Indonesia is a country that has historically experienced high levels of geographic inequality in terms of levels of poverty, range in health care access, and in household burden of health care expenses. ^1 23 For much of the late 20th century, the country’s large population was ruled by a strong central government, which often did not prioritize the needs or conditions of its far-flung citizens.18 The country underwent decentralization starting in 2001, which allowed for greater policy experimentation at local levels. This created opportunities for communities to try to improve access to primary health care services, and locally elected leaders began to link promises for expanded health care coverage to election campaigns.18 Over time, successful policies developed at the local level were adopted nationally18, while the national government also began expanding single-payer health coverage. Initially, only civil servants, the police, and the military were covered by national health care, which progressively expanded to include the country’s poorest citizens, and then to bring in coverage for pregnant women.19 21This incremental progress allowed the government to gradually develop and implement laws and regulations, and respond to challenges as they arose, particularly in trying to integrate its many programs into one place.19 20 

In Indonesia, successful health system reforms have been underpinned by a strong legal and regulatory framework.22 The country’s new single-payer national health insurance scheme was put into place over a period of two decades. When it takes full effect in 2019 it is likely to become the biggest single-payer system in the world.20 23The country has faced challenges to the health reform agenda. Worker shortages in parts of the country, poor quality of care, inequitable access, and high maternal mortality rates are all major hurdles.24 The health reform process, combined with the decentralized nature of service delivery, has created communication and management challenges across the health system, which potentially limited efforts to strengthen the quality of health care.22 However, planners and implementers took steps to anticipate these challenges. A former Health Minister, who helped to lead the reform process, wrote that “we tried hard to create the best system possible…but we also knew that we would need to make adjustments as we implemented” 19. Critical elements to creating the framework for successful reform included strong political commitment and buy-in from partners inside and outside of health sectors, including the national planning board, Parliament, and ministries of finance and home affairs.25 Additionally, comprehensive analysis of the national health system - in terms of both coverage and quality - along with multiparty participation in developing and implementing the plans that included national and local-level authorities and input from provider associations; and systematic, continuous monitoring and evaluation that included technical and administrative perspectives and helped ensure successful reform.19