Hospital nurses’ perceptions of distributive justice under the national health insurance scheme in Indonesia

Background: National Health Insurance (NHI) is a health financing scheme implemented in Indonesia to achieve universal health coverage. This is a mandatory social insurance with approximately two-thirds of the members made up by the poor, who are subsidised by the government. The principle of distributive justice is central in the NHI relating to fairness and equity in accessing health care, especially in this resource-constrained country. The nursing workforce is the largest direct health care provider and the workforce that experiences the impact of this policy. Objective: To describe narrative views and experiences of hospital nurses regarding fairness and equity in implementation of the NHI. Research design: This study employed a qualitative approach. Individual semi-structured interviews were conducted with a non-probability sampling technique of hospital nurses. Data were analysed using content analysis technique. Participants and research context: Study participants included 16 nurses recruited from three different types of hospitals at secondary and tertiary levels in East Java province, Indonesia. Findings: Data analysis from interviews with study participants yielded the following four themes and categories: 1) helping the neediest people: a) access to affordable health care, b) sharing for solidarity, c) adequate standardised treatment; 2) a discriminatory service system: a) the dilemma of paying for priority services, b) different professional and resource allocations; 3) enduring impacts of the policy: a) higher workload, b) different attitudes for different social classes, c) unimproved financial incentives; and 4) managing new changes: a) nurses as the centre of communication, b) addressing patients' complaints, c) strengthening teamwork. Conclusion: The findings highlight distributive justice challenges in implementing the NHI system in hospitals, as voiced by nurses. Despite more people enjoying the benefits of NHI, the hospital service system has allowed a discriminatory approach in caring for patients, with nurses bearing the burden of impacts and being obliged to make continuous adjustments. Understanding and addressing these issues will improve fairness and equity in utilising quality health care.