JKN is intended to address these growing disparities in health care in Indonesia. Its main objective is to create a well-integrated, sustainable, accessible, and equitable health system that provides comprehensive, high-quality care to all Indonesians.
During the years between passage of Law 40 in 2004 and the launch of the consolidated National Health Insurance Scheme on 1 January 2014, many steps were taken toward fulfillment of the national commitment to have a health care system for all Indonesians. When the law was adopted in 2004, only civil servants, the military, and the police were covered by health insurance, each in a separate program. Attention was first directed to develop new coverage for the health needs of the poor. In 2005, a new Social Health Insurance for the Poor program was launched for that purpose (called Asuransi Kesehatan untuk Yang Miskin or Askeskin). In 2008, Askeskin evolved into a broader program of health insurance (known as Jamkesmas)10 with wider coverage and incorporating lessons learned from Askeskin.
In 2010, a new program was added to reduce maternal and child mortality, providing coverage for all pregnant women (Jaminan Persalinan or Jampersal). The final years of preparation for the launch of JKN focused on designing how to consolidate the multiple programs under one national administrative, management, and service system while at the same time identifying and moving to ”fill gaps” in coverage (improving equity) and raising the quality of services. This period included the development of a “road map” for continuing expansion of the system from its launch in 2014 to the achievement of UHC by 2019.
The development of JKN was based on five core principles:
- The spirit and practice of gotong royong, meaning mutual support.
- Mandatory membership for all Indonesians by 2019.
- “Portability” of the right to service: members of JKN are entitled to service anywhere in Indonesia.
- Principles and best practice of social health insurance to guide the management of JKN.
- Medical service is equal for all JKN members; however, members paying all or a portion of their own membership can choose to pay for a higher level of in-patient service.
An early challenge in the implementation of JNK was integrating into one system the separate insurance programs that had covered the poor and near poor (PBId), civil servants, the military, the police, pensioners, and some staff of state enterprises (BUMNe). Except for PBI, these insurance programs all involved financial contributions by both the employer and the employee. Under JKN all of these systems became part of the unified National Social Health Insurance Scheme with a single management system as well as a single system of rights and benefits for members. On 1 January 2014, membership in JKN was opened to others, defined as independent members, who would pay their own premiums. Some provincial and district governments also chose to enroll the near poor from their local programs in JKN, thereby bringing the total number of poor and near-poor subsidized by government to 93.9 million by 31 August 2014.f
Under JKN, the Ministry of Health is responsible for setting clinical guidelines and technical norms. On the other hand, health care delivery depends on a mix of public and private providers. The financial affairs of JKN are run by an independent management agency for the health wing of the Social Security System, called BPJS Health. This agency manages the new health insurance system, including recruitment of members, payment to service providers, and collection of fees.
Another major goal of JKN, which was important to policy makers, was improving the quality of care. In order to move forward on this objective, and based on the principle that what could be measured would be well managed, we did a full assessment of our system's quality of care both from the providers’ technical perspective as well as from the patients’ satisfaction standpoint. We then sought to strengthen our medical education system, to assure the availability of qualified staff at primary health centers (PHCs) and hospitals through the rotation and field assignments of doctors and specialists and to encourage service by qualified doctors in the most challenging island, border, and isolated posts through the introduction of incentives (financial and educational opportunities).
Key Challenges of Building JKN
The Ministry of Health established six working groups to address key challenges in implementing the JKN:
- Regulatory infrastructure for both service delivery and management
- Finance, transformation, and integration of programs and institutions (from former programs)
- Health facilities, referral, and infrastructure
- Human resources and capacity building
- Pharmaceutical and medical devices
- Socialization and advocacy