Developing Indonesia’s Universal Health Coverage System

Introduction: The Government of Indonesia has been promoting increased and wider access to publicly funded healthcare as a priority and has been committed to achieving universal health coverage (UHC) or known as Jaminan Kesehatan Nasional (JKN), whereby the entire population is covered under a single public health insurance scheme by 2019. This system was launched on 1st January 2014 and is managed by BPJS Kesehatan (a legal public institution). Even though UHC is one important priority, many countries including Indonesia are still struggling to implement this ambition (BPJS Kesehatan, 2014). There are a number of issues and challenges, such as how to ensure that all sectors are covered programme given that Indonesia is the fourth most populous country in the world with a total population of 269.54 million in 2019 (World Population Review, 2019). Even so, Indonesia has a long history of developing a social health insurance system from 1968 up until the declaration of the ambition by the Government of Indonesia on 1st January 2014 for UHC or JKN.

Objectives: This study will examine how to achieve successful implementation, what the impact of UHC is, how to establish effective regulation, and what targets are necessary and appropriate to achieve successful implementation of UHC.

Method: This study represents a qualitative research using thematic analysis, entailing in-depth interviews and focus group discussions. The study was undertaken in Jakarta and Yogyakarta provinces. The respondents in this study have been chosen by Stratified Purposeful Sampling. The subjects include the key stakeholders, i.e. members of Health Financing and Health Insurance of the Ministry of Health (MoH), Directorate General of Social Protection and Social Insurance of the Ministry of Social (Welfare), National Security Council (DJSN) and BPJS Kesehatan in addition to the health providers from primary health centres, district, public and private hospitals in Yogyakarta who are knowledgeable about social health insurance schemes and regulations.

Results: The updated data from BPJS Kesehatan on 1st January 2019 shows that the total population covered under JKN is 215.784.340, such that approximately 53.755.660 (that is, 19%) of the population are yet to be covered by UHC. Of those people covered under Indonesian UHC, most are covered by the public subsidised systems of the State Budget (APBN) and Regional Budget (APBD) systems which amount to 44.78% (BPJS Kesehatan, 2019) of the population.

Examination of the level of coverage of low-income people data, whose premium is covered by the government, needs to be undertaken to ensure that it effective coverage is achieved. This study reveals that synchronisation of premium and healthcare package needs to be re-examined, particularly for those people working in the informal sector and, therefore, without a permanent income.
From a health service provider standpoint, respondents from Primary Health Centres (Puskesmas) noted a lack of community awareness to participation in the JKN programme. Communities do not have a sufficiently good understanding of the referral system and, hence, would rather access health service in a hospital directly even though the care can actually be undertaken at the primary level.

Conclusion: The findings in this study conclude that better implementation and synchronisation is needed of the new system’s regulations by key stakeholders, such as the Ministry of Health, the Board of National Security (DJSN), BPJS Kesehatan and the Ministry of Social Welfare. Communication and coordination are vital components required by related stakeholders at a central level in making decisions or issuing regulations.

Even so, Indonesian society plays a crucial role in supporting the success of UHC, in particular the willingness to participate in the JKN programme, as well as the awareness of their rights and responsibilities.

Keywords: Universal Health Coverage, National Health Insurance, Jaminan Kesehatan
Nasional (JKN)