Mapping Social Health Financing Mechanisms and Their Equity Implications in Indonesia: A Scoping Review

Abstract

Background: Health financing is central to universal health coverage (UHC), determining whether individuals can access healthcare without financial hardship. In Indonesia, the Jaminan Kesehatan Nasional (JKN) programme has substantially expanded population coverage, but registration does not necessarily ensure equitable healthcare utilization or financial protection. Poor and vulnerable populations, including informal workers and rural and remote communities, may continue to face barriers to healthcare access.

Aims: This scoping review aimed to map social health financing mechanisms implemented or studied in Indonesia and examine their implications for equitable healthcare access and financial protection among poor and vulnerable populations.

Methods: This review followed the Joanna Briggs Institute (JBI) methodology for scoping reviews and was reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews (PRISMA ScR). Searches were conducted in PubMed/MEDLINE, Scopus, Web of Science, Embase, Google Scholar, and Garuda, supplemented by grey literature from the World Health Organization, World Bank, Ministry of Health of Indonesia, BPJS Kesehatan, Dewan Jaminan Sosial Nasional, and Bappenas. Literature published between 2019 and 2026 was considered. Eligible sources addressed health financing mechanisms, healthcare access, equity, or financial protection among poor or vulnerable populations in Indonesia. Data were charted using a standardized extraction form and synthesized descriptively and thematically.

Results: A total of 235 records were identified, of which 30 sources, comprising 24 peer reviewed studies and 6 grey literature reports, met the inclusion criteria. Five broad categories of social health financing mechanisms were identified: national social health insurance through JKN and BPJS Kesehatan, government premium subsidies for poor populations through Penerima Bantuan Iuran (PBI), community and employment based contributory financing, non-contributory social assistance such as Program Keluarga Harapan (PKH), and faith based or philanthropic financing, including zakat based schemes. Although JKN registration reached 98.45% of the population by the end of 2024, active utilization was substantially lower at 78.83%. Equity implications differed across mechanisms: JKN and PBI extended nominal coverage and modestly reduced out-of-pocket payments for some vulnerable groups, community- and employment-based contributory financing showed unstable enrolment among informal workers, non-contributory social assistance influenced health-seeking behaviour only indirectly, and faith-based and philanthropic financing remained almost entirely unevaluated. Out-of-pocket and catastrophic health expenditure continued to affect poorer and informally employed households despite these gains, indicating that financial protection remained incomplete. Poor, informally employed, and geographically remote populations continued to experience greater financial and access barriers. Key challenges included administrative complexity, limited ability and willingness to pay among informal workers, geographic disparities in healthcare availability, and imperfect targeting of subsidy programmes.

Conclusion: Social health financing in Indonesia has expanded nominal coverage under JKN and PBI, but this nominal coverage has not consistently translated into effective, equitable healthcare access and financial protection: registration is not the same as effective coverage or genuine financial protection. Evidence on community based and faith-based financing remains limited. Future research should prioritize comparative equity evaluations, particularly among informal workers and populations in eastern Indonesia.