JKN aims at narrowing the gap in inequity and therefore, this paper’s analysis concentrates on the evaluation of how far the JKN is moving towards such direction. After seven years of implementation, it is necessary to evaluate progress towards JKN’s main goal to remove financial barriers as regards usage of health services that is based on need instead of household income. Prior to JKN, limited access to care was evidently experienced especially to specialist care which was attributed both to financial as well as access disparities (6, 7).
In general, JKN has seen a remarkable trend in membership expansion. From the study result, it is seen that membership doubled (increased by 110%), from 133 million in 2014 to 208 million population coverage in 2018. JKN, being arguably one of the biggest single-payer SHI had started from 117 million coverage as the result of blending different ad-hoc health insurance schemes, including local health insurance (Jamkesda), for-the-poor health insurance (Jamkesmas), as well as different ad-hoc schemes (8). In precedent, many countries with similar characteristic, including China, Vietnam, and the Philippines, went on similar reform to evolve the existing health insurance schemes into a single-payer SHI for improving coverage and access (9–11). As JKN grows in size to alleviates access to care, it is imperative that equity becomes attention of JKN going forward.
The extensive coverage of JKN is parallel with equity in its service delivery, particularly to its main recipients. From the study, it is concluded that JKN significantly improved access to outpatient and inpatient services, particularly for the poor or 3rd membership class. This finding is consistent with other studies reporting the same positive effects of removing financial barriers to increase equity of health care, especially within lower- and middle-income countries(12–15). This trend was also observed in other low and middle-income countries (LMICs). This indicates that the JKN is on the right track to improve access to health care for low-income households who faced financial barriers before the JKN, therefore championing universal health coverage (UHC).
Despite the achievement in narrowing the gap of access in the lower-income household, the trend was not all seen in other subgroups; in the case of 1st and 2nd membership class of entailing membership of formal and informal workers, JKN was seen to have improved access to only outpatient care. Such decline in hospital admission rates but increased in outpatient visits among such groups may be attributed to the JKN design features of gate-keeping and case-based payment which seek to control overutilization and unnecessary care, saving use of resources for the long run. A similar trend was also observed in the US and China, in which public health insurance prompted increased outpatient care particularly to the poor segment (16, 17). A study in Korea reported that public health insurance is associated with increase of outpatient expenditure but not utilization (18).
In order to facilitate better access, supply-side strengthening becomes imperative in facilitating the rising demands of healthcare due to JKN. In our study, service utilization was improved when there was a necessary supply of hospital beds to accommodate services. This is a considerable challenge to equity in that there is a wide variation of hospital supply beds in Indonesia, with the eastern and most remote part has the highest bed-to-population ratio (19).
Parallel with JKN implementation, which facilitates demand acceleration in healthcare; there is no known disruptive policy at the national level that was necessarily designed to accommodate supply-side readiness. Consequently, a gap in access was previously felt especially in urban area where there was no adequate supply(20). In Japan, after the implementation of national health insurance, there was supply-side boost response particularly for hospital beds, which is akin to our study result (21). Without adequate supplies and infrastructure investment, as evidently shown by countries including Nepal & Ghana, demand-side intervention similar to social health insurance (SHI) will not accelerate the improvement of access (22, 23).
Ultimately, equity is an important consideration for JKN going forward, especially for accelerating the progress of UHC. Myriad studies from other countries provide lessons that an expansion of SHI scheme does not automatically translate to equity in access, particularly to some beneficiary subgroups (24, 25). Moreover, in achieving UHC, it important to look at factors that also facilitates the optimization of SHI, aside from the aforementioned supply-side interventions (26, 27). Thus, through SHI, equity needs to be embedded into the health system framework enabling an acceleration of UHC achievement.