AgBioForum, 24(2): 196-205. ©2022 AgBioForum Implementation of National Health Insurance Policy Through the Social Security Implementing Agency Health During the Pandemic the Covid-19 Bambang Santoso Haryono Faculty of Administrative Sciences, Brawijaya University, Indonesia Email: bambangsfia@ub.ac.id Ahmad Rizki Sadiq Faculty of Administrative Sciences, Brawijaya University, Indonesia Email: riskisadig@yahoo.com Abdul Hakim Faculty of Administrative Sciences, Brawijaya University, Indonesia Email: hakimend61@gmail.com Imam Hanafi Faculty of Administrative Sciences, Brawijaya University, Indonesia Email: imamhanafi@ub.ac.id The Covid-19 pandemic has significantly impacted global health, notably in Indonesia. The Indonesian government reacted swiftly to the increase in cases by implementing strategic measures to sustain the health and economic recovery momentum and combat the pandemic's huge expansion. This necessitates the Indonesian government takes extraordinary policy measures to address health issues, protect the general public with social security, and defend the business sector as a top priority. This study aims to describe the Social Security Administration Agency's implementation of health insurance policies during the COVID-19 pandemic in Indonesia. This study utilizes cross- sectional data and a Likert scale questionnaire to obtain information. During the Covid-19 epidemic, the development of national health insurance policies must be founded on the state's responsibility to meet the people's safety and fundamental needs through comprehensive health care. The research is new to the academic literature, and its findings establish a novel relationship. The study has theoretical and practical implications for enhancing Indonesia's health care. The recommended future directions for this research are reasonable for contributing significantly to future research. Key words: Implementation Policy, National Health Insurance, Social Security Implementing Agency, Pandemic Covid-19. 1. INTRODUCTION Universal health coverage (UHC) is a health service guarantee scheme with a prepaid healthcare funding system designed to provide the population with quality health services. The global impact of the Covid-19 pandemic has influenced socio-economic, unemployment, and social and health inequalities between men and women, posing a threat to the global economy. Political and social leaders are crucial in establishing policies encouraging worker participation and continued community education (Dartanto, Halimatussadiah, et al., 2020). The health system arose in the 19th century due to the people's expectation that an organized health social security system would be implemented to benefit broad and social coverage of public health services (Muttaqien et al., 2021). The purpose of universal health coverage is to ensure that all individuals and groups have access to basic medical care throughout their lives, including protection, diagnosis, rehabilitation, and pain management. Each nation must evaluate the policy model of the healthcare coverage system, which includes the capacity to support health workers, health service facilities, and budget management, to provide effective, efficient, and productive services for the benefit of society (Osungbade et al., 2014). The Covid-19 pandemic has provided important lessons and reflections on the need to improve the National Health Insurance Policy (NHIP) in Indonesia, particularly "prevention capabilities including testing, tracing, and tracking as well as handling capabilities in the mobilization of health resources such as health facilities, pharmaceuticals, and medical devices, health workers, laboratories, and health financing." A political comprehension of UHC is required to get health for all (Laksono et al., 2021). The Covid-19 pandemic is a turning point and the correct impetus to reevaluate health insurance policy for the entire community in pursuing sustainable development goals (SDGs). Indonesia confronts global issues and assures its readiness to meet pandemics and other health calamities (Yuniarti et al., 2019). The Government of Indonesia has updated the UHC system to align with the conditions and goals of "professional, efficient, and effective national health care that reaches all levels of society." During the global Covid- 19 pandemic, the UHC program that is integrated between the National Social Security System (NSSS) and the national health system is highly relevant for the execution of public health based on the cooperation, solidarity, and empathy of all citizens. Increased media engagement for public education about the Covid-19 pandemic is crucial for reducing uncertainty during the epidemic (Moeloek, 2017). Following the constraints posed by the distributive justice component of establishing the hospital care service system, promoting equality in utilizing high-quality health care is essential (Barua et al., 2020). UHC objectives and obstacles to achieving the SDGs by 2030 necessitate a national budget allocation mechanism to combat the "COVID-19 pandemic" (Erlangga et al., 2019). The theory of public policy that underpins research on the implementation of national health policy is Anderson's theory, which states that public policy is a relationship mailto:bambangsfia@ub.ac.id mailto:riskisadig@yahoo.com mailto:hakimend61@gmail.com mailto:imamhanafi@ub.ac.id AgBioForum, 24(2), 2022 | 197 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … between a government unit and the environment that is formulated by an actor such as an executive/president through a presidential decree or a decision by several actors including executive, legislative, and judiciary (Moeloek, 2017). In a crisis of this nature, formulating public policy in response to situations and occurrences during a pandemic requires boldness, precision, and swiftness. Social protection policy aims to ensure that everyone can meet their basic necessities for a good existence. "The NSSS policy is the procedure for administering the Social Security program by the Health and Manpower Social Security Administration" (Aizawa, 2019; Barua et al., 2020). This study examines the implementation of the NHIP in Indonesia via the "social security administration body" for health. To discuss the implementation of national health policies in hospitals, researchers employ a central government-developed implementation mechanism approach. In this study, four aspects of the implementation of the health insurance program are examined: the health budget allocation policy during the Covid-19 pandemic, the drug distribution policy in handling the Covid-19 Pandemic, the policy on the realization of funds for health workers during the Covid-19 pandemic, and the policy for "recipients of health insurance contribution assistance" during the Covid-19 pandemic. This research contributes to the description of critical situations or events in the field regarding the decision-making and implementation of the NHIP through the "social security" implementing agency health during the Covid-19 pandemic in the Indonesian economy, society, and health. 2. REVIEW OF LITERATURE According to Budiono et al. (2020), a policy is "the intellectual task of decision making that includes the explanation of objectives, deliberation of trends, analysis of circumstances, projections of future development and research, assessment and research, and the evaluation and selection of potential outcomes." According to the opinion of Suparmi et al. (2019), "a policy is defined as an intellectual task of decision-making that includes a description of the tendency to select multiple goals that are appropriate to the situation, the development of the impact and performance of future policies, and the conduct of research and evaluation." According to Li et al. (2012) to comprehend the many definitions of public policy, several fundamental principles must be understood. According to Dartanto, Pramono, et al. (2020) "public policies are actions made and implemented by government agencies that represent legal, political, and financial authority". Wulandari et al. (2020) state that "public policy seeks to address problems or concrete needs that emerge in society". "Generally speaking, public policy is not a single decision, but rather a collection of actions or strategies chosen to achieve certain goals for the benefit of the people" (Hsu et al., 2015). According to Muhlis (2022), public policy is typically a communal effort to address societal issues. However, public policy can also be established based on the premise that the existing policy framework would resolve societal problems and, as a result, some activities are unnecessary. Moreover, "public policy contains a statement or justification for the formulated steps or action plans" (Sari et al., 2019). According to Laksono et al. (2021) "decisions that have been formulated in public policy can be made by a government agency or by several representatives of government institutions". Nasution et al. (2020a) classify the stages of public policy as "policy formation and design, policy implementation, and policy evaluation." In the meantime, Nasution et al. (2020b) state that "there are five stages in the policy process, namely problem identification, formulation, legitimacy, application, and evaluation." According to Fossati (2016) "there are five stages of the public policy process." Initially, Dartanto, Halimatussadiah, et al. (2020) stated, "identification of needs is to identify the needs of the community in development by following several criteria, including data analysis, sample analysis, statistical data, simulation models, causal analysis, and forecasting techniques." Muttaqien et al. (2021) also reported "formulation of policy proposals that include strategic factors, generic alternatives, technological stability, and environmental impact analysis." In addition, Laksono et al. (2023) claimed that "adoption involves political feasibility analysis, a combination of multiple political theories, and the application of unemployment techniques." Indeed, Barua et al. (2020) claimed that "implementation of the program includes organizational forms, scheduling model, elaboration of decisions, pricing decisions, and implementation scenarios." Similarly, Anggriani et al. (2020) observed that "evaluation utilizes experimental methods, information systems, auditing, and surprise evaluation." The NSSS is an Indonesian social security system established by Law No. 40 of 2004. (Dartanto, Halimatussadiah, et al., 2020). According to Dartanto, Pramono, et al. (2020), "this social security is a form of social protection organized by the Republic of Indonesia to ensure its citizens live a decent life and realize an independent, progressive, just, and prosperous Indonesian society." According to Muttaqien et al. (2021), article 34, paragraph 2 of the constitution of 1945 states, "The state shall develop a social security system for all people and empower the weak and incapable through human dignity." The following programs were implemented when the NSSS went into force on January 1, 2014: First, "health insurance is required to ensure that participants receive health care benefits and protection to meet their fundamental health needs." The second purpose of work accident insurance is to ensure that participants receive health care benefits and monetary compensation in the event of a workplace accident or occupational sickness. Thirdly, "old age insurance is maintained to ensure that participants receive cash upon retirement age, sustaining a total and permanent disability, or passing away." Fourthly, AgBioForum, 24(2), 2022 | 198 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … "pension insurance is provided to help participants maintain a decent standard of living when they lose or reduce their income due to retirement or total permanent disability." Fifthly, "death insurance is believed to provide death benefits paid to participants' heirs" 3 (three) principles, namely "the principle of humanity, the principle of benefit, and the principle of social justice for all Indonesian people," as well as 9 (nine) principles, namely: "cooperation, non-profit, openness, prudence, accountability, portability, mandatory participation, mandated funds, and the results of fund management," support the implementation of the NSSS. The "social security administering body for health" is a "public legal entity" created by the government to handle the NHI program for all Indonesian citizens. "The formation of health is based on Law No. 24 of 2011 regarding the mechanism or procedure for its implementation, which is governed by Ministerial Regulation No. 71 of 2013 on Health Services in the National Health Insurance" (Laksono et al., 2021). According to the 2016 BPJS report, around 70% of Indonesia's entire population, or approximately 172 million Indonesians, are enrolled in the "national health insurance system" (Yuniarti et al., 2019). The goal is to attain "universal health" insurance coverage by the end of 2019, when the whole population of Indonesia, estimated at that time to be 257.5 million people, has been registered as a participant in health insurance (Moeloek, 2017). The benefits package or guaranteed health services formulated in the SJSN Law is a guaranteed health service package that is by the principles of social insurance; guaranteed health services are to meet the basic health needs of each participant, and health insurance benefits are comprehensive individual services includes; promotive, preventative, curative, and rehabilitative services; the guarantee package must be adequate and beneficial to ensure the continuation of the program and its benefits; and the guarantee package must be sufficient and beneficial to ensure the continuity of the program and its benefits. The amount of contributions is the key to "sustainability, the quality of health insurance, the impact on new poverty, and increasing population productivity" (Barua et al., 2020). The NSSS Law has governed contributions to health insurance. The availability of high-quality health services at a reasonable distance is the second element to the successful implementation of the NHI. The Health Law stipulates that NHI will pay an agreed-upon amount for government-owned and privately-owned health institutions in a given area (Simon et al., 2017). This rule stipulates that payments must be based on economic pricing when private facilities can cover expenditures that vary by location. Figure 1 depicts the framework for the present study. H1: Health budget allocation has an impact on the implementation of the health insurance policy. H2: Drugs distribution policy has an impact on the implementation of the health insurance policy. H3: Funds for health workers have an impact on the implementation of the health insurance policy. H4: Public health attitude has an impact on the implementation of the health insurance policy. Figure 1: Research Model 3. Methodology This research is based on "quantitative data," as previous studies in this field also employed this methodology. This study used a "rating scale" questionnaire for data collection and analysis. In addition, Jacobs et al. (2010) adapt the scale for variable health budget allocation to quantify its impact on health insurance policy directly. Moreover, McGinty et al. (2020) have adapted the variable Health Budget Allocation Drugs Distribution Policy Health Insurance Policy Funds of Health Workers Public Health Attitude AgBioForum, 24(2), 2022 | 199 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … pharmaceuticals distribution policy scale to measure its impact on health insurance policy directly. Similarly, Mullei et al. (2010) modified the ranking for the variable finances of health workers to examine its direct effect on health insurance policy. In addition, Zanolin et al. (2007) updated the scale for the variable public health attitude to examine its direct impact on health insurance policy. Finally, Osungbade et al. (2014) are the source for the health insurance policy scale. These materials were sent to several university professors for "face validity." The government officials of the NHI department are the subjects of this study, which utilized a random sample technique to collect data. This research employs a "cross- sectional" methodology and collects data within a fixed time frame. In this study, the "unit of analysis" is the individual. This study's "sample size" is based on 399 responses gathered via "survey." In addition, "structural equation modeling" was employed for data analysis and findings of each hypothesis in this research. 1. Findings and Data Analysis This study's data analysis was conducted using "PLS Bootstrapping" and "PLS Algorithm" computations. For validity and reliability, the research relied on "Cronbach's alpha ()," "composite reliability (CR)," and "average variance extracted (AVE)." Shevlin et al. (1998) note, "Factor loading indicates how well an item represents the underlying construct, and it must be greater than 0.70." Tavakol et al. (2011) noted, "Cronbach's alpha ( > 0.70) is a measure of internal consistency, that is, the degree to which a group of items is connected. It is considered a measure of the trustworthiness of scales." Composite reliability (CR > 0.70) is a measure of internal consistency in scale items, similar to Cronbach's alpha, according to Raykov (1997). Alarcón et al. (2015) noted, "average variance extracted (AVE > 0.50) is a measure of the amount of variance captured by a measurement error variance construct." The significant "measurement model" results are shown in Table 1 and Figure 2. Figure 2. Reliability and Validity According to Alarcón et al. (2015), "discriminant validity tests whether concepts or measurements that are not intended to be related are unrelated." According to Ab Hamid et al. (2017), "cross-loading to establish discriminant validity at the item level means there is a high correlation between items of the same construct and a very weak correlation between items of different constructs." According to Ab Hamid et al. (2017), HTMT is a measure of the similarity between latent variables. According to Gold et al. (2001), "the HTMT threshold is debatable; the majority of publications recommend a value below 0.90." Cross-loadings' important values are shown in Table 2, and that values are presented in Table 3. 0 0.2 0.4 0.6 0.8 1 1.2 D D P 1 D D P 2 D D P 3 D D P 4 D D P 5 FH W 1 FH W 2 FH W 3 FH W 4 FH W 5 H B A 1 H B A 2 H B A 3 H B A 4 H B A 5 H B A 6 H IP 1 H IP 2 H IP 3 H IP 4 H IP 5 H IP 6 H IP 7 P H A 1 P H A 2 P H A 3 P H A 4 P H A 5 Drugs Distribution Policy Funds of Health Workers Health Budget Allocation Health Insurance Policy Public Health Attitude Reliability and Validity Factor Loadings Cronbach' Alpha CR AVE AgBioForum, 24(2), 2022 | 200 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … Table 1. Convergent Validity Constructs Items Factor Loadings Cronbach' Alpha CR AVE Drugs Distribution Policy DDP1 0.888 0.947 0.959 0.826 DDP2 0.891 DDP3 0.903 DDP4 0.935 DDP5 0.926 Funds of Health Workers FHW1 0.888 0.940 0.954 0.807 FHW2 0.907 FHW3 0.904 FHW4 0.902 FHW5 0.892 Health Budget Allocation HBA1 0.896 0.951 0.961 0.804 HBA2 0.902 HBA3 0.900 HBA4 0.882 HBA5 0.894 HBA6 0.906 Health Insurance Policy HIP1 0.905 0.955 0.963 0.789 HIP2 0.923 HIP3 0.914 HIP4 0.870 HIP5 0.878 HIP6 0.860 HIP7 0.865 Public Health Attitude PHA1 0.694 0.911 0.935 0.743 PHA2 0.878 PHA3 0.912 PHA4 0.903 PHA5 0.904 Table 2. Cross Loadings Drugs Distribution Policy Funds of Health Workers Health Budget Allocation Health Insurance Policy Public Health Attitude DDP1 0.888 0.815 0.865 0.605 0.665 DDP2 0.891 0.852 0.849 0.563 0.624 DDP3 0.903 0.884 0.847 0.608 0.652 DDP4 0.935 0.872 0.871 0.601 0.648 DDP5 0.926 0.856 0.844 0.613 0.655 FHW1 0.810 0.888 0.819 0.591 0.637 FHW2 0.850 0.907 0.820 0.547 0.599 FHW3 0.837 0.904 0.813 0.536 0.601 FHW4 0.890 0.902 0.862 0.604 0.646 FHW5 0.841 0.892 0.826 0.596 0.672 HBA1 0.831 0.835 0.896 0.692 0.728 HBA2 0.840 0.826 0.902 0.591 0.638 HBA3 0.840 0.835 0.900 0.593 0.636 HBA4 0.839 0.817 0.882 0.655 0.691 HBA5 0.847 0.831 0.894 0.638 0.693 HBA6 0.866 0.819 0.906 0.641 0.672 HIP1 0.632 0.607 0.659 0.905 0.828 HIP2 0.594 0.578 0.644 0.923 0.846 HIP3 0.628 0.595 0.687 0.914 0.860 HIP4 0.586 0.577 0.647 0.870 0.831 HIP5 0.551 0.540 0.583 0.878 0.809 HIP6 0.531 0.518 0.564 0.860 0.788 HIP7 0.567 0.570 0.626 0.865 0.818 PHA1 0.669 0.606 0.611 0.590 0.694 PHA2 0.579 0.557 0.608 0.821 0.878 PHA3 0.615 0.603 0.659 0.844 0.912 PHA4 0.573 0.568 0.622 0.851 0.903 PHA5 0.585 0.563 0.630 0.867 0.904 Table 3. HTMT Drugs Distribution Policy Funds of Health Workers Health Budget Allocation Health Insurance Policy Public Health Attitude Drugs Distribution Policy Funds of Health Workers 0.887 Health Budget Allocation 0.863 0.768 Health Insurance Policy 0.691 0.675 0.742 Public Health Attitude 0.792 0.784 0.771 0.791 AgBioForum, 24(2), 2022 | 201 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … The results of the "structural model" are utilized to path the outcomes "t > 1.96 and p< 0.05." This study determined that health budget allocation positively influences the execution of health policy, thereby confirming the first hypothesis. The current study found that drug distribution policy favorably influences the implementation of health policy, supporting the second hypothesis. Thirdly, a recent study determined that the funding of health workers has a favorable effect on the implementation of health policy, supporting the third hypothesis. The current research has determined that public health attitudes positively influence the execution of health policy, and the fourth hypothesis is also significant. The outcomes of important hypotheses are provided in Table 4. Figure 3. Structural Model Table 4. Path Results Original Sample Standard Deviation T Statistics P Values Health Budget Allocation -> Health Insurance Policy 0.158 0.078 2.015 0.044 Drugs Distribution Policy -> Health Insurance Policy 0.441 0.060 7.351 0.000 Funds of Health Workers -> Health Insurance Policy 0.113 0.028 4.035 0.000 Public Health Attitude -> Health Insurance Policy 0.920 0.029 32.066 0.000 4. Discussion The pandemic in numerous countries has forced the global economy into a recession that cannot be avoided. According to the World Bank, the impact of the Covid-19 pandemic will cause 92% of countries to enter a recession. According to the World Bank's World Economic Prospects study, the global economy will contract by 5.2% this year due to the COVID-19 epidemic (Laksono et al., 2021; Muhlis, 2022; Muttaqien et al., 2021). The worldwide recession was the worst since the Second World War, and the State of Indonesia, a country also afflicted by the Covid-19 outbreak, is undergoing a severe slump. "The compatibility between theory and policy implementation requires a strategy to develop a strategy via a professional grand design or map, increased coordination between the central and regional governments, and the establishment of appropriate economic policies, including budget allocations and priorities" (Osungbade et al., 2014). Establishing "laws and regulations as the basis of authority and a strong legal umbrella for the Government of Indonesia" is one of the Government of Indonesia's efforts to maintain the stability of its financial and economic sectors, as well as the security and safety of its citizens. Moreover, "the government's strategic response to abnormal situations is exceptional, with public health and safety receiving budgetary priority" (Barua et al., 2020; Laksono et al., 2021; Nasution et al., 2020a). The implementation of government-implemented programs in the health sector is examined in depth. The budget allocation for health care is approximately 87.73% or a total of 65.8 trillion rupiahs for health care spending, which includes "medical devices, reagents, ventilators, AgBioForum, 24(2), 2022 | 202 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … hand sanitizers, and health facilities and infrastructure, including upgrading 132 houses referral hospital for handling Covid-19 patients," including the largest hospital in Jakarta. 7.8 percent of the health staff budget, or 5.9 trillion rupiahs, is allocated to incentives for central and local media personnel: Regional medical staff totaling Rp4.6 trillion and central medical personnel amounting to Rp1.3 trillion; Incentives for physicians, general practitioners, nurses, and other health professionals. Contribution subsidies for tariff adjustments for Non- Wage Recipients and Non-Employees following Presidential Regulation No. 75 of 2019 get a budget allocation of 3% or a total of 3 trillion rupiahs. In addition, the government provides a centralized budget for the expense of treating Covid-19 patients, which the "Ministry of Health administers." The government is responsible for all maintenance costs according to regular handling fees. Standard treatment costs encompass a whole package, from physician fees to repatriating the patient's remains in the event of death. The funding for Covid-19 patients comes from the State and Regional Budgets for 2020. The government also provides tax incentives for commodities and services required to combat the Covid- 19 epidemic. In general, many nations, notably South Africa and Nigeria, have made modifications and revisions to budget allocations to combat the Covid-19 pandemic as a rapid governmental response to preserve public safety by suspending budgetary policy (Laksono et al., 2021; Muhlis, 2022; Sari et al., 2019). When reviewing budget allocations during the COVID-19 pandemic, it is essential to have a thorough grasp of the political and economic backdrop elements in allocating health insurance for all communities, which must be considered when increasing the national level. While technical considerations take a back seat to political priorities in building a structure for national health care, they must be addressed to achieve sustainable UHC in Indonesia in the future (Budiono et al., 2020; Li et al., 2012; Suparmi et al., 2019). It was thought important to survey the central and regional governments to acquire an accurate picture of "the effectiveness of the implementation of health regulations in the regions." (Aizawa, 2019; Anggriani et al., 2020; Simon et al., 2017). According to Laksono et al. (2023), "the role of the state in meeting the people's basic needs is extremely important, particularly in the form of comprehensive health services, because health is one of the human rights." Article 34 of the Constitution of 1945 declares that "the state shall establish a social security system for all citizens and empower the weak and incompetent with human dignity." In this context, "the state plays a role in improving the welfare of the people in the health sector by developing a social security system for the welfare of all people and increasing NHI premiums for participants, which are deemed unfeasible and burdensome to the community, particularly the poor who are currently affected by the Covid-19 pandemic" (Dartanto, Halimatussadiah, et al., 2020; Muttaqien et al., 2021). Mandatory Health Insurance coverage extends to the whole population of Indonesia, including foreign residents who have resided in the country for more than six months. Participants in the NHI are required to pay a predetermined amount, while the government must cover the cost for the impoverished and those who cannot afford to pay payments. The presidential regulation significantly impacts a person's ability to pay dues, hence affecting the viability of other programs (Laksono et al., 2023; Moeloek, 2017; Yuniarti et al., 2019). Indonesia still has opportunities to establish a fair and equitable health financing system that guarantees the poor are financially protected, despite the slowing progress of the overall health financing system from 2015-2019. (Anggriani et al., 2020; Barua et al., 2020; Erlangga et al., 2019). When the COVID-19 pandemic has shifted towards endemic, Indonesia must reflect on its existing payment system and move towards a more sustainable payment mechanism by integrating COVID-19 payments into the current national health insurance to make package payments more sustainable. This can be accomplished by formulating a comprehensive compensation package for COVID-19 (Aizawa, 2019; Budiono et al., 2020; Simon et al., 2017), including care services (Budiono et al., 2020; Li et al., 2012; Suparmi et al., 2019). The role of NHI with the Healthy Indonesia Card has contributed to boosting health insurance coverage for all of the poor, notwithstanding its impact on increasing government spending such that UHC aspirations can be met in 2024, as opposed to the 2030 SDGs target (Muhlis, 2022; Sari et al., 2019). Indeed, efforts must be made to increase the coverage of the Health Insurance Contribution Assistance (PBI-JK), which decreased in November and December 2021, by expanding health insurance coverage for all, utilizing informal figures through the word-of-mouth effect, and engaging influential community leaders in the region (Barua et al., 2020). High-quality health care in hospitals and health centers is a significant factor in expanding coverage, as it encourages individuals to obtain national health insurance. In addition, the availability of health workers at the public health center and physicians will influence the community's participation in health insurance, as there are primary health facilities in every subdistrict of Indonesia (Dartanto, Halimatussadiah, et al., 2020). Because they are frequently exposed to individuals afflicted with COVID-19, frontline healthcare staff who interact directly with COVID-19 patients face grave occupational health risks. Given the difficulty of the task and the high contagiousness of Covid-19, healthcare professionals cannot avoid the risk of exposure. During the pandemic, thousands of frontline healthcare workers have been infected with Covid-19. Even the number of healthcare personnel killed by Covid-19 has reached hundreds. When the incidence rate of the Covid-19 pandemic case in 2019-2020 reached 95.65%, the allotment of funds for health professionals rose. Inadequately designed AgBioForum, 24(2), 2022 | 203 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … incentives might hinder an organization's ability to accomplish its objectives. To ensure that Covid-19 health personnel have a positive work attitude and work ethic when providing services, the number of incentives offered and their implementation must be meticulously designed. The incentive system must be built on the principles of fairness and suitability because it can boost employee happiness and excitement for their work (Banerjee et al., 2019; Nasution et al., 2020a, 2020b). The government policy "Presidential Decree No. 11 of 2020 Concerning the Establishment of a Covid-2019 Public Health Emergency" and "Presidential Decree No. 12 of 2020 Concerning the Determination of Non-Natural Disasters Spreading Covid- 19 as a National Disaster" establish an emergency "due to the Covid-19 pandemic." The government also utilizes its constitutional authority when a Presidential decree is issued. Regarding the State Financial Policy and Financial System for Handling the Pandemic, the government has made "Article 22 of the 1945 Constitution the basis for issuing Government Regulation rather than Law Number 1 of 2020." The implementation of national health insurance policies during the Covid-19 pandemic must be based on the role of the state in meeting the safety and basic needs of the people in the form of comprehensive health services, given that health as a human right is mandated by Article 34 of the 1945 Constitution, which states that "the state develops a social security system for all the people and empowers the weak and disadvantaged by human dignity." 5. THEORETICAL AND PRACTICAL IMPLICATIONS Theoretically, this study significantly contributes to knowledge because the newly established associations have enriched the existing literature on NHI. In this approach, our study contributed to the literature by demonstrating that health budget allocation positively affects the implementation of health policy, hence advancing understanding of health policy implementation. Secondly, the current research contributes to the literature showing drug distribution policy favorably influences the execution of health policy, thereby expanding the knowledge of health policy implementation. Thirdly, this analysis contributed to the literature by demonstrating that finances for health workers have a favorable effect on the implementation of health policy, enhancing our understanding of the implementation of health policy. Lastly, the current research contributes to the literature showing public health attitudes favorably influence the implementation of health policy, which is in addition to the understanding of health policy implementation. This study concluded that the current Covid 19 pandemic would diminish the macroeconomic level, impact low- income people, reduce the ability to pay contributions, and result in arrears contributions, necessitating a selected policy for determining the NHI recipient program. Second, the research indicated that limiting the risk of supporting beneficiaries of health insurance contribution aid to the state's financial capability is crucial owing to the state budget's heavyweight during the pandemic to avert a deficit in the national budget. Thirdly, the Indonesian government must strengthen coordination and communication between all central and regional parties to oversee policy execution. In addition, the government must expand the role and responsibilities of the ministry of health so that it can handle COVID-19 more effectively and systematically by prioritizing an integrated and comprehensive public health approach to measure public health resilience. Lastly, the government must implement comprehensive reforms to the national health system and ensure Indonesia's readiness to face the threat of a pandemic and other health emergencies by bolstering the healthy paradigm through policy influence and public awareness of public health obligations and rights. 6. FUTURE DIRECTIONS During the Covid-19 epidemic, the development of national health insurance policies must be founded on the state's responsibility to meet the people's safety and fundamental needs through comprehensive health care. The research is new to the academic literature, and its findings establish a novel relationship. The study has theoretical and practical implications for enhancing Indonesia's health care. The recommended future directions for this research are reasonable for contributing significantly to future research. However, proposals for additional research are analyzing the social security administration's policy implementation of the NHI. Future research could examine the moderating effect of budgetary transparency on implementing NHI in Indonesia. Future research may also investigate the mediating effect of government oversight on the distribution of health budget funds and the implementation of NHI in Indonesia. In addition, future research may examine the moderating effect of health budget donations on health budget allocation and the implementation of NHI in Indonesia. Similarly, future research may examine the direct connection between transparency, emergency health insurance, and health services and the implementation of NHI in Indonesia. REFERENCES Ab Hamid, M., Sami, W., & Sidek, M. M. (2017). Discriminant validity assessment: Use of Fornell & Larcker criterion versus HTMT criterion. Paper presented at the Journal of Physics: Conference Series: IOP Publishing 890(1), 012163. doi: https://doi.org/10.1088/1742- 6596/890/1/012163 Aizawa, T. (2019). The impact of health insurance on out- of-pocket expenditure on delivery in Indonesia. Health Care for Women International, 40(12), 1374-1395. doi: https://doi.org/10.1080/07399332.2019.1578778 Alarcón, D., Sánchez, J. A., & De Olavide, U. (2015). Assessing convergent and discriminant validity in the ADHD-R IV rating scale: User-written commands for Average Variance Extracted https://doi.org/10.1088/1742-6596/890/1/012163 https://doi.org/10.1088/1742-6596/890/1/012163 https://doi.org/10.1080/07399332.2019.1578778 AgBioForum, 24(2), 2022 | 204 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … (AVE), Composite Reliability (CR), and Heterotrait-Monotrait ratio of correlations (HTMT). Paper presented at the Spanish STATA meeting 39. Retrieved from https://www.guiyastudio.com/meeting/spain15/a bstracts/materials/spain15_alarcon.pdf Anggriani, Y., Ramadaniati, H. U., Sarnianto, P., Pontoan, J., & Suryawati, S. (2020). The impact of pharmaceutical policies on medicine procurement pricing in Indonesia under the implementation of Indonesia’s social health insurance system. Value in Health Regional Issues, 21, 1-8. doi: https://doi.org/10.1016/j.vhri.2019.05.005 Banerjee, A., Finkelstein, A., Hanna, R., Olken, B. A., Ornaghi, A., & Sumarto, S. (2019). The challenges of universal health insurance in developing countries: Evidence from a large- scale randomized experiment in Indonesia. Retrieved from doi:https://doi.org/10.3386/w26204. Barua, P., & Narattharaksa, K. (2020). The impact of the stateless health insurance scheme on inpatient service utilization of stateless children at the four selected district hospitals in Tak Province, Thailand. The International Journal of Health Planning and Management, 35(1), e12-e27. doi: https://doi.org/10.1002/hpm.2913 Budiono, A., Absori, A., Harun, H., Nugroho, H. S. W., Dimyati, K., & Wardiono, K. (2020). The ideal management of health insurance for Indonesia according constitution. Quality Access to Success, 21(176), 48-50. Retrieved from http://repo.poltekkesdepkes- sby.ac.id/id/eprint/2399 Dartanto, T., Halimatussadiah, A., Rezki, J. F., et al. (2020). Why do informal sector workers not pay the premium regularly? Evidence from the National health insurance system in Indonesia. Applied Health Economics and Health Policy, 18(1), 81-96. doi: https://doi.org/10.1007/s40258-019-00518-y Dartanto, T., Pramono, W., Lumbanraja, A. U., Siregar, C. H., Bintara, H., & Sholihah, N. K. (2020). Enrolment of informal sector workers in the National Health Insurance System in Indonesia: A qualitative study. Heliyon, 6(11), e05316. doi: https://doi.org/10.1016/j.heliyon.2020.e05316 Erlangga, D., Ali, S., & Bloor, K. (2019). The impact of public health insurance on healthcare utilisation in Indonesia: evidence from panel data. International Journal of Public Health, 64(4), 603-613. doi: https://doi.org/10.1007/s00038- 019-01215-2 Fossati, D. (2016). Beyond “Good Governance”: The multi-level politics of health insurance for the poor in Indonesia. World Development, 87, 291- 306. doi: https://doi.org/10.1016/j.worlddev.2016.06.020 Gold, A. H., Malhotra, A., & Segars, A. H. (2001). Knowledge management: An organizational capabilities perspective. Journal of Management Information Systems, 18(1), 185-214. doi: https://doi.org/10.1080/07421222.2001.1104566 9 Hsu, M., Huang, X., & Yupho, S. (2015). The development of universal health insurance coverage in Thailand: Challenges of population aging and informal economy. Social Science & Medicine, 145, 227-236. doi: https://doi.org/10.1016/j.socscimed.2015.09.036 Jacobs, J. A., Dodson, E. A., Baker, E. A., Deshpande, A. D., & Brownson, R. C. (2010). Barriers to evidence-based decision making in public health: a national survey of chronic disease practitioners. Public Health Reports, 125(5), 736-742. doi: https://doi.org/10.1177/003335491012500516 Laksono, A. D., Nugraheni, W. P., Ipa, M., Rohmah, N., & Wulandari, R. D. (2023). The Role of Government-run Insurance in Primary Health Care Utilization: A Cross-Sectional Study in Papua Region, Indonesia, in 2018. International Journal of Social Determinants of Health and Health Services, 53(1), 85-93. doi: https://doi.org/10.1177/00207314221129055 Laksono, A. D., Wulandari, R. D., & Matahari, R. (2021). The determinant of health insurance ownership among pregnant women in Indonesia. BMC Public Health, 21(1), 1-7. doi: https://doi.org/10.1186/s12889-021-11577-z Li, Y., Wu, Q., Xu, L., et al. (2012). Factors affecting catastrophic health expenditure and impoverishment from medical expenses in China: policy implications of universal health insurance. Bulletin of the World Health Organization, 90, 664-671. doi: https://doi.org/10.2471/BLT.12.102178 McGinty, E. E., Stone, E. M., Kennedy-Hendricks, A., Bachhuber, M. A., & Barry, C. L. (2020). Medication for opioid use disorder: a national survey of primary care physicians. Annals of Internal Medicine, 173(2), 160-162. doi: https://doi.org/10.7326/M19-3975 Moeloek, N. F. (2017). Indonesia national health policy in the transition of disease burden and health insurance coverage. Medical Journal of Indonesia, 26(1), 3-6. Retrieved from http://mji.ui.ac.id Muhlis, A. N. A. (2022). Determinants Of The National Health Insurance Uptake In Indonesia. Indonesian Journal of Health Administration, 10(2), 11. doi: https://doi.org/10.20473/jaki.v10i1.2022.111- 121 Mullei, K., Mudhune, S., Wafula, J., et al. (2010). Attracting and retaining health workers in rural areas: investigating nurses’ views on rural posts and policy interventions. BMC Health Services Research, 10(1), 1-10. doi: https://doi.org/10.1186/1472-6963-10-S1-S1 https://www.guiyastudio.com/meeting/spain15/abstracts/materials/spain15_alarcon.pdf https://www.guiyastudio.com/meeting/spain15/abstracts/materials/spain15_alarcon.pdf https://doi.org/10.1016/j.vhri.2019.05.005 https://doi.org/10.3386/w26204 https://doi.org/10.1002/hpm.2913 http://repo.poltekkesdepkes-sby.ac.id/id/eprint/2399 http://repo.poltekkesdepkes-sby.ac.id/id/eprint/2399 https://doi.org/10.1007/s40258-019-00518-y https://doi.org/10.1016/j.heliyon.2020.e05316 https://doi.org/10.1007/s00038-019-01215-2 https://doi.org/10.1007/s00038-019-01215-2 https://doi.org/10.1016/j.worlddev.2016.06.020 https://doi.org/10.1080/07421222.2001.11045669 https://doi.org/10.1080/07421222.2001.11045669 https://doi.org/10.1016/j.socscimed.2015.09.036 https://doi.org/10.1177/003335491012500516 https://doi.org/10.1177/00207314221129055 https://doi.org/10.1186/s12889-021-11577-z https://doi.org/10.2471/BLT.12.102178 https://doi.org/10.7326/M19-3975 http://mji.ui.ac.id/ https://doi.org/10.20473/jaki.v10i1.2022.111-121 https://doi.org/10.20473/jaki.v10i1.2022.111-121 https://doi.org/10.1186/1472-6963-10-S1-S1 AgBioForum, 24(2), 2022 | 205 Haryono, Sadiq, Hakim and Hanafi. — Implementation of National Health Insurance Policy Through the Social Security … Muttaqien, M., Setiyaningsih, H., Aristianti, V., et al. (2021). Why did informal sector workers stop paying for health insurance in Indonesia? Exploring enrollees’ ability and willingness to pay. PLOS ONE, 16(6), e0252708. doi: https://doi.org/10.1371/journal.pone.0252708 Nasution, S. K., Mahendradhata, Y., & Trisnantoro, L. (2020a). Can a national health insurance policy increase equity in the utilization of skilled birth attendants in Indonesia? A secondary analysis of the 2012 to 2016 national socio-economic survey of Indonesia. Asia Pacific Journal of Public Health, 32(1), 19-26. doi: https://doi.org/10.1177/1010539519892394 Nasution, S. K., Mahendradhata, Y., & Trisnantoro, L. (2020b). Changes in Determinants and Equity of Family Planning Utilization after the Implementation of a National Health Insurance Policy in Indonesia: A Secondary Analysis of The 2012-2016 National Socio-Economic Survey of Indonesia. 1-20. doi: https://doi.org/10.21203/rs.2.11463/v3 Osungbade, K. O., Obembe, T. A., & Oludoyi, A. (2014). Users’ satisfaction with services provided under National Health Insurance Scheme in south western Nigeria. Int J Trop Dis Health, 4(5), 595- 607. doi: https://doi.org/10.9734/IJTDH%2F2014%2F728 0 Raykov, T. (1997). Estimation of composite reliability for congeneric measures. Applied Psychological Measurement, 21(2), 173-184. doi: https://doi.org/10.1177/01466216970212006 Sari, B., & Idris, H. (2019). Determinant of independent national health insurance ownership in Indonesia. Malaysian Journal of Public Health Medicine, 19(2), 109-115. doi: https://doi.org/10.37268/mjphm/vol.19/no.2/art. 177 Shevlin, M., & Miles, J. N. (1998). Effects of sample size, model specification and factor loadings on the GFI in confirmatory factor analysis. Personality and Individual Differences, 25(1), 85-90. doi: https://doi.org/10.1016/S0191-8869(98)00055-5 Simon, K., Soni, A., & Cawley, J. (2017). The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. Journal of Policy Analysis and Management, 36(2), 390-417. doi: https://doi.org/10.1002/pam.21972 Suparmi, M. I., & Lestari, H. (2019). Health insurance as a solution for barriers to maternal healthcare access in Indonesia. Indonesia, 2-5. Retrieved from http://www.healthpolicyplus.com/ns/pubs/17359 -17647_PBHealthInsurance.pdf Tavakol, M., & Dennick, R. (2011). Making sense of Cronbach's alpha. International Journal of Medical Education, 2, 53. doi: https://doi.org/10.5116%2Fijme.4dfb.8dfd Wulandari, R., Laksono, A., & Matahari, R. (2020). The effects of health insurance on maternity Care in Health Services in Indonesia. Int J Innov Creat Chang, 14(2), 478-497. Retrieved from https://www.researchgate.net/profile/Agung- Laksono-2/publication/343850454 Yuniarti, E., Prabandari, Y. S., Kristin, E., & Suryawati, S. (2019). Rationing for medicines by health care providers in Indonesia National Health Insurance System at hospital setting: a qualitative study. Journal of Pharmaceutical Policy and Practice, 12(1), 1-11. doi: https://doi.org/10.1186/s40545- 019-0170-5 Zanolin, M. E., Visentin, M., Trentin, L., Saiani, L., Brugnolli, A., & Grassi, M. (2007). A questionnaire to evaluate the knowledge and attitudes of health care providers on pain. Journal of Pain and Symptom Management, 33(6), 727- 736. doi: https://doi.org/10.1016/j.jpainsymman.2006.09.0 32 https://doi.org/10.1371/journal.pone.0252708 https://doi.org/10.1177/1010539519892394 https://doi.org/10.21203/rs.2.11463/v3 https://doi.org/10.9734/IJTDH%2F2014%2F7280 https://doi.org/10.9734/IJTDH%2F2014%2F7280 https://doi.org/10.1177/01466216970212006 https://doi.org/10.37268/mjphm/vol.19/no.2/art.177 https://doi.org/10.37268/mjphm/vol.19/no.2/art.177 https://doi.org/10.1016/S0191-8869(98)00055-5 https://doi.org/10.1002/pam.21972 http://www.healthpolicyplus.com/ns/pubs/17359-17647_PBHealthInsurance.pdf http://www.healthpolicyplus.com/ns/pubs/17359-17647_PBHealthInsurance.pdf https://doi.org/10.5116%2Fijme.4dfb.8dfd https://www.researchgate.net/profile/Agung-Laksono-2/publication/343850454 https://www.researchgate.net/profile/Agung-Laksono-2/publication/343850454 https://doi.org/10.1186/s40545-019-0170-5 https://doi.org/10.1186/s40545-019-0170-5 https://doi.org/10.1016/j.jpainsymman.2006.09.032 https://doi.org/10.1016/j.jpainsymman.2006.09.032