Indonesia's success in achieving 90 percent coverage and minimizing out-of-pocket expenses through national health insurance expansion

Indonesia

Photo: WHO/Andi Gultom. Dr Mohammad Yassin checking the data in Adam Malik’s TB laboratory in Rumah Sakit Umum Pusat Provincial Hospital.

National health insurance expansion

In 2014, Indonesia faced a critical healthcare crisis: less than half its population was financially protected, out-of-pocket spending was high, comprising 45 percent of the current health expenditure [1], rendering healthcare unaffordable for many, and worsening health disparities. To address this, the Government of Indonesia launched the National Health Insurance, Jaminan Kesehatan Nasional (JKN), scheme to achieve universal healthcare coverage (UHC). WHO’s technical expertise was invaluable in integrating international best practices into the scheme’s framework. The JKN scheme saw remarkable expansion over short span of time, covering over 260 million people, or more than 95 percent of the population [2], by December 2023. This transformed Indonesia's healthcare landscape, reducing financial barriers to healthcare, and lowering out-of-pocket expenses to 27.5 percent of current health expenditure [3]. Furthermore, catastrophic health expenditure rates dropped from 4.5 percent in 2017 to 2 percent in 2021 [4], easing the healthcare financial burden on households. To build on these accomplishments, in 2022 and 2023 WHO launched several initiatives focusing on research knowledge exchange, aiming to generate strategic solutions to Indonesia's evolving healthcare needs (as described below). These initiatives align with the objectives outlined in SDG 3.8.2, focusing on mitigating catastrophic health expenditure, and addressing the impact of out-of-pocket health spending that contributes to poverty.

Key WHO Contributions

Offered ongoing technical advice for JKN improvement focused on achieving Universal Health Coverage.
Assisted in calculating national health expenditures in line with global standards and conducting research for mid-term planning, including a comprehensive background study on JKN in 2023.
Facilitated the exchange of country experiences for strategic purchasing and is conducting an in-depth political health economy analysis to inform Indonesia's future healthcare planning.

“Indonesia's journey in the healthcare sector, particularly through the implementation of the National Health Insurance (JKN) scheme, exemplifies a commitment to achieving improved health outcomes. The goal is to ensure that investments translate effectively into enhanced healthcare access and quality for all citizens.”

Dr Yuli Farianti, Former Director of Centre of Health Financing and Decentralization Policy, Ministry of Health

How did Indonesia, with the support of WHO, achieve this?

By 2020, Indonesia had made progress in reducing financial hurdles to healthcare access. However, the country continued to face notable health challenges. These included inequitable healthcare access in resource-constrained areas, high maternal mortality rates [5] and a considerable tuberculosis (TB) burden, with Indonesia ranking third globally in TB case numbers.[6] Furthermore, Indonesia grappled with child stunting, which was prevalent in 21.6 percent of children in 2022.[7][8]

To better understand ongoing health challenges, WHO Indonesia provided technical expertise on a comprehensive research project to examine the JKN scheme, emphasizing healthcare access, service quality, and financing. The research adopted a mixed-method, sequential, exploratory approach. It started with a review of existing documents, progressed to analyzing secondary data focusing on service utilization, financial protection, and equity, and concluded with qualitative data collection, including stakeholder meetings for more in-depth understanding of the JKN scheme's influence. This research significantly contributed to shaping Indonesia’s National Medium-Term Strategic Plan and enabled WHO Indonesia to provide evidence-based technical advice based on the national health expenditure calculations for 2022-2023.

^{Patients waiting to register at Christina Marta Tiahahu Primary Health Centre in Ambon Citu, Maluku, Indonesia.}Photo credit: WHO/Nyimas Laula.

WHO Indonesia together with the Regional Office proactively hosted webinars to promote the sharing of information and experiences with other nations regarding strategic healthcare purchasing. Furthermore, a team comprising experts from WHO's Country Office, Regional Office, and headquarters conducted a thorough political health economy analysis. This retrospective assessment focused on Indonesia's health economic reforms, identifying areas requiring improvement. Looking ahead, WHO plans to undertake a forward-looking analysis aimed at developing strategic solutions and formulating recommendations tailored to Indonesia's healthcare needs.

“While the National Health Insurance (JKN) scheme has significantly increased health insurance coverage in Indonesia, reaching over 90 percent of the population, it is important to recognize that mere participation in this program does not automatically fulfill the broader objective of Universal Health Coverage (UHC). The JKN represents just one aspect of the comprehensive endeavor required to realize UHC in Indonesia. Achieving UHC will necessitate addressing underlying challenges such as disparities in healthcare access, especially in resource-limited areas, and ensuring that all segments of the population benefit from the healthcare system.”

-Dr Yuli Farianti, Former Director of Centre of Health Financing and Decentralization Policy, Ministry of Health

The initiatives undertaken by WHO have supported Indonesia in alleviating financial challenges related to healthcare, moving towards equal access to healthcare for all its citizens. However, substantial efforts are still required to guarantee that quality healthcare is accessible to all.

References

Tim Nasional Percepatan Penanggulangan Kemiskinan. Sekretariat Wakil Presiden Republic Indonesia (National Team for the Acceleration of Poverty Reduction. Secretariat of the Vice President of the Republic of Indonesia). The impact of Indonesia’s rapid move towards Universal Health Insurance on Total Health Care Expenditure [report]. The impact of Indonesia’s rapid move towards Universal Health Insurance, accessed 16 February 2024.
Dewan Jaminan Sosial Nasional Sistem Monitoring Terpadu - Indonesia National Social Security Council Integrated Monitoring System [web portal]. Indonesia National Social Security Council Integrated Monitoring System, accessed 20 February 2024.
World Health Organization. Health Systems Governance and Financing. WHO Health Financing Dashboard (Indonesia, Universal Health Coverage) [web portal]. WHO Health Financing Dashboard (Indonesia, Universal Health Coverage), accessed 16 February 2024.
World Health Organization. Health Systems Governance and Financing. WHO Health Financing Dashboard (Indonesia, Universal Health Coverage) [web portal]. WHO Health Financing Dashboard (Indonesia, Universal Health Coverage), accessed 16 February 2024.
World Health Organization. Trends in maternal mortality 2000 to 2020. Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division [publication]. Trends in maternal mortality 2000 to 2020, accessed 16 February 2024.
World Health Organization. Global tuberculosis report 2022 [report]. Global tuberculosis report 2022, accessed 16 February 2024.
Ministry of Health, Republic of Indonesia. The Indonesian Nutrition Status Survey (SSGI) 2022 [presentation in Bahasa Indonesia]. The Indonesian Nutrition Status Survey (SSGI) 2022, accessed 16 February 2024.
Indonesian Academy of Food and Nutrition. Indonesian Academy of Sciences. Transforming the food system through reinforcing local food diversity for public health resilience and excellent generation of Indonesia [policy brief]. Transforming the food system through reinforcing local food diversity, accessed 16 February 2024.
Indonesian Academy of Food and Nutrition. Indonesian Academy of Sciences. Transforming the food system through reinforcing local food diversity for public health resilience and excellent generation of Indonesia [policy brief]. Transforming the food system through reinforcing local food diversity, accessed 16 February 2024.