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services as it targets very poor households with pregnant or breastfeeding mothers, newborns, or
school-age children. In 2011, the programme was expanded to 25 out of 33 provinces and PKH
beneficiaries were made eligible for free-of-charge services at primary health care or Puskesmas
(Mahendradhata et al., 2017).
Community-based primary health service delivery has historically been a priority for Indonesia.
However, after the decentralisation and the removal of central programming, community-based
primary healthcare delivery and vertical programming weakened in many districts. To strengthen
community-based service delivery through various policy changes and restructuring of primary health
care delivery, several attempts are made. For example, the Healthy Indonesia programme that is
implemented through the Family Approach Program (PIS-PK) aims to strengthen community-based
outreach and health service delivery by asking Puskesmas personnel to undertake regular household
visits to monitor 12 health indicators including maternal and child health, family planning, TB
surveillance, hypertension, access to sanitation and clean water.
More recently, these efforts included the launch of the National Health Insurance programme (Jaminan
Kesehatan Nasional (JKN)) in January 2014. This insurance programme replaced various previously
existing health funding schemes for the poor and insurances, pooling contributions from the
government and contributing members who pay in accordance to the health services desired.
Premiums for members who are categorized as poor and near poor are paid for by the government.10
Jameskas, the largest of these three programmes targeted 76.4 million poor and near poor in 2014
(Marzoeki et al., 2014). There is strong political commitment and support to achieve full health
insurance coverage of the Indonesian population with the current President being one of the major
advocates for the programme.
Learnings from Indonesia’s JKN
Four years into the health insurance programme approximately 165 million Indonesians have
enrolled, making JKN the biggest single-pooled health insurance system in the world (Wiseman,
Thabrany et al., 2018). However, stakeholder impressions and first assessments of the effectiveness of
JKN in easing poor households’ financial burden when accessing health services have had mixed
results. Although annual household surveys of Indonesia show that poor households were more likely
to utilize health service facilities since the roll-out of the scheme (Sharma, 2018), 11 there is growing
evidence that JKN is underperforming and excluding a large proportion of the population who works
in the informal sector (WHO 2017, Wiseman, Thabrany et al., 2018), that the selection process of
subsidised and non-subsidised JKN members leads to unfair exclusions of poor people (Idris,
Satriawan et al., 2017, WHO, 2017), and that people who do not own a national identity card including
homeless people; orphans; the elderly who live in nursing homes; some indigenous and tribal
population groups living in rural and remote areas; and nomadic people in remote mountainous areas
of Indonesia are excluded.12 Furthermore, many JKN members also still occur high out-off-pocket
payments for some services (GIZ, 2015) as the covered costs for inpatient care are very low and e.g.
only allows patients to stay for a maximum of three days in care after which the patients either have
to leave or pay themselves for additional days of inpatient care.
Indirect health care costs pose another considerable financial burden for poor households, because
JKN only provides financial protection for medical cost, and indirect costs such as transportation and
accommodation still have to be covered by out of pocket payments. According to one key informant,
10 28 million fell below Indonesia’s national poverty - set at consumption outlays of US$25 per month per person - in March 2014,
around 68 million were classified as near poor or vulnerable (Aji, 2015).
11 Especially, maternal and newborn health services were utilised more frequently in the Eastern provinces.
12 For example, a recent study on access to legal identity across 17 provinces found that only half of women in the poorest 30 percent
of households have identity cards, varying significantly across provinces. This is very much related to the lack of birth certificates,
which 88 per cent of the adults in the poorest 30 per cent of Indonesian households do not possess. This share is higher amongst rural
households and 5 times as high amongst people with disabilities (Sumner and Kusumaningrum, 2014).