National Health Insurance Membership Association with Disease Claims under Non-Capitation Payment at Primary Healthcare Facilities

Mohammad Yusuf Setiawan; Achmad Djunawan; Enny Mar’atus Sholihah

doi:10.14710/jphtcr.v9i2.31554

DOI: https://doi.org/10.14710/jphtcr.v9i2.31554

National Health Insurance Membership Association with Disease Claims under Non-Capitation Payment at Primary Healthcare Facilities

Mohammad Yusuf Setiawan¹, Achmad Djunawan¹

, Enny Mar’atus Sholihah²

¹Stikes Yayasan RS Dr Soetomo, Indonesia

²Universitas Muhammadiyah Lamongan, Indonesia

Received: 10 Mar 2026; Published: 31 Aug 2026.

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

BibTex Citation Data :

@article{JPHTCR31554,
    author = {Mohammad Setiawan and Achmad Djunawan and Enny Sholihah},
    title = {National Health Insurance Membership Association with Disease Claims under Non-Capitation Payment at Primary Healthcare Facilities},
    journal = {Journal of Public Health for Tropical and Coastal Region},
  volume = {9},
    number = {2},
    year = {2026},
    keywords = {chronic disease, health insurance, primary healthcare, universal health coverage},
    abstract = {  Introduction:  Primary healthcare plays a central role in Indonesia’s National Health Insurance system in managing population health needs. Understanding morbidity patterns and their relationship with insurance membership categories is essential for service planning and financial sustainability. This study aimed to analyze disease claim patterns at non-capitation primary healthcare facilities and their association with insurance membership types between 2015 and 2023.   Methods:  A quantitative analytic study using secondary administrative claims data from primary healthcare facilities under the National Health Insurance scheme. The dataset consisted of 201,297 non-capitation service records collected between 2015 and 2023. Variables included diagnosis codes, insurance membership type, sex, and facility characteristics. Data using frequency distribution and chi-square tests to assess the association between insurance membership categories and disease claims.   Results:  The most frequently reported diagnoses across all membership categories are non-communicable diseases particularly type 2 diabetes mellitus and essential hypertension. Maternal and reproductive health conditions also rank among the top diagnoses especially among government-subsidized participants. A statistically significant association between insurance membership type and morbidity pattern (p < 0.001). The strength of the association is weak.  Conclusion:  Morbidity patterns in primary healthcare reflect a dual burden of chronic and maternal conditions and vary across insurance membership categories. These findings highlight the need for membership-based intervention strategies and strengthened chronic disease management to ensure sustainability within the National Health Insurance system.},
   issn = {2597-4378},  doi = {10.14710/jphtcr.v9i2.31554},
    url = {https://ejournal2.undip.ac.id/index.php/jphtr/article/view/31554}
}

Citation Format:

Abstract

Introduction: Primary healthcare plays a central role in Indonesia’s National Health Insurance system in managing population health needs. Understanding morbidity patterns and their relationship with insurance membership categories is essential for service planning and financial sustainability. This study aimed to analyze disease claim patterns at non-capitation primary healthcare facilities and their association with insurance membership types between 2015 and 2023.

Methods: A quantitative analytic study using secondary administrative claims data from primary healthcare facilities under the National Health Insurance scheme. The dataset consisted of 201,297 non-capitation service records collected between 2015 and 2023. Variables included diagnosis codes, insurance membership type, sex, and facility characteristics. Data using frequency distribution and chi-square tests to assess the association between insurance membership categories and disease claims.

Results: The most frequently reported diagnoses across all membership categories are non-communicable diseases particularly type 2 diabetes mellitus and essential hypertension. Maternal and reproductive health conditions also rank among the top diagnoses especially among government-subsidized participants. A statistically significant association between insurance membership type and morbidity pattern (p < 0.001). The strength of the association is weak.

Conclusion: Morbidity patterns in primary healthcare reflect a dual burden of chronic and maternal conditions and vary across insurance membership categories. These findings highlight the need for membership-based intervention strategies and strengthened chronic disease management to ensure sustainability within the National Health Insurance system.

Note: This article has supplementary file(s).

Fulltext | Research Instrument

Similarity test

Subject
Type	Research Instrument
	Download (2MB) Indexing metadata

Email colleagues

Keywords: chronic disease, health insurance, primary healthcare, universal health coverage

Article Metrics:

Article Info

Section: Articles

Language : EN

In Vol 9, No 2 (2026): Journal of Public Health for Tropical and Coastal Region

Nushratu H. Detik News. 2023. BPJS Kesehatan Menanggung Manfaat Medis Komprehensif Tanpa Diskriminasi
Alatas MBI. Antara News. 2024. Bappenas dan BPJS Kesehatan luncurkan Buku Tabel Morbiditas Indonesia
Dewi EAT, Sofiatin Y, Setiawati EP, Wahyudi K, Afriandi I. Analisis Pembiayaan JKN Pasien Hipertensi Di FKTP Jawa Barat Tahun 2015-2016 (Analysis of JKN Non Capitation Financing for Hypertension Patients at West Java FKTP 2015-2016). Jurnal Kebijakan Kesehatan Indonesia. 2021;10(2):78–85
Rosanti IW, Budiantara IN. Pemodelan Faktor-Faktor Yang Mempengaruhi Morbiditas Di Jawa Tengah Menggunakan Regresi Nonparametrik Spline Truncated. Inferensi. 2020;3(2):107–14
Rahman R, Hidayat B. Analisis Pemanfaatan Pelayanan Kesehatan Peserta Jaminan Kesehatan Nasional (JKN) Penderita Tuberkulosis Paru Di Fasilitas Kesehatan Tingkat Pertama (FKTP): Analisis Data Sampel BPJS Kesehatan Tahun 2022. Jurnal Cahaya Mandalika ISSN 2721-4796 (online). 2024;2313–23
Jatmiko LD. Bisnis.com. 2018. Inikah Penyebab BPJS Kesehatan Defisit?
Nugraheni WP, Mubasyiroh R, Hartono RK. The influence of Jaminan Kesehatan Nasional (JKN) on the cost of delivery services in Indonesia. PLoS One. 2020;15(7):e0235176
Djunawan A, If’al Lillah A, Dewi RS. Pemanfaatan Fasilitas Pelayanan Kesehatan Primer di Area Perkotaan Berdasarkan Status Ekonomi dan Kepemilikan Jaminan Kesehatan (Analisis Data IFLS 5). MEDIA KESEHATAN MASYARAKAT INDONESIA. 2022;21(4):224–37
Djunawan A, Haksama S. Correlation of Midwife’s Cooperation, Motivation, Attitude and Performance on Antenatal Care. Jurnal Administrasi Kesehatan Indonesia. 2015;3(1):11–20
Djunawan A. Pengaruh jaminan kesehatan terhadap pemanfaatan pelayanan kesehatan primer di perkotaan Indonesia: adilkah bagi masyarakat miskin? Berita Kedokteran Masyarakat. 2018;34(5):1–5
Djunawan A. Benarkah subsidi jaminan kesehatan meningkatkan pemanfaatan pelayanan kesehatan primer oleh penduduk miskin perkotaan. Jurnal Kebijakan Kesehatan Indonesia: JKKI. 2019;8(1):18–24

Last update:

No citation recorded.

Last update:

No citation recorded.

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

In order to be accepted and published by Journal of Public Health for Tropical and Coastal Region, the author (s) who submit a manuscript should complete the review process. Journal of Public Health for Tropical and Coastal Region articles are distributed under a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0). Articles can be read, shared, and adapted even for commercial purposes under the following conditions:

Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.
No additional restrictions — You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.

Copyright of accepted articles remains with the author (s). The author (s) have the right to the articles that have been published. The Editorial Team of Journal of Public Health for Tropical and Coastal Region and the Author(s) strive to ensure that no errors occur in the articles that have been published, both data errors and statements in the articles. Authors who publish in this journal agree to the following terms:

Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
The journal allows the authors to hold the copyright and retain publishing rights without restrictions.
Authors can enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.

Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) before and during submission, as it can lead to productive exchanges and earlier and greater citation of published work.