Towards greater health coverage in Indonesia: An evaluation of National Health Insurance (JKN) reform and healthcare use and equity

Following the implementation of National Health Insurance (JKN), the ongoing efforts to improve health coverage in Indonesia face several challenges that need to be explored. These challenges include consolidating existing health insurance schemes and introducing self-enrolled schemes to enhance healthcare utilization effectively. Moreover, socioeconomic and geographic disparities persist, hindering equal access to healthcare benefits across different groups and regions. Another critical aspect is assessing the effectiveness of BPJS Kesehatan's performance-based capitation in addressing health quality concerns, particularly in primary care settings. Additionally, understanding the impact of natural disasters, such as the 2015 forest fires, on healthcare utilization is crucial.

In this doctoral dissertation, we explore these challenges and their implications. Firstly, we examine the relationship between increasing coverage share and healthcare utilization at the district level, revealing a positive correlation, especially in hospital care. However, concerns about adverse selection with self-enrolled schemes pose financial sustainability risks for JKN. Secondly, we assess healthcare funding distribution under JKN, highlighting significant benefit incidence for wealthier groups and regional variation in hospital unit costs. Thirdly, we analyze the implementation of performance-based financing through the KBK scheme for community health centers (puskesmas). Despite high expectations of the results, our findings indicate limited success in promoting primary care utilization (increasing but not met the target). Lastly, we investigate the impact of the 2015 forest fires on healthcare utilization, focusing on specific respiratory conditions. While limited effects were observed for older individuals, positive impacts were noted for young children seeking care in urban primary healthcare facilities.