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Table 3 Selected statements that exemplify key barriers to health insurance access and maternal health services among poor women

From: Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixed-methods study

Topic: Health insurance access
Barrier Themes Illustrative quotes
 Individual Perception that health insurance is unimportant “I’m not sick yet, so I don’t need it.”
- Poor woman, Jakarta
Lack of valid government identification Puskesmas [community health center] has already offered health insurance, but I didn’t have the documents… I didn’t have time to take care of the Kartu Keluarga [government family card].”
- Poor woman, Banten
 Programmatic Miss-targeting of the poor “For Jamkesmas there needs to be a household survey [to identify the poor], after that, the government provides health insurance for those that are poor. However, there is some nepotism that takes place so that some well-off families will also get Jamkesmas health insurance.”
- Midwife, Banten
Topic: Maternal health service
Barrier Themes Select quotes
 Socio-cultural Preference to deliver at parental village “My parents are there, [if I deliver here] no one will help take care of me.”
- Poor woman, Jakarta
Use of traditional birth attendants (TBA) “Women like to use paraji [TBA] because they accept whatever you have… they also help raise the baby, take care of the mother, and help with other household chores.”
- Midwife, Banten
Fatalistic point of view “There was one woman who was delivering her fourth baby with a dukun [TBA]… she had heavy bleeding but did not want any assistance from a midwife or any skilled birth attendant because she believed that life and death is God’s will…both mother and baby died.”
- Midwife, Banten
 Accessibility Distance to health facility “The puskesmas is very far… I delivered with my midwife and dukun [TBA] at home.”
- Poor woman, Banten
Poor referral system “Our referral system is a mess… there is a lot of hospital “touring” as we look for hospitals that can deal with emergency situation… as a result, we have a lot of deaths in transit.”
- Government representative, Banten
Non-facility based expenditure “When we refer patients to higher level health facilities, they sometimes refuse. We tell them that it’s free, but they respond, “It may be free for me, but how do we pay for food for the people that will be waiting with me?”“
- Midwife, Banten
 Quality of care Shortage of qualified health providers “I was afraid last time I was [in the puskesmas]… I was yelling “help doctor, help midwife, my baby is coming!” No one was there, everyone was on vacation… there was only one nurse in the puskesmas.”
- Poor woman, Jakarta
Overcrowded health facilities “Here in this puskesmas, the number of patients is very high…the one that I met on Wednesday originally came down on Monday…ha-ha-ha… there are not enough seats in the waiting room for all the patients.”
- Midwife, Banten
Lack of health facility accreditation “The cost associated with health facility accreditation is very high… you need to hire a consultant and a team to identify the issues… then you need a lot of resources to fix all the issues so you can be accredited… most puskesmas don’t have the money to be accredited.”
- Government representative, Banten