Beyond Primary Care: The Cross-Sector Roots of Preventable Hospital Cost in Indonesia's National Health Insurance (JKN)

Executive summary

This report measures how much of Indonesia's hospital burden and cost under the National Health Insurance scheme (JKN) is rooted in determinants that lie outside the health system: clean water and sanitation, immunisation coverage, nutrition, and vector control. Using the BPJS Kesehatan Sample Data for 2015 to 2024, it attributes each preventable admission to the determinant sector responsible for it and to the ministry that governs that determinant upstream, turning a clinical pattern into a cross-sector budgeting question.

Admissions are assigned to a single sector on the basis of the primary diagnosis only, a deliberately conservative rule that counts an admission as caused by a determinant condition rather than merely accompanied by one. All population figures are survey-weighted national projections and describe people who reach hospital care under JKN, so they are a lower bound on the true community burden, which is largest in under-served regions. Cost figures are verified-paid claim values, not official budget realisation.

Questions this report answers

• How much of JKN's preventable hospital cost is rooted in water and sanitation, immunisation, nutrition, and vector control?
• Which ministry, beyond the Ministry of Health, governs the upstream determinant behind each share of that cost?
• How concentrated is the spending, who carries the burden by age and membership segment, and where does it cluster geographically?
• What would upstream prevention be worth as a cross-ministerial investment rather than a recurring hospital cost?

Key findings

• Across 2015 to 2024, preventable determinant-related hospital claims cost JKN about Rp 41.5 trillion, of which about Rp 31.9 trillion was inpatient care.
• Water, sanitation and hygiene is the largest single sector at about Rp 19.9 trillion, or 47.9 percent of the determinant-related total, placing nearly half of this preventable cost in the domain of public works and local government rather than hospitals.
• The composition is stable over time: in 2024 determinant-related cost reached about Rp 8.4 trillion with water and sanitation still dominant at 49.6 percent, so the priority on water and sanitation holds year after year.
• Spending is concentrated: about 52.4 percent of the cost falls on the most expensive 10 percent of patients, driven by chronic and recurrent conditions such as tuberculosis and urinary tract stones.
• These are diseases of poverty, yet admission rates are lower for the poorest (subsidised) members, signalling unmet need rather than lower burden among the people whose upstream determinants are worst, which makes upstream investment equity-improving.
• The analysis cohort covers 134,199 sampled patients with 345,037 determinant-related primary-diagnosis claims, of which 102,691 were inpatient admissions, and even a conservative scenario that avoids one in five admissions implies annual savings from hundreds of billions to above one trillion rupiah.