Mapping Indonesia’s complex health insurance business processes

For the November 2025 Bhela (community) call, Mr Anis Fuad, Senior Lecturer at the Faculty of Medicine, Public Health and Nursing at the Universitas Gadjah Mada (UGM), together with Dr Lukman Heryawan from UGM’s Department of Computer Science, Faculty of Mathematics and Natural Sciences, presented insights into Indonesia’s National Health Insurance Agency BPJS Kesehatan, which administers the national health insurance scheme, Jaminan Kesehatan Nasional (JKN).

JKN is one of the largest universal health coverage programs in the world, reaching over 98 percent of Indonesia’s population of 285 million, spread across more than 17,000 islands. Having achieved near universal coverage within just a decade, and with the scale and maturity of its operating systems, JKN has attracted considerable interest from international researchers and practitioners.

With financial and technical support from the Asia eHealth Information Network (AeHIN) and GIZ, the team from Universitas Gadjah Mada, led by Mr Fuad and Dr Heryawan, undertook the daunting task of analysing BPJS Kesehatan’s business processes from multiple perspectives  those of the patients, primary care facilities and the referral hospitals in public as well as private sectors. JKN is supported by a range of digital management and health information systems, many of which are proprietary and customised to the Indonesian context.

These processes were then compared with openIMIS (JLN defined business processes), offering a comparative view that highlights key similarities, strategic differences and unique characteristics of the Indonesian system. The complexity of this work is underscored by the scale of JKN itself: more than 32,000 healthcare providers, 652 languages spoken nationwide, over 950,000 payment points, and hundreds of branch and district offices.

In addition to generating learning and identifying best practices, the research team also aimed to develop teaching materials for students at the university. Their work was guided by three core questions: as a digital public good, can openIMIS support a “mini-lab” environment to simulate JKN’s business processes; can it be used to teach health insurance management, enabling students to replicate and extend JKN’s technical and policy components; and can JKN’s own best practices and innovations, in turn, inform the evolution of openIMIS.

Using an Action Learning approach, the research team first examined the policies, rules and regulations governing health insurance in Indonesia. They then analysed workflows across the health insurance delivery chain, from registration through to claims reimbursement at different types of facilities. This included an assessment of the various health information management and electronic medical record systems in use.

More than 700,000 people access BPJS Kesehatan systems every day. In the context of such a vast and complex ecosystem, interoperability emerged as the principal challenge. A national ID number serves as the core identifier for insured members, linking them to multiple digital services, including a beneficiary mobile App, P-Care for primary clinics and VClaim for hospitals, to name a few.

Mr Fuad and Dr Heryawan presented a detailed mapping of how openIMIS could potentially be adapted to support BPJS Kesehatan processes from the perspective of different actors in the system – beneficiaries, administrators, and others. They also shared an early version of an interoperability plan for linking JKN and openIMIS. Several design questions remain to be addressed, including whether to customise openIMIS or to rely on a FHIR-based interface to connect the two platforms. Additional challenges relate to multilingual requirements, handling the Indonesian currency (the Rupiah), and accommodating capitation-based provider payments, which are not yet supported in openIMIS.

However, this huge undertaking has already yielded rich insights for both openIMIS and JKN. With the mapping work now complete, attention is turning to experimentation, interoperability and learning. A future Healthy Developments article, focusing on exchanges between openIMIS and academic institutions, will offer further updates and an analysis of the lessons learned. Please stay tuned.
 

For the recording and PDF of the presentation, please check our documentation in the openIMIS wiki.