SP4PHC in Indonesia

SP4PHC is focused on improving the ways in which primary health care services are purchased by the Government of Indonesia (GOI), both through its national health insurance scheme, Jaminan Kesehatan Nasional (JKN), and other GOI mechanisms. The SP4PHC team in Indonesia is continuing to support the GOI to analyze and improve how JKN purchases primary health care (PHC) services from public and private providers and fostering the integration of telemedicine into PHC purchasing arrangements. Building on this, the team is currently supporting the GOI to set up and coordinate a catalytic learning platform, called the PHC Consortium. This will enable key national and subnational government, academic, and other partners to work together to diagnose and improve primary health care purchasing, with an increased focus on the subnational level and performance management.

ThinkWell’s accomplishments in Indonesia

  • Supported the Center for Health Financing and Decentralization Policy (Pusjak PDK) to lead policy discussions on how to make JKN more sustainable. Our analysis of JKN’s effect on OOP payments provided key analytical insights to the Minister of Health’s team about the benefits of JKN versus its increasing costs.
  • Partnered with the University of Gadjah Mada to implement a mixed-methods study on why private midwives largely operate outside of The team, in collaboration with the USAID-funded Health Financing Activity (HFA) and the GOI’s Maternal and Newborn Health (MNH) Technical Working Group, used the findings from the study to test a new way for JKN to pay MNH provider networks that include private midwives.
  • Assessed the effect of JKN on FP services, and reviewed how FP claims are managed and utilized). We partnered with the University of Gadja Mada (UGM) to map how funds flow for FP from the national level down through the districts to providers and users. This is contributing to the design and implementation of BKKBN’s fund for those FP services that are not covered by JKN (BOK-KB), and into the design of a new case-based payment for PPFP.

Current workstreams and activities

Workstream One: Support Ministry of Health’s consortium to strengthen integrated primary care (ILP) services

  • Develop and co-coordinate a primary health care (PHC) learning platform, the PHC Consortium, that, with national, subnational, and external partners, conducts studies based on Ministry of Health (MOH) priorities and informs evidence-based policy decisions to improve health outcomes.
  • Build capacity and provide technical assistance for local institutions to improve performance management, public financial management, and PHC financing.
  • Identify the sources and types of funds that flow to facilities, potential bottlenecks, and usage of these funds.
  • Partner with local universities to conduct PHC performance assessments at district level.
  • Cost the ILP at the national and subnational levels.
  • Prepare and support implementation, and tracking of ILP reform.

Workstream Two: Improve how JKN purchases PHC services

  • Provide technical support in monitoring the implementation of revised JKN tariffs (capitation, non-capitation, and INA-CBGs) and revising them in 2024.
  • Generate evidence on how JKN members can be redistributed between public and private PHC facilities to cover a more integrated set of services.
  • Analyze trends for the utilization of health services and out-of-pocket (OOP) health expenditures in the JKN program from 2019 to 2024.

Workstream Three: Foster integration of digital health into purchasing arrangements for PHC services

  • Generate evidence around how the GOI can better integrate telemedicine into its health system.
  • Test solutions around financing telemedicine within a regulatory sandbox in collaboration with the Digital Transformation Office (DTO).
  • Support telemedicine (tele-ECG, tele-USG, tele-IVA) design and implementation in four districts of the PHC Consortium.

More information can be found in this project one-pager and this overview presentation.

Featured learning products

National health insurance contribution to family planning program funding in Indonesia: A fund flow analysis

In April 2024, ThinkWell published a study in Gates Open Research in April 2024 that maps the flow of family planning (FP) funds from the national level down to the provider level and the contribution that national health insurance (JKN) makes to this fund flow. The study revealed that in 2019, Indonesia’s FP program was predominantly funded by the government (64%) and personal contributions (34%), with the National Population and Family Planning Board (BKKBN) serving as the primary financier. JKN played a minimal role, contributing less than 0.4%. This study indicates that there is significant potential for JKN to increase how much they spend on FP services to increase coverage and related outcomes and enhance the efficiency of funding for FP in Indonesia. This could be achieved through the realignment of the roles of BKKBN and JKN, as well as by JKN contracting more private providers, who deliver the bulk of popular FP methods in Indonesia.

How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket payments by vulnerable populations in Indonesia

Although the Government of Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out of pocket (OOP) for their health care. This journal article, published in July 2022 in PLOS Global Public Health, analyzes how JKN is influencing OOP payments, especially among poor and rural people, at a range of public and private PHC providers and hospitals across the country.  While the results show that JKN has a protective effect, especially for the poor, it still needs to better engage the private sector (especially in the east) to further reduce OOP payments and improve the quality of services to ensure effective coverage.

Bringing private midwives into Indonesia’s national health insurance scheme

ThinkWell and Universitas Gadjah Mada’s Center for Reproductive Health conducted a landscaping assessment to better understand why private midwives are not joining JKN. This report, published in July 2020, also has policy recommendations for JKN administrators to incentivize private midwives to enroll in the scheme. Strategic purchasing techniques can then be used to improve quality of care, increase access to affordable services, and strengthen coordination within the service delivery system.

Minding the gap between utilization and coverage of maternal and newborn services in Indonesia 

This brief, published in August 2022, summarizes findings from our study in Indonesia on the use of JKN for maternal and neonatal health (MNH) services. This study found that JKN has not been used optimally for all MNH services. The brief presents a summary of our findings, and offers policy recommendations for how the Government of Indonesia, particularly Badan Penyelenggara Jaminan Sosial Kesehatan (BPJSK) as the administrator of JKN, can strengthen the system both on the demand- and supply-side to reduce maternal health risk factors and potentially reduce the number of maternal and neonatal deaths.

Other learning products

SP4PHC aims to improve how governments purchase primary health care services, with a focus on family planning and maternal, newborn, and child health. SP4PHC is supported by a grant from the Bill & Melinda Gates Foundation.