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
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Special attributes of Indonesia that are relevant to a universal health-care (UHC) system:
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262 million inhabitants with more than 300 ethnic groups and 730 languages spread over 17 744 islands
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Gross domestic product grew at 5·6% per year with disparities yielding a Gini coefficient of 0·395
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UHC must meet national health system requirements and decentralised implementation at the district level
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A combination of factors comprises the unique approach to the UHC system:
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Operated by a single quasi-government entity
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Pays primary care providers using a prospective payment of capitation, and payment based on case-based groups for secondary providers
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The Ministry of Health determines the standard of care, treatment, and referral to ensure primary care provider capability and service are standardised
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The system designates the primary care provider as the entry point for UHC and the referral channel for specialised care
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Involvement of private sector providers is encouraged to broaden care availability
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Accomplishments of the Indonesian UHC system:
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The largest single-payer system in the world
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Improved coverage and use of services
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Improved efficiencies of service delivery
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Reduction of service fees
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Public health system challenges remain, such as high stunted growth in children and high maternal and neonatal deaths
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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
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A robust and dynamic information system for front-line health workers is needed to continually guide system improvements, which will support:
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The need to actively track UHC coverage and advocate UHC benefits to ensure higher participation
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Improved efficacy and efficiency of service delivery
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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
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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.