Introduction

Health insurance is a cornerstone of sustainable development, enhancing individual well-being and driving economic and social progress. Comprehensive programs have improved public health, reduced poverty, and promoted equitable access to essential services globally. In Indonesia, the National Health Insurance (NHI) program exemplifies this, addressing the unique challenges of a diverse population and evolving healthcare system. As a state initiative, the NHI has boosted economic growth and healthcare access [1], reflecting the government’s commitment to equitable healthcare [2]. Understanding the dynamics of this program within Indonesia contributes to the global discourse on UHC. Examining this program provides valuable lessons for strengthening health systems and advancing Universal Health Coverage (UHC) in similar settings.

As of December 2021, participation in the NHI had reached 235 million participants, covering approximately 86.55% of Indonesia’s population (with a projected population of 272 million in 2021) [3]. However, this figure falls significantly short of the participation target set in the National Medium-Term Development Plan (RPJMN), which aims for 98% coverage by 2024 [4]. Fluctuations have been observed despite the overall increase in NHI membership since its inception in 2014. Membership decreased by 1.7 million in 2020, likely due to economic challenges, but rebounded with a 5.97% increase in 2021, reflecting the government’s intensified efforts to expand coverage. These fluctuations highlight the challenges of sustaining membership growth and achieving the UHC target by 2024 [3].

This shortfall underscores governmental concerns regarding the suboptimal implementation of the compulsory enrollment principle to attain universal health coverage (UHC) under the NHI [5]. Various factors contribute to this shortfall, notably compliance enforcement, particularly among economically vulnerable demographics [6,7]. A comprehensive approach encompassing education, legal enforcement, and incentives is imperative to ensure a universal understanding of the significance and obligations associated with NHI participation [8,9].

Several factors influence NHI membership in Indonesia, including demographics (age, gender, and marital status) [10,11], socioeconomic conditions (wealth, education level) [12], and geographic disparities (urban vs. rural residence). Older individuals with stable employment and urban residents are more likely to own NHI due to better access to information, resources, and healthcare services [13,14]. Economic status also plays a crucial role, as higher-income individuals can afford premiums, while lower-income groups face affordability challenges. Additionally, individuals with chronic illnesses or poor self-perceived health are more inclined to own health insurance to support their medical needs. These factors, though significant, interact in complex ways, reflecting the multifaceted nature of NHI ownership in Indonesia. [11].

Education enhances health literacy, enabling individuals to understand the benefits of health insurance, navigate the enrollment process, and access healthcare services effectively. 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 those with no education to have health insurance [15]. Another study in China found that education significantly increased the demand for commercial health insurance [16]. 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 [17]. Additionally, educated individuals are more likely to engage in healthy behaviors and recognize the importance of health insurance.

UHC ensures that all individuals can access promotive, preventive, curative, and rehabilitative health services of sufficient quality without experiencing financial hardship [18]. In Indonesia, the government launched the NHI scheme under the National Social Security System Law 2004, which became operational in 2014, mandating universal participation. Despite a 95% coverage target by 2019, the scheme achieved 85.3% coverage by the end of that year [19]. The 2020–2024 RPJMN aims for 98% population participation in NHI to further UHC’s goals of financial protection and equitable healthcare access. Presidential Instruction No. 1 of 2022 reinforces this effort, tasking all levels of government to accelerate UHC implementation, highlighting the shared responsibility of national and local governments in achieving this critical objective.

This study examines the role of various socio-economic elements—particularly education level, wealth status, employment, and residential location—in shaping NHI membership in Indonesia. These factors are especially relevant among disadvantaged populations facing compounded health insurance enrollment barriers. While previous studies have examined factors influencing NHI membership in Indonesia, limited research has explored how multiple socio-economic characteristics—such as education, employment, wealth, and geographic location—jointly influence NHI membership in Indonesia, particularly among the poor and disadvantaged groups. This research aims to assess multiple socio-economic factors, including education, that interact with structural disadvantages such as poverty and rural residence to influence NHI participation. The study further disaggregates the influence of education within subgroups to better understand its differential effect on advancing UHC. Studies in Ghana and India have demonstrated that higher education levels correlate with increased health insurance enrollment rates [20,21]. However, the specific dynamics in Indonesia, especially concerning the disadvantaged population, have not been fully explored. This study contributes to the literature by analyzing data from the 2023 National Socioeconomic Survey to examine these relationships.

The potential benefits derived from this research are substantial. Examining the role of education level on NHI membership in Indonesia can provide crucial insights that inform more targeted and effective policy making. Specifically, understanding how education influences health insurance uptake can help policymakers design interventions that better address the disparities in coverage, particularly in underserved regions like eastern Indonesia [22]. These insights could guide the allocation of resources, ensuring that investments in health infrastructure and human resources are directed where they are most needed, thereby reducing inequalities between provinces [23,24].

Moreover, this research has the potential to increase the overall effectiveness of the NHI Program by highlighting the importance of integrating educational initiatives with insurance enrollment efforts. This could lead to higher participation rates, especially among low-income and less-educated communities, ultimately contributing to greater health equity nationwide. By addressing these gaps, the study supports the broader goal of achieving universal health coverage in Indonesia, ensuring that every citizen, regardless of their educational background, can access the healthcare services they need.

Materials and methods

Results

Table 1 presents the outcome of descriptive statistics of participant analysis. Socioeconomic factors, including education, employment, wealth status, and residence, showed significant associations with NHI membership. For instance, individuals in urban areas and those in the wealthiest quintile were more likely to be enrolled in the NHI. According to residence type, urban areas have a higher ratio of NHI members than rural areas. Meanwhile, the study shows that the average age of people with NHI is older than those without.

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Table 1. Descriptive statistic of participants.

https://doi.org/10.1371/journal.pone.0329781.t001

Based on gender, Table 1 displays that females have more NHI members than males. Regarding marital status, never in the union has the lowest ratio of NHI members. On the other hand, according to employment status, the employed have a higher NHI members ratio than the unemployed. Furthermore, the richest have the highest proportion of NHI members based on wealth status.

Following this, the collinearity examination was conducted. Based on the test results, no discernible correlation exists between the independent variables. The variance inflation factor value for each variable is less than 10.00, while the significance level of the tolerance value exceeds 0.10. During the investigation, it was determined that the regression model lacked multicollinearity; this indicates that the test’s foundation for concluding was robust.

Table 2 presents National Health Insurance (NHI) membership distribution across various socioeconomic and demographic characteristics, stratified by education level. The data reveal a consistent trend in which individuals with higher educational attainment, particularly those with a college-level education, exhibit higher NHI membership rates across all categories, including urban residence, formal employment, marital status, and higher wealth quintiles. Urban residents, for instance, show a notably higher proportion of NHI membership as education level increases, with 85.97% of college-educated individuals insured, compared to 72.01% among those with only primary education. Similar patterns are observed among those in wealthier groups and those employed, suggesting that higher education correlates with improved access to resources that facilitate NHI enrollment. Statistically significant associations (p < 0.001) and moderate effect sizes (Cramer’s V ranging up to 0.128) underscore the multifactorial influences of education on insurance uptake in Indonesia.

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Table 2. Distribution of NHI membership according to socioeconomic characteristics and education level in Indonesia (n = 1,223,377).

https://doi.org/10.1371/journal.pone.0329781.t002

Regarding NHI membership in Indonesia, the logistic binary regression analysis outcomes are shown in Table 3. Regarding education level, the result indicates that junior high school is 1.214 times more likely to be an NHI member than primary school 95% CI 1.200–1.228). Meanwhile, senior high school is 1.301 times more likely than primary school to be an NHI member (95% CI 1.286-1-1.315). Moreover, college is 1.916 times more likely to own NHI than primary school (95% CI 1.878–1.954).

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Table 3. The results of the logistic binary regression analysis concerning NHI membership in Indonesia in 2023 (n = 1,223,377).

https://doi.org/10.1371/journal.pone.0329781.t003

The six variables included in the study—age, gender, marital status, employment status, wealth status, and residence—were adopted as independent variables to predict NHI membership. Education was treated as the primary independent variable, while the others were controlled to isolate the effect of education on NHI membership. Analysis revealed significant differences in demographic and socioeconomic characteristics across education levels. Individuals with lower education levels (e.g., primary school) were more likely to reside in rural areas, have lower wealth status, and be employed in informal sectors. Conversely, those with higher education levels (e.g., college) predominantly lived in urban settings, exhibited higher wealth indices, and were more likely to be formally employed. Gender disparities were also noted; females were more represented among higher-educated groups than males.

According to residence type, someone in rural areas is 0.807 times less likely to be an NHI member than those in urban areas (95% CI 0.800–0.814). Moreover, the results show that four demographic characteristics are associated with NHI membership: age, gender, marital status, and employment status. Based on wealth status, Table 2 shows that the wealthier the status, the more likely the likelihood of being an NHI member.

Discussion

Since 2014, the NHI program has been a cornerstone of the country’s social health insurance system, aiming to ensure equitable access to healthcare for all citizens. Over the years, NHI coverage has steadily expanded, encompassing a growing number of participants across diverse socioeconomic groups [27]. By 2023, approximately 72.5% of the population was enrolled, though efforts are ongoing to reach remote and underserved areas. The program has also improved its benefits package, adding specialized treatments to address participants’ evolving healthcare needs. During the COVID-19 pandemic, the NHI demonstrated resilience, providing essential services such as testing and treatment for COVID-19, reinforcing its role as a key pillar of Indonesia’s healthcare system.

The government has prioritized digitalization efforts to enhance the efficiency and accessibility of the NHI program. Innovation includes developing integrated information systems for participant management, claims processing, and provider payments, enabling more streamlined and transparent operations [7,9]. Additionally, digital health platforms have been introduced to support telemedicine, simplify registration, and facilitate real-time data exchange between stakeholders. Efforts to improve the quality of services under the NHI program include implementing digital quality monitoring tools, establishing performance-based incentives, and utilizing analytics to identify service gaps [28]. However, challenges remain, such as ensuring equitable access to digital tools in remote areas, addressing data security concerns, and enhancing user adoption among healthcare providers and participants. By addressing these challenges and expanding digital innovations, the NHI program can better fulfill its goal of providing equitable and high-quality healthcare access for all citizens.

Education is critical in overcoming barriers to NHI enrollment, particularly for disadvantaged populations. Higher education levels enhance health literacy, enabling individuals to navigate complex enrollment processes and access healthcare services. Higher education levels enhance health literacy, enabling individuals to navigate complex enrollment processes and access healthcare services [14,29]. However, wealth and geographic disparities exacerbate challenges for low-income and rural populations [30]. These disparities can impact healthcare access equity. Policymakers should prioritize education-based interventions alongside financial subsidies to bridge these gaps and promote universal coverage.

Previous studies have found similar results, indicating that individuals with higher levels of education are more likely to participate in NHI programs, even within low-income groups [14]. This means that poor individuals with higher levels of education are more likely to enroll in NHI. This trend is often attributed to better awareness of healthcare options, a greater understanding of the benefits of health insurance, and potentially higher income levels are more common among those with higher education, all of which facilitate NHI enrollment [31–34].

The observed differences in characteristics between education levels suggest the need for tailored interventions. For instance, efforts targeting individuals with lower education levels should emphasize outreach in rural areas and focus on improving awareness through locally relevant health promotion campaigns. Financial barriers, common among lower-educated populations, could be addressed through subsidies or simplified registration processes. Meanwhile, interventions for higher-educated individuals could leverage digital platforms and workplace-based enrollment strategies to enhance NHI participation further. Recognizing these distinctions can help policymakers design more effective, education-specific strategies to achieve universal health coverage.

Higher education strongly correlates with increased NHI membership, as it enhances access to information, health literacy, and economic opportunities [35,36]. Studies from Indonesia [37] and other countries, including Ghana [21], India [20], and Congo [38], demonstrate that education improves employment prospects and income, enabling individuals to afford health insurance. Higher education levels in Indonesia are particularly linked to formal employment and economic security, underscoring the need for policies addressing educational disparities to promote equitable NHI enrollment [14,39].

According to residence type, people in rural areas were less likely to be NHI members than those in urban areas. Rural populations may have lower health literacy levels and less awareness of the importance of health insurance. Limited access to information and educational resources about NHI programs can contribute to lower enrollment rates in rural areas [40]. Additionally, Indonesia’s status as a middle-income country with a population of 262 million dispersed across 17,744 islands provides special challenges for the health system and UHC coverage [7]. The leading cause of low health insurance coverage in rural Indonesia is a lack of public information, socialization, education, and health promotion media, particularly about insurance membership and how to obtain it [41]. This contributes to household leaders’ limited awareness of the need for health insurance protection in supporting productivity. Insurance knowledge is essential to increasing premium payment compliance and expanding insurance coverage [42].

Socioeconomically disadvantaged communities in rural areas of Indonesia face significant barriers to accessing primary healthcare, which impacts their participation in the NHI program. These barriers include a shortage of healthcare facilities and providers and logistical challenges like long-distance and inadequate transportation options, making it difficult for rural residents to enroll in NHI, even if they understand its benefits [43]. Additionally, cultural beliefs that emphasize self-reliance and the use of home remedies, coupled with skepticism toward government institutions, further diminish the perceived need for health insurance in these communities. These factors contribute to lower NHI enrollment rates in rural areas, consistent with findings from a meta-analysis of 12 publications, which identified rural residency as a significant factor influencing NHI ownership in Indonesia.

Moreover, the results show that four demographic characteristics are associated with NHI membership: age, gender, marital status, and employment status. Younger individuals are less likely to enroll in NHI due to limited awareness of the importance of health insurance or financial constraints. Conversely, older adults, especially those nearing retirement age or experiencing health issues associated with ageing, are more likely to prioritize health insurance coverage and thus have higher enrollment rates [44]. Gender can influence NHI membership rates due to differences in healthcare-seeking behaviors and employment patterns [34]. Women, particularly those of childbearing age, may be more likely to enroll in NHI due to pregnancy-related healthcare needs and preventive care services. Men may be less likely to prioritize healthcare or may face barriers to enrollment due to factors such as employment instability or lower health literacy levels. Married individuals, especially those with children, may prioritize health insurance coverage for their families, leading to higher enrollment rates. Single individuals, particularly those without dependents, may be less likely to prioritize health insurance or face financial barriers to enrollment. Employment status is a significant determinant of NHI membership, as many countries tie health insurance coverage to employment. Full-time employees often have access to employer-sponsored health insurance plans or may be required by law to enroll in NHI, leading to higher enrollment rates among this group [44].

Based on wealth status, the wealthier the status, the more likely the likelihood of being an NHI member. The association between wealthier socioeconomic status and higher NHI membership rates reflects the intersection of financial resources, access to employer-sponsored benefits, healthcare utilization behaviors, health literacy, and perceptions of healthcare as a priority [45]. Wealthier individuals typically have more financial resources available to afford health insurance premiums. NHI programs often require individuals to pay premiums or contributions, and those with higher incomes are better positioned to meet these financial obligations without significant strain on their budgets. Even with insurance coverage, individuals may still face out-of-pocket costs such as deductibles, copayments, and coinsurance [44]. Wealthier individuals can better afford these costs, reducing financial barriers to seeking healthcare services and thus increasing the likelihood of NHI membership.

Conclusions

This study demonstrates that educational attainment plays is pivotal in determining enrollment in Indonesia’s National Health Insurance (NHI) program. Individuals with higher levels of education are significantly more likely to be NHI members, which may be attributed to greater health literacy, better understanding of insurance benefits, and enhanced access to relevant information. In addition to education, other socio-economic and demographic variables—including wealth status, residence (urban or rural), age, sex, marital status, and employment—were also found to be statistically significant predictors of NHI membership.

The findings indicate that individuals residing in rural areas, those with lower educational levels, the unemployed, and members of the lowest wealth quintiles are less likely to be enrolled in the NHI. This underscores persistent disparities in access to social protection and suggests the need for more equitable outreach and policy intervention.

To improve NHI coverage and ensure that the goal of universal health coverage (UHC) is realized, particular attention must be directed towards these underserved populations. Policy responses should include strengthening community-based health literacy programs, simplifying administrative enrollment procedures, offering premium waivers or targeted subsidies for low-income groups, and enhancing the accessibility of primary healthcare services across all regions, particularly in rural and remote areas.

Acknowledgments

The author expresses gratitude to Indonesian Statistics for granting access to the 2023 National Socioeconomic Survey so that this research can be conducted.