Can Indonesia achieve universal health coverage? Organisational and financing challenges in implementing the national health insurance system.

Indonesia's National Health Insurance system - the Jaminan Kesehatan Nasional (JKN) - is one of the largest single-payer health insurance schemes in the world, aiming to provide equitable and affordable healthcare to a population of over 280 million. Since its launch in 2014, the JKN has achieved near-universal enrolment, covering 98 % of Indonesians in 2024. However, progress towards universal health coverage - understood as access to the health services people need, when and where they need them, without financial hardship - has been hindered by financing deficits and operational hurdles faced by healthcare providers. In this paper, we examine critical issues affecting the implementation of JKN through the analysis of 20 in-depth interviews and a focus group discussion with government officers and health sector managers at the national and provincial level. Data analysis was guided by a framework combining health systems building blocks and dimensions of access to services. The findings highlight persistent challenges despite the JKN's wide coverage, including difficulties among informal sector workers in paying premiums, regional disparities in service access and health workforce distribution, inefficiencies in provider payment mechanisms, and weak information systems for tracking subsidised members. Interviews also revealed a growing financial and administrative strain on hospitals linked to frequent regulatory changes. To address these issues, we recommend three priority reforms: (1) implement sliding-scale subsidies for informal sector workers; (2) improve provider payment models by introducing cost-sharing for elective services; and (3) adopt participatory policymaking processes to ensure reforms are sustainable and inclusive.