FISCAL STRESS SYNDROME DALAM UNIVERSAL HEALTH COVERAGE: ANALISIS MULTIKABUPATEN/KOTA TERHADAP KONSEKUENSI FISKAL IMPLEMENTASI JKN DI INDONESIA

Ahyar Wahyudi; Rasyid Ridha

doi:10.69957/praob.v6i04.3127

Authors

Ahyar Wahyudi Lembaga Akreditasi Fasilitas Kesehatan Indonesia
Rasyid Ridha Dinas Kesehatan Provinsi Kalimantan Selatan

DOI:

https://doi.org/10.69957/praob.v6i04.3127

Keywords:

Fiscal Stress Syndrome, Universal Health Coverage, Jaminan Kesehatan Nasional (JKN), Keberlanjutan Fiskal

Abstract

Universal Health Coverage (UHC) telah menjadi indikator utama keberhasilan sistem kesehatan di berbagai negara. Namun, tingginya cakupan kepesertaan belum tentu mencerminkan keberlanjutan pembiayaan kesehatan dalam jangka panjang. Di Indonesia, implementasi Program Jaminan Kesehatan Nasional (JKN) dalam kerangka desentralisasi fiskal telah menimbulkan kewajiban fiskal baru bagi pemerintah daerah dalam mempertahankan perlindungan kesehatan masyarakat. Penelitian ini bertujuan menganalisis dinamika pencapaian UHC dan perkembangan kepesertaan JKN, mengidentifikasi faktor-faktor pembentuk Fiscal Stress Syndrome, menyusun tipologi kerentanan fiskal pasca-pencapaian UHC, serta membangun model konseptual hubungan antara ekspansi kepesertaan JKN dan tekanan fiskal daerah. Penelitian menggunakan pendekatan mixed methods dengan desain explanatory sequential. Unit analisis mencakup 13 kabupaten/kota di Provinsi Kalimantan Selatan. Data kuantitatif mengenai cakupan UHC, tingkat keaktifan peserta, peserta PBPU yang dibiayai pemerintah daerah, dan kapasitas fiskal dianalisis secara deskriptif-komparatif. Data kualitatif diperoleh melalui telaah dokumen kebijakan dan sintesis literatur mengenai fiscal stress, fiscal federalism, dan keberlanjutan pembiayaan kesehatan. Seluruh kabupaten/kota telah mencapai atau mendekati target UHC nasional, namun menunjukkan variasi yang signifikan dalam tingkat keaktifan peserta. Meningkatnya jumlah peserta nonaktif, tunggakan peserta mandiri, serta penonaktifan peserta PBI yang dibiayai pemerintah pusat mendorong migrasi kelompok rentan ke dalam skema PBPU yang dibiayai pemerintah daerah. Proses tersebut meningkatkan kewajiban pembiayaan APBD dan menghasilkan tekanan fiskal dengan tingkat kerentanan yang berbeda. Penelitian ini mengembangkan konsep Fiscal Stress Syndrome, menghasilkan tipologi Stable UHC, Vulnerable UHC, dan Fiscal-Stressed UHC, serta membangun model konseptual yang menjelaskan hubungan kausal antara pencapaian UHC dan kerentanan fiskal daerah. Keberhasilan UHC tidak lagi dapat diukur semata-mata berdasarkan cakupan kepesertaan. Evaluasi UHC perlu memasukkan dimensi keberlanjutan fiskal perlindungan kesehatan (fiscal sustainability of coverage) agar perlindungan kesehatan universal dapat dipertahankan secara berkelanjutan tanpa menimbulkan tekanan fiskal yang mengancam stabilitas pembangunan daerah. Temuan penelitian ini menunjukkan bahwa keberlanjutan fiskal perlu ditempatkan sebagai indikator pelengkap dalam evaluasi keberhasilan UHC di Indonesia.

References

Ahrens, T., & Ferry, L. (2020). Financial resilience of English local government in the aftermath of COVID-19. Journal of Public Budgeting, Accounting & Financial Management, 32(5), 813–823. https://doi.org/10.1108/JPBAFM-07-2020-0098

Aikins, M., Tabong, P. T.-N., Salari, P., Tediosi, F., Asenso-Boadi, F. M., & Akweongo, P. (2021). Positioning the national health insurance for financial sustainability and universal health coverage in Ghana: A qualitative study among key stakeholders. PLOS ONE, 16(6), e0253109. https://doi.org/10.1371/journal.pone.0253109

Aizenman, J., Jinjarak, Y., Nguyen, H. T. K., & Park, D. (2019). Fiscal space and government-spending and tax-rate cyclicality patterns: A cross-country comparison, 1960–2016. Journal of Macroeconomics, 60, 229–252. https://doi.org/10.1016/j.jmacro.2019.01.006

Akita, T., Riadi, A. A., & Rizal, A. (2021). Fiscal disparities in Indonesia in the decentralization era: Does general allocation fund equalize fiscal revenues? Regional Science Policy & Practice, 13(6), 1842–1866. https://doi.org/10.1111/rsp3.12326

Asante, A., Cheng, Q., Susilo, D., Satrya, A., Haemmerli, M., Fattah, R. A., et al. (2023). The benefits and burden of health financing in Indonesia: Analyses of nationally representative cross-sectional data. The Lancet Global Health, 11(5), e770–e780. https://doi.org/10.1016/S2214-109X(23)00104-7

Atake, E.-H. (2020). Does the type of health insurance enrollment affect provider choice, utilization and health care expenditures? BMC Health Services Research, 20, 1003. https://doi.org/10.1186/s12913-020-05879-0

Barbera, C., Jones, M., Korac, S., Saliterer, I., & Steccolini, I. (2021). Local government strategies in the face of shocks and crises: The role of anticipatory capacities and financial vulnerability. International Review of Administrative Sciences, 87(1), 154–170. https://doi.org/10.1177/0020852319842661

Borge, L.-E., & Hopland, A. O. (2023). Fiscal and political determinants of local government maintenance. Building Research & Information, 51(8), 937–948. https://doi.org/10.1080/09613218.2023.2206089

Chen, C., Zheng, M., & Zhu, J. (2023). How does fiscal decentralization affect health outcomes? Evidence from China. Risk Management and Healthcare Policy, 16, 1893–1903. https://doi.org/10.2147/RMHP.S412547

Cho, V., Trowbridge, J., Perreira, T., Sodhi, S., Karsan, A., Hassan, H., Perrier, L., Prokopy, M., Dale, A., & Brown, A. (2025). Definition and key concepts of high-performing health systems: A scoping review. BMJ Open, 15(7), e094124. https://doi.org/10.1136/bmjopen-2024-094124

Chollete, L., & Harrison, S. G. (2021). Unintended consequences: Ambiguity neglect and policy ineffectiveness. Eastern Economic Journal, 47(2), 206–226. https://doi.org/10.1057/s41302-021-00187-7

Endalamaw, A., Gilks, C. F., Ambaw, F., & Assefa, Y. (2022). Universality of universal health coverage: A scoping review. PLOS ONE, 17(8), e0269507. https://doi.org/10.1371/journal.pone.0269507

Hailu, A., Eregata, G. T., Stenberg, K., & Norheim, O. F. (2021). Is universal health coverage affordable? Estimated costs and fiscal space analysis for the Ethiopian essential health services package. Health Systems & Reform, 7(1), e1870061. https://doi.org/10.1080/23288604.2020.1870061

Halim, A. (2001). Anggaran daerah dan fiscal stress (Sebuah studi kasus pada anggaran daerah provinsi di Indonesia). Jurnal Ekonomi dan Bisnis Indonesia, 16(4), 346–357.

Harikrishnan, K. S., & Hiremath, G. S. (2024). Asymmetric fiscal federalism and public provision of healthcare: New insights from India. Indian Journal of Human Development, 17(3), 420–438. https://doi.org/10.1177/09737030241239736

Hidayat, M. S., Permana, Y. H., Puspandari, D. A., Siregar, D. R., Setyaningsih, H., Aristianti, V., Baros, W. A., Atsna, Z., Fadlika, F., & Boenjamin, A. (2025). Payment compliance of informal sector workers in Indonesia National Health Insurance: A study on ability and willingness to pay. Health Economics Review, 15, 109. https://doi.org/10.1186/s13561-025-00702-y

Laksono, A. D., Rukmini, R., Tumaji, T., Ipa, M., & Wulandari, R. D. (2022). National Health Insurance Membership among Urban Poor Societies in Indonesia in 2019: Are They Protected? Economies, 10(8), 196. https://doi.org/10.3390/economies10080196

Laksono, A. D., Wulandari, R. D., Efendi, D. E., Tumaji, T., & Nantabah, Z. K. (2024). Role of socioeconomic status in national health insurance ownership in Indonesia’s rural areas. Journal of Research in Health Sciences, 24(1), e00608. https://doi.org/10.34172/jrhs.2024.143

Leiser, S., Wang, S., & Kargman, C. (2021). Perceptions of local government fiscal health and fiscal stress: Evidence from quantile regressions with Michigan municipalities and counties. State and Local Government Review, 53(4), 279–292. https://doi.org/10.1177/0160323X211038356

Lhutfi, I., Ritchi, H., & Yudianto, I. (2019). Bagaimana pemerintah daerah merespon fiscal stress? Jurnal Ilmiah Ekonomi Global Masa Kini, 10(2), 76–81. https://doi.org/10.36982/jiegmk.v10i2.840

Maino, F., & Maioni, A. (2024). Federalism and health care: A comparative policy analysis of Canada and Italy. Journal of Comparative Policy Analysis: Research and Practice, 26(5), 385–406. https://doi.org/10.1080/13876988.2024.2336538

Mawejje, J. (2024). Fiscal vulnerabilities in low-income countries: Evolution, drivers, and policies. World Bank Publications. https://doi.org/10.1596/42239

Nurhasana, R., Hidayat, B., Pujiyanto, Ratih, S. P., Hartono, R. K., & Dartanto, T. (2021). The sustainability of premium payment of national health insurance’s self-enrolled members in Jakarta Greater Area. Journal of Public Health Research, 11(1), 2392. https://doi.org/10.4081/jphr.2021.2392

OECD. (2015). Fiscal sustainability of health systems: Bridging health and finance perspectives. Organisation for Economic Co-operation and Development Publishing. https://doi.org/10.1787/9789264233386-en

Ohno, T., Ishida, M., & Kobayashi, W. (2022). Local government cash flow situation as viewed from the fiscal indicators of the assessment of fiscal conditions. Public Policy Review, 18(2), 1–29.

Padovani, E., Iacuzzi, S., Poljasevic, J., & Valle de Souza, S. (2025). A multicountry analysis of local government financial vulnerability during the 2020 pandemic considering systemic factors. Financial Accountability & Management, 41(1), 42–59. https://doi.org/10.1111/faam.12403

Pedraza, C. C., Matus-López, M., & Báscolo, E. (2019). Fiscal space for health in the Americas: Is economic growth sufficient? Revista Panamericana de Salud Pública, 43, e321. https://doi.org/10.26633/RPSP.2018.321

Peng, F., Zhou, S., & Zhou, P. (2023). Local government fiscal stress and corporate risk-taking: Evidence from a quasi-natural experiment in China. Economic Analysis and Policy, 80, 1677–1695. https://doi.org/10.1016/j.eap.2023.11.009

Pratiwi, A. B., Setiyaningsih, H., Kok, M. O., Hoekstra, T., Mukti, A. G., & Pisani, E. (2021). Is Indonesia achieving universal health coverage? Secondary analysis of national data on insurance coverage, health spending and service availability. BMJ Open, 11(10), e050565. https://doi.org/10.1136/bmjopen-2021-050565

Rahayu, S., Yudi, Y., & Rahayu, R. (2023). Local government performance: Financial condition perspective. Jurnal Perspektif Pembiayaan dan Pembangunan Daerah, 10(6), 395–408. https://doi.org/10.22437/ppd.v10i6.11779

Rao, M., Musso, J. A., & Young, M. M. (2023). Resist, recover, renew: Fiscal resilience as a strategic response to economic uncertainty. The American Review of Public Administration, 53(7–8), 509–526. https://doi.org/10.1177/02750740231186424

Referensi Tambahan yang Sangat Kuat untuk Pembahasan Fiscal Stress Syndrome

Ritonga, I. T. (2014). Modelling local government financial conditions in Indonesia (Doctoral dissertation, Victoria University, Melbourne, Australia). Victoria University Research Repository.

Rodríguez-Pose, A. (2024). Unfunded mandates and the economic impact of decentralisation: When finance does not follow function. Political Studies. https://doi.org/10.1177/00323217221136666

Rotulo, A., Epstein, M., & Kondilis, E. (2020). Fiscal federalism versus fiscal decentralization in healthcare: A conceptual framework. Hippokratia, 24(3), 107–113.

Stoian, A., Brașoveanu, L. O., Brașoveanu, I. V., & Dumitrescu, B. (2018). A framework to assess fiscal vulnerability: Empirical evidence for European Union countries. Sustainability, 10(7), 2482. https://doi.org/10.3390/su10072482

Thapa, B. B., Rahman, M., Were, L., Wamai, R., & Galárraga, O. (2024). Do targeted intergovernmental fiscal transfers improve health outcomes? Evidence from Kenyan decentralization using the difference-in-differences technique. Health Research Policy and Systems, 22, 172. https://doi.org/10.1186/s12961-024-01272-x

Vasudeva, T., Jangra, R., Sharma, D., Nirola, N., Syal, P., Gupta, R., Sharma, S., Kaundal, H., Khanna, P., Singh, A., & Kiran, T. (2024). Socioeconomic and demographic determinants of health insurance knowledge and coverage among street vendors in a North Indian city. Discover Public Health, 21, Article 210. https://doi.org/10.1007/s44189-024-00210-2

WHO. (2026). Fiscal space for health. World Health Organization.

World Health Organization. (2022). Health system performance assessment: A framework for policy analysis. World Health Organization & European Observatory on Health Systems and Policies. https://www.who.int

Wulandari, V. (2023). Determinan fiscal stress pada pemerintah daerah provinsi di Indonesia (Skripsi Sarjana, Politeknik Negeri Sriwijaya). Polsri Repository. http://eprints.polsri.ac.id/14954/

Xu, S. (2025). Establishment of local government financial sustainability and debt risk prevention and control mechanism. Education Insights, 2(7), 194–200.

Zhang, P., & Guo, H. (2024). Navigating local fiscal sustainability: Topics and challenges. Local Government Studies, 50(6), 1094–1104. https://doi.org/10.1080/03003930.2024.2408629

Zhang, X., Feng, T., Wang, C., & Li, C. (2023). Local fiscal pressure and public health: Evidence from China. International Journal of Environmental Research and Public Health, 20(6), 5126. https://doi.org/10.3390/ijerph20065126