers based on Google Data results. RESULT: Virtually walking using google maps and GSV found 8,371 retailers in DKI Jakarta. There were ± 15 cigarette retailers every 1 km2, and an average of ± one cigarette retailer in every 1,000 residents. There were 456 (21.67%) retailers with a radius ≤ 100 meters around elementary schools, even an increase around junior high school locations of 167 (26.05%) retailers. The accessibility of cigarettes among children is easy because the price is relatively low, at Rp1,500/ $0.11 per stick. In addition, 58.1% of retailers allowed customers to buy on debt. Eleven percent of cigarette retailers intended to reduce the sale of cigarettes if the prohibition of single-stick cigarette sales were applied. CONCLUSION: Cigarette retailers were very dense and single-stick cigarettes were still accessible to children in Indonesia. The implementation of the prohibition on single-stick cigarette sales should be added for future tobacco control in developing countries such as Indonesia.

Macroeconomic impact of tobacco taxation in Indonesia.

BACKGROUND: A significant tobacco tax increase has long been advocated to reduce Indonesia's high smoking prevalence. However, implementing such a policy remains challenging due to the tobacco industry's argument that it would negatively impact the economy. OBJECTIVE: This study aims to provide a comprehensive estimate of the net impact of tobacco taxation on Indonesia's economy. METHOD: The impact of the tax hike on the economy is simulated through a change in cigarette demand and reallocation of household's budget and allocation government spending from additional tobacco tax revenue. Input-output analysis is employed to estimate the net effect of the tobacco tax rise on the total economic output, income and employment in Indonesia. FINDING: Increasing the tobacco tax would generate a net positive impact on the economy as it would increase economic output, household income and employment. The positive impact is mainly driven by government spending from additional revenue from increased tobacco taxes. Spending tax revenue using the current structure of government spending has the potential to generate the optimal economic effect. Increasing tobacco tax by 45% from the 2019 tax level would increase economic output, household income and employment by Rp84.2 trillion, Rp24.1 trillion and 400.3 thousand jobs, respectively.

Changes in Smoking Status and Behaviors After the First 10 Months of COVID-19 Pandemic in Indonesia.

INTRODUCTION: There remains inconclusive evidence on potential changes in smoking status and behaviors during the coronavirus disease 2019 (COVID-9) pandemic, especially in developing countries. AIMS AND METHODS: This study explores the direction of changes in smoking status and behaviors after 10 months of the COVID-19 pandemic in Indonesia as well as examining the association between economic shocks and changes in smoking behaviors. Primary data were gathered through a phone survey targeting productive-age mobile-phone users in Indonesia (n = 1082). Descriptive analysis was employed to determine changes in smoking status and behaviors 10 months into the pandemic, while logistic regression analysis was used to investigate how employment shocks, financial strain, COVID-19-related indicators, and demographic characteristics were associated with smoking behaviors of people who continue smoking. RESULTS: Respondents experiencing changes in smoking status were dominated by people who persistently smoked during the pandemic, while those who quit, relapsed, and started smoking, was extremely small. Nevertheless, a considerable portion of people who continue smoking adjusted their smoking behaviors: 40.3% reduced smoking intensity and 25.3% switched to lower-price cigarettes. Multivariable regression analysis revealed that, among people who continue smoking, those who experienced financial strain during the pandemic had higher odds of reducing smoking intensity, while those who switched to lower job status had higher odds of switching to cheaper cigarettes. CONCLUSIONS: The research has shown that smoking status and behaviors of people who continue smoking mostly remained unchanged after 10 months of the COVID-19 pandemic. Changes in employment and financial conditions during the pandemic were associated with modified smoking behaviors. IMPLICATIONS: This study is the first to determine the direction and analyze the factors of changes in smoking during the COVID-19 pandemic in Indonesia. This new understanding should help improve predicting the trends in smoking in future crises or pandemics in developing countries, specifically Indonesia. The discovered patterns on smokers' reaction to an exogenous shock may provide evidence to support tobacco control policies in Indonesia.

Revisiting the Energy-Happiness Paradox: A Quasi-Experimental Evidence of Electricity Access in Indonesia.

This study revisits the energy-happiness paradox hypothesis using the context of a developing nation. We used Indonesia as a case study, a unique archipelagic country with sparse subnational energy infrastructure, leading to the persistent regional energy access gap. We employed an instrumental variable technique to obviate conventional bias in the happiness regression. The model utilised a newly available national-level household survey on life satisfaction and historical data on digital maps of Indonesia's electricity infrastructure conditions in 1985. Unlike the phenomena known as the energy-happiness paradox found mainly in the developed countries that suggest the null relationship between having energy access and people's happiness, our finding reveals a positive effect of electricity access on people's happiness. We also show that the mechanism in which the effect operates is through individuals' satisfaction with housing conditions. The heterogeneity analysis shows that the impact of electricity access on happiness is more prominent in the lagging region. It justifies the placed-based policy strategy by the government in developing countries for expanding electricity access in favour of disadvantaged areas.

The 2019 economic cost of smoking-attributable diseases in Indonesia.

BACKGROUND: In 2019, ever-smoking prevalence among adults in Indonesia was 32.8%, which may correlate with a high burden on the economy. Therefore, there is an urgent need to estimate the economic costs of tobacco use, which are crucial for policymakers in planning healthcare provisions and other public expenditures. METHODS: We follow the WHO standard approach, multiplying the sum of the direct and indirect costs with the smoking-attributable fraction. Direct costs include healthcare and non-healthcare costs. Indirect costs include the loss of productivity resulting from absence from work and premature death due to smoking-related illnesses. FINDINGS: We found that the 2019 economic cost of smoking ranges from Rp 184.36 trillion to Rp 410.76 trillion (1.16%-2.59% of the gross domestic product). This research found a similar economic cost of smoking compared with a previous estimate conducted by Kosen et al of Rp 438.5 trillion. However, the estimated direct cost of smoking ranges from Rp 17.9 trillion to Rp 27.7 trillion, which is higher than the estimate of Rp 15.5 trillion by Kosen et al. Badan Penyelenggara Jaminan Sosial Kesehatan allocated between Rp 10.4 trillion and Rp 15.6 trillion to cover the healthcare costs attributable to smoking, representing between 61.2% and 91.8% of the 2019 deficit. CONCLUSIONS: The vast economic cost of smoking is a waste of resources and a burden on Indonesia's National Health Insurance System. Therefore, the government must increase cigarette taxes to correct the negative externalities of smoking consumption.

Public support for cigarette price increase in Indonesia.

BACKGROUND: The current tobacco control policies in Indonesia are known to be ineffective in reducing tobacco consumption. Therefore, increasing cigarette prices is one of the effective instruments that should be supported by governments and society. This study aims to assess public support for cigarette price increases as well as to generate scientific evidence for the government and policymakers. METHOD: This cross-sectional survey obtained data through telephone interviews with 1000 respondents aged ≥18 years old in Indonesia. The interviews started from 1 May 2018 to 31 May 2018. RESULT: Respondents were varied in terms of age, gender, level of education, income, occupation, area of living and smoking status. This study found that 87.9% of the respondents including 80% of smokers support cigarette price increase to prevent children from buying cigarettes. Approximately 74.0% of smokers said they would stop smoking if cigarette prices were Rp70 000 (US$5) per package. The multivariate analysis revealed that age, income, money spent on cigarettes per day and the perception of current cigarette prices are the factors influencing support for higher cigarette prices. CONCLUSION: The increase in cigarette prices is supported by society at large, including active smokers. The government must consistently adjust cigarette prices through an excise taxing and cigarette retail price mechanism. Governments, academicians, non-governmental organisations and tobacco control activists should generate a unified understanding that increasing cigarette prices will improve overall life quality.

The regional and referral compliance of online healthcare systems by Indonesia National Health Insurance agency and health-seeking behavior in Indonesia.

PURPOSE: Whether the provision of online health care referral systems by the Indonesia National Health Insurance Agency has ensured healthcare referral compliance raises much concern due to the continuing deficit. This study examines the pattern of healthcare referral process, regional and referral compliance from 2015 to 2016. To provide comprehensive analysis on how people seek treatment, this study also aims to understand health-seeking behavior in Indonesia, the utilization of alternative treatment, and health information-seeking behavior on social media. METHOD: The data come from three data files, namely the National Health Insurance membership master data, the First Level Health Facilities transaction data and the Advanced Referral Health Facilities transaction data of 1,697,452 individuals. The regional compliance applies a logit regression model, while referral compliance applies descriptive statistics of the referral pathway. This study also follows a quantitative approach using an online questionnaire, with 463 respondents who have National Health Insurance which applies an ordered logit model. RESULT: We found that several demographic variables and regional health facility availability affect regional compliance. Moreover, we found 19.3% of the transactions did not comply with the prescribed referral sequence. The prescribed referral sequence was mostly followed for patients with malignant diseases. We also found men who perceive that their health condition is healthy will less likely seek health services compared to women. Further, the tendency of alternative treatment increases health-seeking behavior, and the tendency of seeking health information on social media increases the frequency seeking health services. CONCLUSION: We recommend the prescribed referral sequence to be re-evaluated especially for patients with malignant disease; the referral process should not be based on hospital classes but on the competency of the healthcare facility which may indirectly address the deficit issue. It is imperative that the government evaluate health promotion approaches to men and women, both direct and indirect through their significant others.

The sustainability of premium payment of national health insurance's self-enrolled members in Jakarta Greater Area.

BACKGROUND:  The sustainability of the National Health Insurance (NHI) program heavily relies on the premium of its member. The negligence of a large number of members to pay the premium lead to the failure of the Social Security Agency for Health (SSAH) to deliver its services. This study aims at analyzing important factors that influence the sustainability of premium payment of NHI's self-enrolled members in the Jakarta Greater Area. DESIGN AND METHODS: This study performed an econometric analysis from the panel and the same respondent's data in 2015 and 2017. The population of the study was NHI's self-enrolled members who lived in the City of Jakarta, Bogor, Depok, Tangerang, Bekasi, (Jakarta Greater Area) and it represents the urban area of Indonesia. The ordinal logistic regression model was used to determine the type of sustainability NHI premium payment. RESULTS: The survey shows that around 28.3% of self-enrolled members do not pay the NHI insurance premium regularly. Applying ordered logit this study statistically confirms that age of household head, income per month, never experience economic hardship, 1st/2nd class registration, and benefits of SSAH are positively correlated with compliance rate to pay NHI insurance premium. Whereas tobacco consumption, health-seeking behavior, and the 2016 increase of premium are negatively correlated with regular premium payment. CONCLUSIONS: This study calls for policy intervention to improve compliance of premium payment such as i) massive promotion of insurance literacy and benefits of insurance through a health professional, internet, and government officer; ii) expanding auto-debit and installment premium payment; iii) incentive for paying premium regularly and not smoking; and iv) improving access and quality of health services.

Growth mindset, delayed gratification, and learning outcome: evidence from a field survey of least-advantaged private schools in Depok-Indonesia.

Indonesian students perform poorly compared with students in other countries, despite education taking a significant portion of the national budget. Although poor infrastructure is often blamed for this failure, several reports show that it may not be the sole determinant of learning outcomes. Using the concepts of a growth mindset and delayed gratification as proxies for human behavior, we conducted a field survey of four highly disadvantaged private schools in Depok, West Java, Indonesia to observe how human behaviors affect learning outcomes. We use a self-administered mathematics test to measure learning outcomes, and construct a questionnaire based on Dweck's Implicit Theory of Intelligence to measure students' growth mindset. Delayed gratification is measured using a Convex Time Budget (CTB) questionnaire. Controlling for various student characteristics, our estimations show that a more pronounced growth mindset is associated with better math scores. Meanwhile, delayed gratification has mixed effects on learning outcomes: it has no significant effect when the relationship is estimated using an Interval Censored Regression (ICR), but has some statistical significance when an Ordinary Least Square (OLS) regression is used. These results imply that a student's beliefs on a growing intelligence can affect their academic achievement, whereas the ability to resist temptation has inconclusive effects on academic achievement. This difference may be caused by several factors such as the developmental stage of students. Interestingly, satisfactory teaching practices do not necessarily lead to better math scores. Our findings, therefore, suggest that future education policy design must consider aspects of human behavior in order to more optimally benefit students.

Good intentions, unintended outcomes: Impact of social assistance on tobacco consumption in Indonesia.

INTRODUCTION: Social assistance programs create an income effect that allows low-income groups to raise their consumption to improve their well-being. However, this may unintentionally induce an increase in their consumption of temptation goods, including tobacco. By analyzing five massive social assistance programs distributed by the government since 2007, we explore whether those programs may induce increased smoking intensity in Indonesia. METHODS: This study is a quantitative study that applies a Tobit regression, Difference-in-Differences (DiD) regression, Difference regression, and two-sample t-test, using the 2017 Susenas (National Socioeconomic Survey) and the 2007 and 2014 Indonesia Family Life Survey. Estimations using sociodemographic, regional, and social assistance dummy variables are used to explore the impact of the programs on the intensity of cigarette consumption in Indonesia, simultaneously assessing the relationship between cigarette consumption and socioeconomic conditions. RESULTS: Our estimations using Tobit regressions confirm that social assistance recipients consume 3.39 cigarettes per capita per week more than non-recipients. The DiD regressions on IFLS panel data show that social assistance programs significantly increase cigarette consumption by 2.8 cigarettes per capita per week. We also find that: 1) smokers have lower socioeconomic indicators than non-smokers in terms of nutrition and health and education expenditures, and 2) younger household members living with smokers have less educational attainment and higher average sick days. CONCLUSIONS: There is reasonable evidence to support the hypothesis that social assistance programs in Indonesia have contributed to the greater intensity of tobacco consumption among the recipients. The findings call for policy reforms in social assistance programs to be warier with the eligibility conditions for social assistance recipients. Adding new conditions related to smoking behaviors might reduce the smoking intensity of those in low-income groups and, in the long run, might improve the effectiveness of social assistance programs in raising the socioeconomic welfare of the low-income population.

Household financial vulnerability in Indonesia: Measurement and determinants.

This study assesses the level of financial vulnerability of Indonesian households using data from the Household's Balance Sheet Survey (Survei Neraca Rumah Tangga/SNRT) 2016 and 2017. The SNRT are micro-unit of household data that contains information on preferences and behavior. Through both objective and subjective measurements of the Household Financial Vulnerability Index (FVI), we find that the financial vulnerability of Indonesian households is not only strongly influenced by income factors, but also by finance-related behavioral characteristics and several socio-economic factors. As a consistency and robustness check, we also estimate econometric models using the Indonesian Family Life Survey (IFLS) panel data for the periods 1993, 1997, 2000, 2007 and 2014. Our study then conclude that the level of household financial vulnerability decreased in 2017. Moreover, the study suggests that we should carefully monitor the behaviour of middle income group as they contribute significantly to the household financial vulnerability in Indonesia.

COVID-19 in Indonesia: Challenges and Multidisciplinary Perspectives for a Safe and Productive New Normal.

The COVID-19 pandemic has caused disruption in all aspects of life, and countries around the world have been combating this pandemic using multiple approaches. Success in one country does not guarantee a transferable approach to other countries with different contexts. This review describes the challenges of COVID-19 management in Indonesia as a populous, socially and culturally diverse, and archipelagic country. It aims to provide multidisciplinary perspectives for a safe, evidence-based, and productive new normal as well as a comprehensive and integrated actionable policy for COVID-19 control.

Enrolment of informal sector workers in the National Health Insurance System in Indonesia: A qualitative study.

One of the main challenges facing the expansion of universal health coverage (UHC) in developing countries like Indonesia is the high prevalence of those working in the informal sector who must voluntarily register in the National Health Insurance System (NHIS). This condition hinders some from being covered by the NHIS. Following Bourdieu's concepts of field, capital and habitus, this research aims to analyse some aspects that influence the decision of informal sector workers to join the NHIS in Indonesia. We conducted qualitative methods, including in-depth interviews of 29 informants and Focus Group Discussion (FGD) in the three selected regions of Deli Serdang (North Sumatera), Pandeglang (Banten) and Kupang (East Nusa Tenggara). Using thematic content analysis and several triangulation processes, this study found that three main factors influence the decisions of those working in the informal sector to join the NHIS: health conditions, family and peers, and existing knowledge and experience. The stories provided by the informants regarding their decision-making processes in joining NHIS also reveal the necessary and sufficient conditions that enable informal sector workers to join the NHIS, which are individual-specific and which may differ between people, depending on individual characteristics, regional socioeconomic and demographic characteristics and belief systems. These three factors are all necessary conditions to support the joining of informal sector workers into the NHIS. This study suggests that one possible route for expanding the UHC coverage of informal sector workers is through maximising the word-of-mouth effect by engaging local or influential leaders.

A longitudinal study of agriculture households in Indonesia: The effect of land and labor mobility on welfare and poverty dynamics.

The conventional wisdom of Arthur Lewis's dual sector model says that households in the agricultural (traditional) sector who can move out to a non-agricultural (modern) sector will become better off. We then scrutinize the last three waves of the Indonesia Family Life Survey (IFLS) to analyze the existence of the dual theorem. Our study uses Difference in Difference (DiD) regressions and ordered logit regressions to confirm that moving out of agriculture sectors has significantly increased the welfare of poor agricultural households, especially in the period of 2000-2007, but this is not the case of 2007-2014. Movement out of agricultural sectors decreases the probability of being always poor by 13.5 percentage points. However, when the economy transforms into a more advanced economy, simply moving out of agriculture does not guarantee that farmers, especially landless farmers, will become better off. Welfare improvement requires a shifting to formal non-agricultural sectors, but unfortunately farmers might not be readily equipped with the skills required in formal sectors. Our study also obviously confirms that farmland is an important asset for agricultural households. Agricultural households experiencing a decrease of agricultural land also decreased their expenditure per capita by IDR 36,833 in 2000 and IDR 68,683 in 2007. These findings suggest that, currently, moving out of agriculture is not the solution to improve the well-being of farmers. Keeping farmland ownership, raising investment in human capital, and the modernization of agriculture should be the main concerns in agricultural development.

Passive Smokers' Support for Stronger Tobacco Control in Indonesia.

Secondhand smoke exposure in Indonesia is high, especially compared to other Southeast Asian countries. Passive smoking leads to negative impacts on health and socio-economic well-being. Therefore, increasing the price of cigarettes and, thereby, increasing barriers to access to cigarettes could be an effective way to reduce smoking prevalence and protect people from second-hand smoke. This study aims to assess passive smokers' support for cigarette price increases in Indonesia. We perform a quantitative analysis with a cross-sectional design. The data were obtained through phone-based interviews of 1000 respondents aged 18 and older in Indonesia. Only 596 nonsmokers were included to be further analyzed in this study. This study found that 44.1% respondents have at least one family member who smokes. We considered the respondents' age, gender, education level, employment, and the number of people living in the respondent's household that are exposed to passive smoking. Our results demonstrate that passive smokers support stronger tobacco control such as increasing cigarette prices, regulating smoking behavior using a religious approach (Fatwa), and applying more effective pictorial health warnings.

Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia.

BACKGROUND: The challenges of universal health coverage (UHC) in developing countries with a significant proportion of the labor force that works in the informal sector include administrative difficulties in recruiting, registering and collecting regular contributions in a cost-effective way. As most developing countries have a limited fiscal space to support the program in the long run, the fiscal sustainability of UHC, such as that in Indonesia, relies heavily on the contributions of its members. The failure of a large proportion of voluntary enrollees/self-enrolled members/informal sector workers (Peserta Mandiri/Pekerja Bukan Penerima Upah [PBPU] members) to pay their premiums may lead to the National Health Insurance System (NHIS) in Indonesia being unable to effectively deliver its services. OBJECTIVE: This study aims at exploring the important factors that affect the compliance behavior of informal sector workers (PBPU members) in regularly paying their insurance premium. This analysis may be a basis for designing effective measures to encourage payment sustainability in informal sector workers in the NHIS. METHOD: This study utilizes the survey data collected from three regional offices of the Indonesian Social Security Agency for Health (SSAH), which cover approximately 1210 PBPU members, to understand the relationship between members' characteristics and their compliance behavior regarding the premium payment. We applied an econometric analysis of a logit regression to statistically estimate which factors most affect their compliance behavior in paying the insurance premium. RESULTS: This study reveals that almost 28% of PBPU members do not pay their insurance premiums in a sustainable way. Our logistic regression statistically confirms that the number of household members, financial hardship, membership in other social protection arrangements, and the utilization of health services are negatively correlated with the compliance rate of informal sector workers in paying their insurance premium. For instance, people who experience financial hardship tend to have a 7.7 percentage point lower probability of routinely paying the premium. In contrast, households that work in agricultural sectors and have income stability, the cost of inpatient care incurred before joining the NHIS, a comprehensive knowledge of the SSAH's services, and the availability of health professionals are all positively correlated with regular premium payment. CONCLUSION: Although there is no single policy that can ensure that informal sector workers (PBPU members) regularly pay their premiums, this study recommends some policy interventions, including (1) flexibility in applying for a government subsidy for premiums (Penerima Bantuan Iuran [PBI]), especially for people who have financial hardship; (2) an intensive promotion of insurance literacy; (3) expanding the quantity and quality of healthcare services; and (4) tailor-made policies for ensuring the sustainability of premium payments for each regional division.