PONE-D-24-21104National health insurance membership in Indonesia: Does education level matter?PLOS ONE

Dear Dr. Kusnali,

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Isaac Akintoyese Oyekola

Academic Editor

PLOS ONE

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Additional Editor Comments:

Definitely, the paper investigated beyond education. Hence, and as contained in the covering letter, “National health insurance membership in Indonesia: Do socio-economic elements matter” may be considered more appropriate for the title.

In addition to reviewers’ comments, authors should note the following while revising the manuscript:

• Authors should state the research problem and demonstrate the uniqueness of this study. Generally, the background and discussion sections should be more robust, demonstrating scholarship

• The first acronym in Introduction, ‘NHIP’ was not first defined.

• “The survey results indicated that the furnished residences belonged to two discrete classifications: urban and rural.” Why reporting results in methodology? Which one is furnished residences? I believe authors meant “residence was classified into two categories: urban and rural” OR “residence had two categories: Urban and rural”. Authors must carefully select every word used. Just like, “The study displayed that the better the education, the higher the possibility of being an NHI member.” Which one is better education? ALSO, “During this period, individuals' employment status is classified into two separate categories: employed and indigent.” This is not a good classification for employment status. Seeing Table 1, the authors meant to classify into ‘employed and unemployed’. LIKEWISE, “survey classified the income index into five discrete categories, namely the most prosperous, indigent, middle-class, and poorest [23].” Again, this categorization is misleading. Indigent and poorest? Four classifications? Authors must correct this based on the information in Table 1.

• “Domicile, age, gender, marital status, employment status, and wealth status comprised the seven criteria”. Education is missing here, although authors may claim it was an exposure variable. Also, domicile might not be much appropriate, but residence.

• “During the initial phases of the sample”. Of the analysis, or sample?

• “Meanwhile, Fig 1 shows a map illustrating the geographical distribution of hospital utilization across the provinces of Indonesia in 2023. The map indicates that the lowest proportion of NHI members is in Kalimantan and the Nusa Tenggara region.” based on the statement, The Map in Figure 1 is not informative, and may not be considered relevant. Also, the map could not be accessed via the link provided.

• “The investigation determined that Indonesia's average NHI membership rate will be 72.5% in 2023 [Why not, ‘Indonesia’s average NHI membership rate was projected in 20XX to be 72.5% by 2023’]. Meanwhile, Fig 1 shows a map illustrating the geographical distribution of hospital utilization across the provinces of Indonesia in 2023. The map indicates that the lowest proportion of NHI members is in Kalimantan and the Nusa Tenggara region.” The statements did not seem to be the outcome of the investigation. Even the Map was not referenced. These statements would have been better in either Introduction or Discussions.

• Why starting to report Table 1 from gender. Interpret either ‘according to variables’ or ‘base on highest enrolment’.

• What was the reference category for age in Table 2? There is need to show the age category in Table 1, as this will give reader detailed information. The authors should report relevant statistics such as R-square, Coefficient and Standard Errors in Table 2.

• Authors may consider comparing between years (since such cross sectional study is conducted periodically). This is expected to improve the robustness of the study.

• Authors must report the sample size (n) of each category of socio-economic elements (putting % in bracket) in Table 1.

• The note ‘∗p < 0.001’ might not be relevant since no reference to such in the Table.

• “The study informs that six control variables are related to NHI membership in Indonesia.” Were these not the adopted variables in the study. Were other unrelated variables identified? In fact, the Table 2 would not have informed/confirmed the relationship that existed among variables (although it predicted what happens to dependent/outcome variable). Correlation and Chi-Square are necessary to show level and significance of relationship.

• There might be need to report cross tabulation and Cramer’s V to show the relationship and determine the level of corrections.

Discussion

• “Based on Ministry of Health data, the NHI membership coverage is about 95% in 2023”. Compare to “the investigation determined that Indonesia's average NHI membership rate was 72.5% in 2023”. Clarity is required since the study used the same year 2023 survey data.

• Education level plays a significant role in determining NHI membership among the poor population in Indonesia [12,26]. Not only education. Even, the statement is not novel.

• “Moreover, the results show that four [additional] demographic characteristics are associated with NHI membership”. Wealth index/status is missing here, although still discussed in last paragraph.

• The manuscript will benefit from improved discussions.

• Recommendations did not emanate from results. This is very important in scholarly research. For examples, “Continuously expand the coverage of the NHI to include more citizens, especially those from low-income backgrounds and remote areas.” AND “Conduct public awareness campaigns to educate citizens about the benefits of NHI membership, how to enroll, and the services available under the scheme” did not come from the results.” AND “Ensure that healthcare services covered under the NHI meet quality standards.”

ERRORS

• “This investigation utilizing secondary data is exempt from review by the National Ethics Committee of the National Research and Innovation Agency.”

• “qualitative study revealed that Information about plans, services, benefits, and opportunities to get health insurance are important factors in insurance enrolment [34]”. WHY USING UPPER CASE FOR ‘Information’

• “The relationship between higher education and higher enrolment in health insurance is similar to research in Ghana and Thailand [35,36].” authors must have mistaken India for Thailand

• Younger individuals, particularly those who are students or starting their careers, may be less likely to enroll in NHI due to limited awareness of the importance of health insurance or financial constraints. No longer ‘may’. Also authors may remove ‘particularly those who are students or starting their careers’ since age is the focus here not education.

CITATIONS REQUIRED

• “The study employed a method that had been previously devised to examine the multivariate correlation between all independent variables and survey participation in the NHI.” Citation is required.

• Some previous studies showed the same results that Higher education is associated with a higher likelihood of NHI membership among the poor. CITATION IS REQUIRED

• Authors must cite all substantive statements. For examples, out of many in Introduction, Methodology, and Discussion, “Another study showed that Indonesia's health insurance system covers many hospitalized patients, especially the poorest.” AND “However, the eastern region of Indonesia still lacks access to many services, and their benefits are not fully realized.” AND “Demographic factors such as age, region, residence, education, marital status, and employment status play a significant role in the ownership of National Health Insurance (NHI) in Indonesia. For instance, older individuals or those with stable employment are more likely to own NHI.”

• Authors must include complete references such as inclusion of doi.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In my opinion, the relationship between education level and insurance membership is not a meaningful research topic worth pursuing as there is no evidence or knowledge gap for this issue. The author provided a comprehensive summary on the factors that impacted health insurance membership in Introduction and it is clear that there is no new information in this study that can contribute to literature.

Reviewer #2: Introduction

Improve the first paragraph by establishing a context that emphasizes the importance of discussing health insurance issues from a global perspective. Then, continue with a more specific explanation regarding the reasons why research on health insurance in Indonesia is very important.

Following the statement of purpose, it is important to highlight the potential benefits that can be derived from the results of this research. These benefits can range from informing policymaking to increasing the effectiveness of health insurance programs.

Methods and results

The outcome variable in this research is membership in Indonesia's national health insurance. As is known, national health insurance membership in Indonesia is divided into several types, consisting of Contribution Assistance Recipients (PBI in Indonesian), Wage Recipient Workers (PPU), Non-Wage Recipient Workers (PBPU in Indonesian), and Non-Workers (PB in Indonesian). Why doesn't the author differentiate National Health Insurance membership based on this scheme? Can data analysis be carried out taking into account the existence of several of these schemes? If the author has reasons, explain clearly why the data analysis design ignores the types of JKN participation mentioned above.

Discussion

In line 266, the author states the relationship between educational-level access to information and health literacy. Apart from these two things, there is a possibility that education is also related to work and welfare, as quoted from research in India. What about research in Indonesia? Add discussion about this.

Reviewer #3: PLOS ONE National health insurance membership in Indonesia: Does education level matter? PONE-D-24-21104

General comment:

The authors examined the role of education level on NHI membership in Indonesia. Using a cross-sectional design, this study examined 1,223,377 individuals using the latest secondary data from the 2023 National Socioeconomic Survey showing fluctuations in NHI participation since 2021. Authors provided justification the reason of fluctuations indicating Various factors contribute to this shortfall, notably compliance enforcement, particularly among economically vulnerable demographics. A comprehensive approach encompassing education, legal enforcement, and incentives is imperative to ensure a universal understanding of the significance and obligations associated with NHIP participation.

Specific comments

1. Authors focus of interest was contribution of education level to public awareness to participate in NHI membership served as the outcome variable

Comment: the article focused on contribution of education level on public awareness to participate in NHI independently and voluntarily. Please elaborate what the authors mean with public awareness. Is it in the level of awareness or the level of participation. Authors need to justify choosing level of education on NHI participation as variable of interest. As most study identified those with high education level has better health status compared to those with lower education. The authors pointed out that wealthier group have greater chance to be NHI member, which is common in most countries that those with better education and economic status is more concerned on their health, including NHI participation. What is the specific condition of Indonesian NHI compared to NHI in other countries which make the authors pay specific interest on analysis contribution of education level on NHI participation.

"The authors should clarify if they are examining the contribution of education level to public awareness of NHI benefits, or actual participation in the program."

2. Authors admit that Education plays a crucial role in influencing health insurance ownership and utilization. Education level has a significant impact on health insurance ownership. A study conducted in Indonesia found that pregnant women with higher education were 3.349 times more likely than 86 those with no education to have health insurance. Another study in China found that educations significantly increased the demand for commercial health insurance. Furthermore, research conducted on 26 OECD countries from 1995 to 2015 found that adults with higher educational attainment better understand and appreciate health insurance's benefits, thereby increasing ownership rates. Education improves access to resources, including health insurance, which enables individuals to receive better healthcare services. Additionally, educated individuals are more likely to engage in healthy behaviors and recognize the importance of health insurance.

Since contribution of education on NHI membership is the authors main interest, please provide more justification why selecting the variable.

Authors also admit the contribution of other demographic factors on NHI participation. Please elaborate how the intertwined of education level with other demographic factors on NHI participation.

"While the link between education and health insurance is established, the authors should elaborate on why education is a specific interest here. Do they expect a different dynamic in Indonesia's NHI compared to other countries?"

3. Table 1: please add total N in the left column of NHI membership, with column percent to make reader understand the big picture of population according to each explanatory variable.

4. How is the strength of the model as shown in the classification table? How the authors explain the strength of the model to increase NHI participation level?

5. Line 192: authors gave figure on the hospital utilisation. Please explain how the association of the figure with the topic of the manuscript which is contribution of education on NHI membership.

"It would be helpful to understand how the hospital utilization figure connects to the main topic of education and NHI participation. Is it presented as a potential benefit of NHI membership?"

6. Line 258 – 260: please elaborate the meaning of the sentence some previous studies showed the same results that Higher education is associated with a higher likelihood of NHI membership among the poor. Did authors mean poor people with higher education more likely to participate in NHI?

"This sentence could be rephrased for clarity. Did the authors find that even among low-income individuals, those with higher education were more likely to participate in NHI?"

7. The analysis showed that higher education and wealthiest are more likely to participate on NHI than those with lower education and least wealthy. How is the proportion of higher education and wealthiest among Indonesian compared to those with lower education and least wealthy? As authors said those with higher education and wealthier is more exposed to benefit of NHI. What authors recommendation for the government for people with lower education, least wealthy, less exposure to get NHI benefit.

8. Line 289 – 293: Socioeconomically disadvantaged communities living in rural areas in Indonesia face a variety of barriers that limit their access to primary health care; this is the government's primary concern, including the availability of a sufficient number and quality of health workers, combined with a telemedicine approach, to ensure the availability of health services and a reference guide:

Comment: what authors intend to say Socioeconomically disadvantaged communities living in rural areas in Indonesia face a variety of barriers that limit their access to primary health care with the telemedicine approach? Did authors intend to say telemedicine approach as solution for the socioeconomically disadvantaged communities living in rural areas?

o "The authors' discussion of telemedicine as a solution for rural communities with NHI access limitations needs clarification. Is telemedicine presented as a potential solution to improve access for these communities?"

9. Line 294 – 295: did author mean living in rural as barrier for NHI participation?

10. Authors provided comprehensive explanation on the dynamics of NHI participation

11. Thank you

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Reviewer #1: No

Reviewer #2: Yes:  Ratna Dwi Wulandari

Reviewer #3: Yes:  siti isfandari

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PONE-D-24-21104R1National health insurance membership in Indonesia: Does education level matter?PLOS ONE

Dear Dr. Misnaniarti,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 18 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Isaac Akintoyese Oyekola

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The authors have been able to attend to the comments well, except for the following minor corrections:

‘National health insurance membership in Indonesia: Do socio-economic elements matter’ may be considered more appropriate for the manuscript considering the employment of socio-economic variables such as education, wealth, et cetera (NOT ONLY EDUCATION, ALTHOUGH EDUCATION MAY HAVE ‘DOMINANT INFLUENCE’).

Conclusions and recommendations must emanate from findings. For examples, “…COMMUNITY WELFARE provide more opportunities for individuals to engage in NHI” AND “…targeted health literacy initiatives should focus on INFORMAL SECTOR WORKERS…” were not part of the findings. Many more conclusions can be drawn from the findings and more recommendations can be made without exaggeration. Authors should maximize the use of this section to benefit readers and policy makers in a concise manner. For instance, since wealth influenced NHI membership, subsidy/premium waiver for the less-privileged may be more appropriate as recommendation, among others.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The author has responded well to all my previous comments in this revised manuscript.

However, my previous comment about the analysis based on the type of insurance may need to be mentioned in the limitations or added to the suggestions for further researchers to conduct a more in-depth study related to this.

Another crucial point that needs clarification is the need for more detailed information about the differences in characteristics between levels of education. This information is vital for designing effective interventions at each level of education, as the manuscript's title suggests a focus on education.

Reviewer #3: *Comment:**

Thank you for your excellent work in addressing and clarifying the reviewer inputs. Below are my specific comments:

**Abstract:**

- Line 30–31: Consider replacing "control variables" with "covariates."

- Line 39–41: Why do the authors only mention wealth and education in the conclusion?

**Introduction:**

- Line 45–59: The paragraph is too long and includes only two citations. Please condense and shorten it.

- Line 60–73: The main point is the fluctuation pattern of NHI membership. Please clarify the sentences to reflect this.

- Line 74–92: The authors discuss the contributing factors to NHI membership. Please streamline the paragraph to make it more concise and systematic.

- Line 100: Suggest emphasizing that education improves health literacy, leading to better access to health services.

- Line 104–117: This paragraph is too lengthy with only one citation. Please shorten it.

- Line 118–126: The authors seem particularly interested in the role of education in NHI membership among disadvantaged groups. It may be better to focus the analysis on this issue, comparing the impact of education on NHI membership between disadvantaged and better-off groups.

**Results:**

- Line 224: What are the authors trying to convey with Table 2? Please clarify the intent.

- Line 233: In Table 3, the authors should consider presenting the varying contribution of education to NHI membership across different wealth statuses.

**Discussion:**

- Line 247–259: This paragraph is too long and contains only one citation. Please condense it and highlight key findings from your analysis in the first paragraph.

- Line 260–269: The authors discuss the government program, its efforts, and challenges. What innovations are already in place, and what challenges should the government address through digitalization?

- Line 270–284: What are the key points the authors intend to emphasize?

- Line 285–303: What is the main takeaway from this paragraph? Please make it concise and clearer.

Great job overall!

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: Yes:  Ratna Dwi Wulandari

Reviewer #3: Yes:  Siti Isfandari

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PONE-D-24-21104R2National health insurance membership in Indonesia: Do socio-economic elements matter?PLOS ONE

Dear Dr. Misnaniarti,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 08 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Isaac Akintoyese Oyekola

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The authors have been able to attend to the comments well in ‘response to editor’s comment section’. However, I was wondering if the authors effected the corrections in the manuscript submitted for review. Specifically, there seems not to be any difference between the conclusion in Revision 2 and Revision 1.

Additionally, and as noted by the reviewer, authors must modify all sections in the manuscript to reflect the new title.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: generally good. however authors need to correct statements in abstract and introduction in the objective and aim of the study

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #3: Yes:  Siti Isfandari MA

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Comment_jan2025.docx

Attachment

Submitted filename: Comments.docx

PONE-D-24-21104R3National health insurance membership in Indonesia: Do socio-economic elements matter?PLOS ONE

Dear Dr. Misnaniarti,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 03 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Isaac Akintoyese Oyekola

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

* Complete title of Table 2, if still relevant.

* Focusing on socio-economic elements, and not only on education, might address the reviewer’s comments.

* Include age categories also (not only mean age) and report the statistics accordingly in Tables 1, 2, and 3.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: please perform statstic analysis in line with the objective which was to identify the contribution of education level on UHC participation among poor and disadvantage group

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: Yes:  Siti Isfandari

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: R3_1805_2025_Line 105.docx

National health insurance membership in Indonesia: Do socio-economic elements matter?

PONE-D-24-21104R4

Dear Dr. Misnaniarti,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Isaac Akintoyese Oyekola

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: table 2 needs clarification. it is still unclear. It is good authors try to justify the result. better author rethink to present the table 2

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #3: Yes:  Siti Isfandari

**********

Attachments

Attachment

Submitted filename: rev_5_juli_2025.docx