Implementation Research to Strengthen Health Care Financing Reforms Toward Universal Health Coverage in Indonesia: A Mixed-Methods Approach to Real-World Monitoring

Universal health coverage reforms are complex and impact numerous processes, institutions, and individuals. To know whether reforms are being implemented as planned and working as envisioned, policy makers and managers need information and insights on bottlenecks. The United States Agency for International Development (USAID) provided support to build implementation research (IR) capacity and to conduct cycles of research to help Indonesia understand how its single-payer national insurance reform, Jaminan Kesehatan Nasional (JKN), was affecting primary care. Two cycles of IR in Indonesia focused on effects of JKN financing on primary care, as determined through a consultative process with stakeholders at national and district levels. This process generated questions relevant for implementers and policy makers and strengthened government interest in findings. Research was conducted in 5 diverse districts, and methods included key informant interviews, focus groups, document review, health worker surveys, and analysis of service delivery data. Cycle 1 findings showed an uneven understanding of JKN regulations, unequal implementation readiness, and limited evidence of improved productivity. JKN capitation payments did not increase health worker satisfaction or motivate additional effort. Informed by these findings, regulations were rewritten and the capitation payment formula was redesigned to include payment conditional on performance. Cycle 2 found that health workers experienced increased workloads because of increased enrollment in JKN and the requirement that people access primary care before being referred to higher levels of care. In addition, health workers indicated they did not experience the payment system to be fair. Instead of payment being conditional on performance, they indicated it was primarily determined by education and tenure, with only some districts incorporating a small payment component based on behaviors, such as attendance, and performance. The health workers said they preferred to be paid based on achieving primary care targets. Conducting IR so that questions are relevant and the process of finding and sharing answers is timely and cost-effective requires high-level skills, but support to build IR capacity has potential to make a lasting impact.