The Primary Care Financing Paradox Under JKN: A WHO Health System Building Blocks Analysis of Structural Barriers to Primary Care Reorientation in Indonesia

Abstract

Background: Indonesia’s National Health Insurance (JKN) was designed as a primary care–oriented system; however, over 87% of expenditures are concentrated in referral-level services, while primary care receives only 11.2%. The structural determinants of this imbalance remain insufficiently examined. Objective: This study introduces the concept of the  primary care financing paradox and analyzes its structural drivers across health system domains. Methods: A secondary data and comparative policy analysis was conducted using official datasets (2019–2024). The WHO Health System Building Blocks (HSBB) framework was applied through a three-step approach: indicator extraction, cross-domain barrier mapping, and benchmarking against OECD systems with strong primary care performance (United Kingdom, Netherlands, Canada). Results: Five interrelated structural barriers were identified: misalignment in medical education, significant income disparity between primary care physicians and specialists (8–16×), severe geographic maldistribution (51:1), capacity-demand mismatch with primary care facilities serving over 120,000 members, and fragmented governance. These barriers operate across all HSBB domains through mutually reinforcing mechanisms, indicating that single-domain interventions are insufficient. Conclusion: Effective primary care reorientation requires coordinated cross-domain structural reform. International evidence highlights income parity, organizational prestige, and performance-linked financing as essential preconditions currently absent in Indonesia’s system.