Elsevier

The Lancet

Volume 393, Issue 10166, 5–11 January 2019, Pages 75-102
The Lancet

Review
Universal health coverage in Indonesia: concept, progress, and challenges

https://doi.org/10.1016/S0140-6736(18)31647-7Get rights and content

Summary

Indonesia is a rapidly growing middle-income country with 262 million inhabitants from more than 300 ethnic and 730 language groups spread over 17 744 islands, and presents unique challenges for health systems and universal health coverage (UHC). From 1960 to 2001, the centralised health system of Indonesia made gains as medical care infrastructure grew from virtually no primary health centres to 20 900 centres. Life expectancy improved from 48 to 69 years, infant mortality decreased from 76 deaths per 1000 livebirths to 23 per 1000, and the total fertility rate decreased from 5·61 to 2·11. However, gains across the country were starkly uneven with major health gaps, such as the stagnant maternal mortality of around 300 deaths per 100 000 livebirths, and minimal change in neonatal mortality. The centralised one size fits all approach did not address the complexity and diversity in population density and dispersion across islands, diets, diseases, local living styles, health beliefs, human development, and community participation. Decentralisation of governance to 354 districts in 2001, and currently 514 districts, further increased health system heterogeneity and exacerbated equity gaps. The novel UHC system introduced in 2014 focused on accommodating diversity with flexible and adaptive implementation features and quick evidence-driven decisions based on changing needs. The UHC system grew rapidly and covers 203 million people, the largest single-payer scheme in the world, and has improved health equity and service access. With early success, challenges have emerged, such as the so-called missing-middle group, a term used to designate the smaller number of people who have enrolled in UHC in wealth quintiles Q2–Q3 than in other quintiles, and the low UHC coverage of children from birth to age 4 years. Moreover, high costs for non-communicable diseases warrant new features for prevention and promotion of healthy lifestyles, and investment in a robust integrated digital health-information system for front-line health workers is crucial for impact and sustainability. This Review describes the innovative UHC initiative of Indonesia along with the future roadmap required to meet sustainable development goals by 2030.

Introduction

Indonesia is a middle-income country with 262 million inhabitants spread over 17 744 islands. Over the past decade, its gross domestic product (GDP) grew 5·6% per year. The country also achieved a Gini coefficient of 0·395 and a human development index (HDI) of 0·694, placing it in the upper ranks of countries with a medium human development index, and among the best performers in the Asia Pacific region.1 However, socioeconomic conditions vary widely across the country, and internal migration and urbanisation are high. Health indicators reveal a high burden with high maternal mortality (359 deaths per 100 000 livebirths), childhood stunting (31% in children younger than 5 years), tuberculosis (1 million new cases per year), a steep rise in obesity from 10% in 2007 to 21% in 2016, and a rise in non-communicable diseases, including a 63% increase in the number of diabetes cases since 2005. Moreover, because of substantial variations in disease burden by wealth quintile and in rural versus urban residence, and because of a fragmented health financing and insurance system, by 2013, 121 million people (47% of the population) did not have access to adequate health care. A universal health coverage (UHC) scheme that was adaptable and could accommodate these diverse needs and conditions, assure financial risk protection, and assure access to safe, affordable, and effective health care for all as mandated by the sustainable development goals (SDGs) was needed.2, 3, 4 In response, by 2014, the Government of Indonesia launched a comprehensive UHC programme called the National Health Insurance System (NHIS; or Jaminan Kesehatan Nasional)—a single-payer UHC system. With 203 million members in October, 2018, the Indonesian NHIS is the largest single-payer system in the world, and by 2017 was already managing 223·4 million consultations for both primary and advanced treatments, amounting to US$20·15 billion (US$ purchasing power parity [PPP]; PPP allows the comparison of price or value between countries with different currencies) in services provided (table 1).

The Government of Indonesia initiated UHC planning as early as 2002, when the constitution was amended to ensure social security.9 The NHIS was created by merging multiple fragmented health insurance and social assistance schemes into a single public entity named the Social Security Agency for Health (SSAH; or Badan Penyelenggara Jaminan Sosial Kesehatan [BPJS]). The SSAH has several unique features, including standards for staff performance and expertise, coverage goals and health objectives, and payment systems.

Key messages

  • Special attributes of Indonesia that are relevant to a universal health-care (UHC) system:

    • 262 million inhabitants with more than 300 ethnic groups and 730 languages spread over 17 744 islands

    • Gross domestic product grew at 5·6% per year with disparities yielding a Gini coefficient of 0·395

  • UHC must meet national health system requirements and decentralised implementation at the district level

  • A combination of factors comprises the unique approach to the UHC system:

    • Operated by a single quasi-government entity

    • Pays primary care providers using a prospective payment of capitation, and payment based on case-based groups for secondary providers

    • The Ministry of Health determines the standard of care, treatment, and referral to ensure primary care provider capability and service are standardised

    • The system designates the primary care provider as the entry point for UHC and the referral channel for specialised care

    • Involvement of private sector providers is encouraged to broaden care availability

  • Accomplishments of the Indonesian UHC system:

    • The largest single-payer system in the world

    • Improved coverage and use of services

    • Improved efficiencies of service delivery

    • Reduction of service fees

  • Public health system challenges remain, such as high stunted growth in children and high maternal and neonatal deaths

  • Improvements are needed to reduce the UHC coverage gaps between wealth quintiles Q2 to Q4, and among informal sector workers and children younger than 4 years

  • A robust and dynamic information system for front-line health workers is needed to continually guide system improvements, which will support:

    • The need to actively track UHC coverage and advocate UHC benefits to ensure higher participation

    • Improved efficacy and efficiency of service delivery

  • UHC needs to invest and provide incentives for a healthy lifestyle to reduce the risk of becoming ill, especially for chronic diseases. Investments are warranted for maternal care, sanitation, early childhood development, reduction in smoking, healthy and sustainable eating, and increasing physical activity

  • A policy framework for healthier environments and habits is needed for disease prevention and health promotion

In its first 4 years, NHIS coverage reached nearly 70% of the population, with the average number of outpatient and inpatient claims (which are different from the number of consultations) increasing from 25·5 million in 2014 to 56·9 million in 2016.10 The prospective capitation payment for primary care providers and structured referral systems were means to improve efficiency and effectiveness in service delivery and access to health services across regions and income groups. However, challenges remain, such as inadequate numbers and quality of primary care facilities, insufficient availability of specific drugs and medical supplies, mistargeting of low-income and middle-income groups, issues of misconduct, and poor health information systems. In addition, financial sustainability needs to be addressed to accelerate roll-out of NHIS, and to enhance compliance for on-time salary contributions, a major source of financing.

In this Review, we explore the achievements, gaps, and opportunities for NHIS to expand population coverage and equity, ensure quality of care, and enhance its impact on population health. We discuss the importance of innovative frontline digital health-information systems, and how these systems can enhance efficiencies and guide solutions. Given the future needs and projections, especially with regards to the management of non-communicable diseases, we propose a way forward for a sustainable UHC and a healthy society supported by universal risk coverage (URC) and universal cause coverage (UCC) that include capitation payments and policy reforms that support a workforce to promote healthy lifestyles. Finally, we define the gaps in knowledge that need to be addressed to develop an ideal UHC, URC, UCC, and health promotion system. The specific evidence-based lessons could help improve coverage and impact of UHC in sustainable and adaptive ways to create a resilient system. Such knowledge is especially timely, because countries are planning new programmes to pursue the overall integrated approach of the SDGs.

Section snippets

Indonesia: key facts

Indonesia is an archipelago of 17 744 islands dispersed over an area of 5000 km from east to west and 3500 km from north to south, located between the Pacific and Indian Oceans, and linking mainland Asia with the Pacific islands. In total land area, Indonesia ranks 14th in the world with 1·8 million km2, and hosts an enormous range of ethnic, linguistic, cultural, genetic, dietary, geographical, and natural diversity. Bahasa Indonesia is the lingua franca spoken throughout the country; however,

Human resources for health

Decentralisation in governance from the national to district level in 2001 gave districts the autonomy to prioritise sectors for development. Unfortunately, health and its human resource needs have received uneven attention, low funding, and few incentives for equity. From 2004 to 2015, the health worker to population ratio increased slightly or remained static, with 16 physicians, five dentists, 88 nurses, and 44 midwives being deployed per 100 000 people, considerably less than 50% of the

Evolution of the Indonesian NHIS

The design of Indonesia's national system required careful consideration of the diverse health and social conditions. The goal was to create a system that accommodated and adapted to highly variable and heterogeneous conditions, and that enabled health-care reach and impact that was not possible under previous one-size-fits-all systems. This novel perspective recognised the need for a resilient UHC despite rapidly changing conditions of health, development, and unanticipated events such as

Lessons learned

The NHIS aims to improve health-care access for all by creating an adaptive system that accommodates the diversity of Indonesia both now and in the future. The goals of the NHIS include reducing inequity and preventing households from going bankrupt because of severe illness. In addition, by mobilising funds from mandatory contributions, health financing in Indonesia is expected to increase substantially. Although the population coverage and spending by the NHIS increased greatly,66 the

Future directions

The planning and roll-out of the NHIS was driven by provision of curative care and a desire to create a flexible yet accountable health insurance system at scale that would link efficiently with the heterogeneous conditions and resources of the country. As such, efforts focused on adapting to a diverse environment of public and private providers and establishing an infrastructure to administer the NHIS, such as creating and updating the CBGs and drug and supply procurement processes. Clearly,

Summary and conclusions

Indonesia is a rapidly transforming and diverse society that presents unique challenges for health systems and UHC. An initially centralised system improved infrastructure and reduced the mortality rate for children younger than 5 years along with the infant mortality rate, and increased life expectancy. But gains across the country and socioeconomic groups were uneven. Moreover, the maternal mortality rate and neonatal mortality rate remained stagnant, and despite early progress in family

Search strategy and selection criteria

Data for this Review were identified through searches in MEDLINE and PubMed and through references from relevant articles, governmental and non-governmental reports, and databases highlighted by experts from many different sources, such as the Indonesia Demographic and Health Survey, Indonesian Family Life Survey, Social Security Agency for Health, Basic Health Research Survey (RISKESDAS), and Central Agency on Statistics. The National Institute of Health Research and Development confirmed

References (125)

  • Program management and financial report year 2015

  • Program management and financial report year 2016

  • Program management and financial report year 2017

  • Indonesia: implementation of the national social security system law

  • Program management and finance report year 2016

  • P Bellwood

    Prehistory of the Indo-Malaysian archipelago

    (2007)
  • RA Butler

    The top 10 most biodiverse countries

  • T Whitten et al.

    The ecology of Java and Bali

    (1996)
  • J Stone et al.

    Indonesia

  • L Trisnantoro et al.

    The origin of non-state providers in Indonesia

  • P Boomgaard

    The development of colonial health care in Java. An exploratory introduction

    J Human Social Sci Southeast Asia Oceania

    (1993)
  • T Dartanto et al.

    Intrageneration poverty dynamics in Indonesia: households' welfare mobility before, during, and after the Asian financial crisis

    (2016)
  • Statistical yearbook of Indonesia 2017

    (2017)
  • Annual report

  • World development indicators

  • Indicators and data mapping to measure sustainable development goals (SDGs) targets: case of Indonesia

    (2015)
  • R Pinto et al.

    Indonesia. Health financing system assessment: spend more, right, and better. Policy brief

    (2016)
  • Smoking behavior of Indonesian people based on basic health research 2007 and 2013

    (2014)
  • T Dartanto

    Disaster, mitigation and household welfare in Indonesia. LPEM-FEBUI working paper

    (2017)
  • D Christelis et al.

    Household economic decisions under the shadow of terrorism

    Soc Sci Res Net

    (2013)
  • T Krieger et al.

    Does income inequality lead to terrorism? Evidence from the post-9/11 era

    SSRN Electr J

    (2015)
  • World Bank open data

  • GBD compare

  • Indonesia

  • Indonesian population projection 2010–2035. Report

    (2013)
  • National socio-economic survey 2015. Report

    (2015)
  • Basic health research 2013. Report

    (2013)
  • Indonesia demographic and health survey 1997. Report

    (1998)
  • Indonesia demographic and health survey 2002–2003. Report

    (2003)
  • Indonesia demographic and health survey 2007. Report

    (2008)
  • Indonesia demographic and health survey 2012. Report

    (2013)
  • The state of the world's children 2016

    (2016)
  • M Triyana et al.

    The effects of a household conditional cash transfer programme on coverage and quality of antenatal care: a secondary analysis of Indonesia's pilot programme

    BMJ Open

    (2017)
  • Reducing maternal and neonatal mortality in Indonesia: saving lives, saving the future

    (2013)
  • National health facilities research report 2011

    (2012)
  • National health indicator survey 2016

    (2016)
  • Basic health research 2007. Report

    (2008)
  • Balanced diet guidelines

    (2014)
  • Total diet study: Indonesian individual food consumption survey 2014

    (2014)
  • Levels and trends in child malnutrition

    (2017)
  • Cited by (0)

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