Political economy analysis of health financing reforms in times of crisis: findings from three case studies in south-east Asia | International Journal for Equity in Health

We first describe the set of reforms on which our case studies focus. In the case of Thailand, we focus on the 2002 UCS reform moment, while in Nepal the series of reforms bringing in conditional cash transfers, waivers and exemptions for maternal health services and then waivers and exemptions for basic health care over 2005–2020 is our focus. In Indonesia, it is the flagship Jaminan Kesehatan Nasional (JKN/SHI) reforms since 2014. Next, we briefly describe the context of health financing reforms within each of the case studies. We then focus on the stakeholder roles and analyzed their strategies, and how these influenced (and were influenced by) the reform design, adoption, implementation and results, as well as by crises.

Content of health financing reforms

This section outlines the content of the focal health financing reforms. Further details on the process of their development, their drivers and content can be found in the country studies [9,10,11].

Nepal

In 2005, the Maternity Incentives Scheme was launched – a demand side finance approach, which was supplemented by free maternity services in 2006, when the policy was relabelled the Safe Delivery Incentive Programme (SDIP). From this point, a dynamic of adding ‘free care’ components was established. The programme later developed into the Aama programme, in 2008/9, with payments for deliveries made to facilities (to cover services costs), staff (for incentives) and households (to cover access costs), tiered by ecological region. In October 2007, the Government of Nepal declared all health services at health posts and sub-health posts free of charge to all, so people could more easily access and use basic health care services [21]. In January 2009, universal free care was extended to primary healthcare centres, and free outpatient care for targeted groups was expanded to all districts. This included the provision of 40 essential drugs free of charge at district hospitals, and deliveries became free for all women at government institutions nationwide [22]. These policies aimed to reduce financial barriers to seeking delivery care, provide relief to poor families, promote the utilization of essential health care services, increase maternal and newborn survival, and ultimately improve the health status of women and newborns. Free newborn care was added to the package in 2016 in recognition of the effectiveness and popularity of the Aama programme.

The 2015 constitution of Nepal declared basic healthcare as a fundamental right of citizens, placing the responsibility of financing such care on the central state and the delivery of basic health services on local governments. Additionally, increasing state investment in the health sector and providing health insurance for all were defined as state policies in the 2015 constitution. A specific package of basic health services was defined through the enactment of Public Health Service Act in 2018 and its Regulations in 2020. The list of free essential drugs has been widened to 98 types, which are being supplied primarily through basic health care facilities. Additionally, in 2016, the government introduced a health insurance scheme to cover services beyond the basic health services package. A national health insurance bill was passed in 2017, which enabled expansion of the pre-established health insurance scheme, aiming to ensure quality healthcare through the prepayment and pooling of financial resources. The state covers premium for the citizens identified as poor and target categories, and further complements with substantial budgetary support, making it a tax-financed scheme in essence. More recent reforms include the provision of free essential drugs and free treatment for patients of specific disease conditions, which include cardiovascular disease, cancer, spinal injuries, renal ailments, and sickle cell anemia through the Disadvantaged Citizens Medical Treatment Fund [23].

These reforms have contributed to widening access to health services, but challenges remain in fully implementing these policies. The initiation of these various schemes reflects the government’s commitment to improving public health and reducing inequalities. However, the political commitment has not been backed up by the required resources, thus leading to weak results. For example, the percentage of facilities having the tracer medicines necessary to provide quality care was found to be 41% in 2021 [24]. Similarly, despite the expansion of the publicly administered health insurance scheme throughout the country, only 16% of the population maintained active enrollment status as of the fiscal year 2022/23 and nearly one-quarter of the people did not renew their enrollment status [25]. The UHC service coverage index is still low at 53 and OOP expenditure remains the dominant source of financing [24]. Moreover, the multitude of schemes has led to fragmentation in the health financing architecture. Such challenges were the drivers for the development and endorsement of a national health financing strategy in 2023, which has been on the agenda for more than a decade. This recent strategy focuses on mobilizing equitable resources for health towards achieving UHC [26].

Thailand

During the period between the 1970s and 1990s, Thailand had made progress towards establishing prepayment mechanisms for different groups within its population. These included the Medical Welfare Scheme (MWS) covering the poor, elderly, disabled, children under 12 years old and other vulnerable population groups, the Civil Servant Medical Benefit Scheme (CSMBS) for government employees, including their dependents, the Social Security Scheme (SSS) for private-sector employees, and the Voluntary Health Card Scheme, as a voluntary scheme for self-employed and/or informal workers. However, by the early 2000s, 29% of the population was still not covered by any form of health insurance [27, 28].

In order to extend coverage to the entire population and achieve UHC, the 2002 National Health Security Act envisaged the introduction of the UCS. The UCS was a tax-funded scheme, initially with a co-payment of 30 Baht per visit or admission (which was then terminated in November 2006). It was established by merging two existing schemes, the MWS and the Voluntary Health Card Scheme, with increased funding from the government (30 billion Baht) which allowed to cover the 30% uninsured population. It did not substitute the existing CSMBS and SSS schemes, but complemented those two by covering the population groups that did not have access to them [28].

The UCS established a comprehensive benefits package with a primary care focus and gatekeeping function [28]. The initial benefit package was designed based on existing ones and in particular the MWS one, and included outpatient, inpatient, medicine and other high-cost services. Subsequent revisions of the benefit package were mandated to be guided by health technology assessment, including cost-effectiveness analysis, budget impact assessment, equity and ethical considerations, and supply-side capacity to scale up. Major additions over time were Anti-Retroviral Therapy (ART) in 2006 and renal replacement therapy in 2008 [29].

Strategic purchasing was introduced with a fixed annual budget per member (capitation based) and a cap on provider payments (age adjusted capitation for outpatient services, and Diagnostic Related Groups (DRG) within an annual global budget for inpatient services), which aimed to put a “hard” limit to the budget and contain costs. Overtime, the capitation payment increased from 1202 Baht per capita in 2002 and to 2693.5 Baht in 2011 due to expansion of the benefit package, labour costs and medical products inflation [27, 28].

The reform also introduced a radical reorganisation of the Ministry of Public Health (MOPH) by creating a provider-purchaser split through the establishment of a new institution, the National Health Security Office (NHSO) responsible for purchasing of health services, and its governing body, the National Health Security Board (NHSB), responsible for setting policy, rules and guidelines and making decisions on the benefits package and on appropriate provider payment methods [30].

Overall, the reform has been considered a major success and a number of documents detail the achievements of UCS and the UHC reform over time. In particular, Evans et al. (2012) stress how the first decade of its implementation achieved improved access to essential health services for Thai citizens, especially for the poor; decreased catastrophic expenditures and household impoverishment; and increased satisfaction of UCS beneficiaries and healthcare providers.

Indonesia

Historically, the country had an assortment of five distinct health insurance categories: (1) serving civil servants and military personnel, (2) catering to private employees, (3) for poor people provided by national government, (4) for poor people provided by regional governments, and (5) private health insurances. Prior to the implementation of JKN, over 74% of the population lacked any form of health insurance coverage [31]. This subgroup was predominantly composed of informal workers, who constituted 54% of the population during that period [32].

As the constitution was amended to ensure the provision of social security and the National Social Security Act (NSSA) Law mandated the availability of national health insurance, in 2014 Indonesia initiated the UHC program called JKN. JKN is operationalized by Social Security Implementing Agency (SSIA) called BPJS Kesehatan. The Law 24/2011 on SSIA changed the management of the various insurance into a single public entity. JKN operates as a non-profit social health insurance program, with mandatory participation for the entire population, financed through participant contributions [33]. The government provides premium subsidies for the economically disadvantaged segment of the population. Central to JKN is the principle of gotong royong (mutual support), wherein individuals in good health support those in need of healthcare, the young support the elderly, and the rich help the poor. In January 2014, more than 121 million participants transitioned to the JKN. They were originally the members of previous schemes (civil servants, the poor, military personnel, and some part of formal workers) [34]. Presently, JKN provides coverage to over 260 million participants, constituting approximately 96% of the population [35].

Participants in the JKN programme are bound by established procedures, including for example initial consultation at a public or private primary healthcare facility. Hospitals may be accessed following a referral from the primary healthcare facility, unless the situation pertains to a medical emergency. The primary healthcare facilities, functioning as gatekeepers, are mandated to manage up to 144 primary diagnoses, thereby serving as a critical mechanism for ensuring quality assurance and cost control within the system. In general, JKN offers a comprehensive range of benefits, encompassing basic outpatient services and extending to catastrophic provisions, such as hemodialysis and cardiac surgeries.

The number of health facilities collaborating with BPJS Kesehatan has increased over the years. In 2014, more than 15,000 primary health care facilities, comprising 9,000 public primary health care (Puskesmas), and 6,000 private clinics, general practitioners, and dentists [34]. Currently, the number of contracted primary care facilities has surged to almost 24,000 [35]. In the context of hospitals, the number has expanded from 1,700 in 2014 to 3,000 in 2023 [34, 35]. In the JKN era, MOH continues to play a significant role in supporting the implementation of JKN towards UHC. The MOH is responsible for the formulation of clinical guidelines, setting technical norms, and allocating funds for subsidizing the poor.

The implementation of the JKN programme has also introduced a strategic purchasing approach aimed at improving the overall performance of the healthcare system. Within this framework, primary healthcare services are remunerated through a capitation scheme, which is calculated based on the number of registered participants at a given facility. In contrast, hospitals operate under the Indonesian Case-Based Groups (INA-CBGs) payment model.

Numerous research studies have been conducted to evaluate the efficacy of JKN programme in increasing population health outcomes. The JKN programme has been associated with improved accessibility to healthcare services, particularly inpatient and outpatient services, increased quality of care for maternal health services, as well as reducing healthcare inequality [36,37,38]. However, some improvements are still needed to leverage the benefits of JKN in Eastern Indonesia where the availability of healthcare service providers remains constrained [37].

Context of health financing reforms

In this section, we provide information on the broader context and background to the health financing reforms in terms of the economic, political and health contexts in which they occurred (see also Box 1 and Table 1 for summary indicators by country). We focus in particular on the shock or crisis that have affected each setting to reflect on their direct and indirect influence on the health financing reform processes.

Nepal

Nepal has passed through a prolonged period of political transition since 1996, from a monarchy to a multiparty democracy, marked by armed conflict, ethnic protests, and frequent changes in government during the last two decades. Key political events included the civil war with Maoists, peace settlement, new constitution, and federalisation. Nepal was also hit by natural disasters, such as the major earthquake in 2015.

Nepal continued to face high levels of poverty (Table 1), though it has been moving out of least developed status. Nepal’s proposal to graduate from the Least Developed Country (LDC) category was endorsed by the United Nations General Assembly 2021 [39]. Per capita GDP, tax revenues, and government expenditure has been growing, however Nepal’s economy has become highly dependent on remittances, which was a major challenge during the COVID-19 pandemic [40,41,42]. Health, one of the strong contributors in the development pathway, also played important role in pulling down poverty in the country [43]. With the reduction in multidimensional poverty from 30% to 17% (2019) in five years, health has the lowest contribution to overall poverty given the low incidence of child mortality among the poor [44]. However, relative to other countries, health remains an important source of poverty.

Following the Comprehensive Peace Agreement (CPA) in 2006, health became a common agenda of the political parties. The constitution of 2015 institutionalised a rights-based approach to health, formulated policy to increase state investment in health, and steered the process for federal restructuring.

While Nepal’s spending in health has increased over the years, it is much lower than the countries in the region and health financing has remained dependent on OOP expenditure. With an average growth rate of 6% per annum (over 20 years- in constant value), per capita current health expenditure in Nepal has reached to US$53 in 2019 [40]. In 2017, the government health expenditures represented around 1.3% of GDP, while the same figures for low-income countries and the region were 2.8 and 2% respectively [45]. In 2000 to 2019, OOP spending has been over 50% of total health expenditure [46].

External actors have played a significant and growing role in the health sector. Within the framework of the Sector Wide Approach (SWAp), which was launched in 2004, the share of External Development Partners (EDPs) in national health budget increased from 21% in 2002/03 and reached about 50% in 2006/07 and 2007/08, later dropping to 28% in 2024/25 [47].

Most health and development indicators for Nepal’s population of 30 million have shown progress, with the incidence of poverty, for example, falling from 47% in 1990 to 20% in 2022 [48]. However, there have been long-standing concerns about maternal health, with maternal mortality ratios per 100,000 live births estimated at 539 in 1996, though now somewhat reduced to 329 in 2018 [44]. Within the health sector, maternal health was established as the common agenda of the government and the development partners in the mid-2000s. This led to the introduction of demand side financing to promote institutional delivery, as described above.

Thailand

During its modern history, Thailand has alternated periods of managed democracy, with continuing strong role of the monarchy, to others of military rule. A major turning point was the 1997 Constitution (the “people’s constitution”), which was the first to be drafted by a popularly elected Constitutional Drafting Assembly and entailed a reformist approach and renewed attention to civil liberties and public participation. This had important effects on the political and cultural context and influenced the results of the 2001 elections, paving the way for social reforms, including in the health sector [49].

However, the struggle to get the Constitution passed became intertwined with the Asian Financial Crisis (AFC) of 1997. Thailand was one of the fastest growing economies in Asia between 1960s and 1990s, but experienced cyclical crises including the 1997 one, which required that the country relies on an International Monetary Fund (IMF) support package to ensure recovery. The country completed the repayment of loans in 2003, but it took 10 years to recover from the crisis so that Gross National Income (GNI) per capita in 2006 was the same as that in 1997 [49].

In the 2001 elections, the newly formed, populist Thai Rak Thai (TRT) Party led by Thaksin Shinawatra proposed policies that appealed to the mass electorate, including a radical health financing reform and won with a large popular mandate [50]. Since 2001, the political history of Thailand has been dominated by the rise and fall from power of former Prime Minister Thaksin Shinawatra, and conflict over the rising military influence in politics [51].

Other critical events that occurred in Thailand during the 2000–2020 period include:

• The conflict due to the separatist movement in three South Muslim-majority provinces, which significantly worsened since 2004 but declined after a peak in 2010. Almost 7,000 people are estimated to have died and the conflict is still unresolved;

• The 2004 Indian Ocean earthquake and tsunami caused over 5,000 deaths;

• Floods in 2011 resulted in economic losses estimated at US$46 billion;

• Thailand was one of the first countries affected by the global COVID-19 pandemic in 2020. While it was relatively successful in containing the virus, its tourism-dependent economy was badly affected [9].

Despite political changes and instability, health has been a constant political priority in Thailand since the 1970s and has enjoyed continued political commitment. This has resulted in significant investment in health infrastructure and in particular primary health care, district and provincial referral hospitals, as well as support to a functioning healthcare workforce, ensuring rural retention through multiple strategies [27, 52]. During the decade of the 2000s, Thailand introduced several major health financing-related reforms to ensure a continuous gradual expansion of the health insurance coverage.

In terms of health financing, there has been a clear trend of increased public expenditure (general tax revenue) and a corresponding reduction of OOP expenses, from 34% to 9% of total health expenditure over 2000–2019, corresponding with the achievement of UHC in 2002 [53]. Development assistance has remained negligible overtime. Achievement in financial risk protection is evident by a noticeable reduction in the number of non-poor households being impoverished by health payment. Curative expenditure dominates total health spending, at about 70% of total [27].

Indonesia

Following World War II, Indonesia declared its independence from the Netherlands. The Undang-Undang Dasar (UUD) 1945 became the constitution and the primary source of state law. At the onset of its independence, Indonesia grappled with formidable political and economic challenges [54]. The political landscape was challenged by the large and diverse landscape, lack of cohesion, legacies of colonialism and separatist movements [55]. Concurrently, Indonesia’s micro and macroeconomic conditions faced stagnation, characterized by soaring inflation rates, an economic blockade, and an empty state treasury [56]. By 1950, political stability and a more consolidated Indonesian government emerged, particularly with the establishment of the Unitary State of the Republic of Indonesia [57].

The evolution of democracy in Indonesia has been very dynamic. From independence to the present, the country has experienced at least four distinct forms of democracy, each marked by upheavals and conflicts [58]. Firstly, there was parliamentary democracy (1945–1959), modelled on the Western concept, where parliament played a fundamental role in the government. However, this form of democracy was deemed less suitable for Indonesia due to the nascent democratic culture. Secondly, guided democracy (1959–1965) emerged, designating the first President Sukarno as the paramount leader in both democracy and revolution. The third phase was Pancasila democracy, marked by a leadership shift from President Sukarno to President Suharto, who then ruled for 32 years amid irregularities such as unfair general elections, restricted political freedom for civil servants, limited freedom of expression, a constrained party system, and widespread instances of collusion, corruption, and nepotism. The last phase is the democracy reform since 1998, triggered by the AFC in 1997/98. This era aimed to reinstate the fundamental principles of democracy, including direct general elections, freedom of the press, decentralization, regional autonomy, protection of citizens’ basic rights, and inclusive political recruitment.

Before being hit by the AFC, Indonesia had achieved impressive gains in economic growth since 1970. Until mid-1997, GDP grew an average of 7% a year, inflation was controlled, and the poverty rate fell to 11% [59, 60]. However, the crisis during 1997/98 was characterized by a fall in GDP of 13%, the collapse of the exchange rate against the US dollar, high inflation, and the poverty rate soaring to 27% [60, 61]. Around the same period as the AFC, Indonesia was also facing a series of natural disasters in rapid succession. These included widespread rice harvest failures in numerous regions due to an extended and intense dry season, infestations of crop pests, and extensive forest fires in Kalimantan. Additionally, mid-May 1998 witnessed riots that swept through many cities, leading to the ousting of President Suharto. Subsequently, this tumultuous period saw the separation of East Timor Province from Indonesian territory.

The AFC also had a direct impact on health financing and health service utilization in Indonesia. At the government level, the crisis reduced government expenditures for health care by 9% and 13% in 1996–1998 and 1998/99, respectively [62]. This declined resulted in shortages of pharmaceutical supplies, such as antibiotics and contraceptive pills [63]. As many households experienced a reduction in their purchasing power during the crisis, access to health facilities also became challenging. Households reduced the share of their budget spent on health services and increased their spending on food [63]. In addition, a significant decrease in utilization of government and private health facilities was also identified [62].

Like other countries in the region, Indonesia is experiencing an epidemiological transition, shifting from communicable diseases to an increasing burden of non-communicable diseases (NCDs) [64]. However, the maternal mortality rate continues to be among the highest in SEA and the poverty headcount remains at 10% in 2020 (down from 15% in 1990) [65,66,67].

Health financing data show an increase in Current Health Expenditure (CHE) from US$16 per capita in 2000 to US$133 in 2020. Out-of-pocket spending also continues to decrease from 45% in 2000 to 32% in 2020 as more people joined the JKN program. In 2020, the government contribution to CHE rose sharply from 30% in 2000 to 55% mostly for the COVID-19 prevention and care. Moreover, Government of Indonesia also increased its spending to pay the subsidy for the poor in the JKN program. In 2023, more than 96 million of poor people in Indonesia was subsidized to participate in the JKN program.

Stakeholder positions and influence

In this section, we focus on the stakeholder roles, their positions in relation to the reforms and the degree of influence that they had over their introduction and implementation. We then move on in the discussion to the analysis of the strategies used by reform leaders to further the reforms. We summarise the findings using the categories proposed by Campos and Reich (2019), including the change teams, political leaders, budget and finance-related groups, bureaucrats, beneficiaries, interest groups and external actors.

Nepal

As summarised in Table 3, in Nepal there was strong political commitment from the major political parties in mainstreaming social protection, including investment in maternal health. This was driven by their political interests and previous commitments during the election period [10]. For example, the Communist health minister in the coalition government of the Nepali Congress and the Communist Party of Nepal-United Marxist Leninist (CPN-UML) in 2004 used their power to introduce the SDIP, which was previously committed to in their party manifesto. The Maoist government was highly supportive of maternity care for leftist ideological reasons. The party also wanted to gain more female votes in the upcoming parliamentary election. All political parties promoted a rights-based approach as per the CPA. This was supported by external development partners, who mobilised technical and financial resources in support of the sector (after initial resistance by some partners, due to concerns about sustainability) and specifically its focus on maternal health. Local democracy, as the system moved to a more federal approach, also promoted the health agenda and specifically women’s health. In addition, Non-Governmental Organizations (NGOs) advocated for maternal health and women’s rights, and some had strong connections to political leadership.

Thailand

There is a broad consensus in the literature that the UHC reform in 2002 was driven by the convergence of political commitment, civil society mobilisation and technical experience and knowledge [28]. However, all analysts stress the key role played by a group of like-minded “reformists” in the MOPH and at the Health Systems Research Institute, who had been systematically documenting health inequities and developing evidence-based policy options to tackle them, including radical financing reforms to achieve universal coverage [28] (Table 4). In 2000–2001, they were able to take advantage of the climate of reform to present the UCS proposals to the TRT Party leader and gain his support. In addition, the change team also developed strong ties with Non-Governmental Organizations (NGOs) and civil society organisations, and in turn, civil society played a key role in securing Parliament’s commitment to UHC.

With political and broader societal backing secured, the change team and technocrats took the lead. To formulate specific policies, the MOPH set up 10 working groups, each with representatives from the public health-care sector, consumer groups and private healthcare providers, and also in collaboration with many functional departments within the MOPH. A committee known as the “War Room”, chaired by the Deputy Minister of Public Health, was set up to coordinate and monitor activities pertaining to policy implementation and to solve emerging problems [28].

There is general agreement in the literature that the UHC reform was not slowed down by budgetary concerns. The decision to adopt an annual per-capita budget for the UCS took away much of the discretionary power of the Ministry of Finance’s Bureau of Budget that had previously done all the budget negotiations [68], based on an opaque “patronage system” (KII 1 Thailand). Efforts were made to create a transparent process that involved multiple stakeholders (e.g., representatives of public hospitals, private hospital associations, academia and NGOs), and was evidence-based, so that the Bureau of Budget became one among numerous other actors involved in the process. This initially generated substantial tensions but was accepted in the longer term [68].

The financial sustainability of the UCS had raised questions from some opposition groups as well as international experts [28]. The World Bank in particular raised concerns that the reform was not sustainable in the longer term due to unpredictability of future costs and too small fiscal space in the context of the recovery from the AFC. It also feared it would bankrupt public hospitals and dilute quality of services [69]. The change team used their links with other international organisations and in particular WHO and the International Labour Organisation (ILO) to counter this criticism and provide greater legitimacy to the reform [69].

Other groups opposed to the reform included the medical profession and private health providers. Doctors in particular were concerned by the system of complaints and malpractice that was being set up and the liability this provision would generate, while private hospitals were concerned about cost sustainability. The change team managed these concerns by dropping the complaints system and ensuring a rapid approval of the reform before opposition could consolidate. In addition, it is noted that the opposition groups lacked the power and resources that the change team had, in terms of political, social and international links [69].

There was also some opposition from within the MOPH, mostly because the reform had changed the internal structure by introducing a provider/purchaser split and redirected most of the MOPH budget to the NHSO. The difficult relationship between NHSO and some within the MOPH resulted in attempts from MOPH “conservatives” to slow the pace of reform and was worsened by critical and adversarial NHSO statements [28]. Only strong political leadership and the fact that the MOPH leadership was mostly in favour of these reform stopped the MOPH conservatives derailing the reform [69]. A change in tone by the NHSO also helped to reduce opposition.

Indonesia

Studies suggest that the success of putting the NSSA law in place was largely due to the leadership of President Megawati [70, 71]. President Megawati used her power and authority to establish a task force to promote social security issues both in government and in the public arena. With this task force, President Megawati formed strategic alliances to prepare draft legislation and academic papers for the NSSA. During this time, members of the task force worked hard not only to prepare the bill, but also to educate the public, the private sector, and even the government and line ministries about the importance and benefits of having a social security system in place. Nonetheless, there were also many conflicting interests from the private sector, business associations, foreign investors, international organisations, and even from within the government itself, who were opposed to the law being enacted. Fears that the forthcoming social security law would hamper the business of private insurance companies, reduce business profits, and disrupt the state budget were among the reasons for opposition. In dealing with the groups that opposed the draft of NSSA law, the task force team had to negotiate and make some compromises, particularly on the issue of premium contributions.

Some tensions between the MOH and other ministries, such as the Ministry of Finance (MOF) and the Ministry of State Enterprise, also occurred concerning program administration, membership, and the roles of local government in providing and administering health services [71]. Under the leadership of Minister Nafsiah Mboi (June 2012-October 2014) the support of the MOH towards the social health insurance scheme was more apparent. She demonstrated strong attention towards the scheme and prioritized finalizing the conceptualization and planning for implementation of JKN, while also aiming to expand healthcare facilities and strengthen the capacity of healthcare providers through continuous training [72].

Six working groups involving various people from the health sector and domestic and international experts were established to address key challenges in implementing the JKN. Members of the working groups came from, among others, the Indonesian Medical Association, Health Economists, representatives from the MOF, the National Planning Board, and other organizations. The working groups were set up to ensure the timely and smooth launching of JKN in early 2014. The MOH also participated in designing the social health insurance, together with the NSSA task force team and parliament members [71].

After Megawati stepped down, political momentum slowed, especially during the first period of Yudhoyono’s presidency. Other priorities intervened, and there was a lot of pressure on the government from those who did not want the law to be implemented because they would lose direct access to the social security funds administered by the four state social security companies, as well as pressure from private insurance companies which were concerned about losing their market.

After more than ten years after the launch of the NSSA Law in 2004, the JKN was successfully implemented in January 2014, thanks to continued pressure and support from a variety of stakeholders (Table 5), including parliamentarians, international organisations, and academics. Parliamentarians played a particularly crucial role: their engagement extended to design contributions and urging the government to expedite the enactment of the SSIA law before the stipulated timeframe in the NSSA expired.

The establishment of Komite Aksi Jaminan Sosial (KAJS/Social Security Action Committee) as a civil society response to the delay from the government was significant in pushing the social security reform. The committee comprised of dozens of national labour unions, professional/employee unions, and various social movements, including representatives from farming, fishing, students, and poor urban communities. KAJS serves as the overseeing body responsible for monitoring the implementation of NSSA Law. The committee played a pivotal role in steering the formulation of the SSIA Bill by actively engaging with the government during that period. Employing a multifaceted approach, KAJS actively advocates for the advancement of the SSIA agenda through channels such as dialogues, marches, deliberations, and public demonstrations, and in certain instances, through legal actions taken against the government to expedite the implementation of social health insurance. Substantively, KAJS benefited from the support and guidance of academics and international organizations. During this period, the support for SSIA was far greater than those in opposition. Opposition primarily came from a minority faction of workers/employees and employers’ associations.

Strategies used by change teams to move forward reform

In this section, we examine the strategies used to move forward the reforms in the three cases.

In Nepal, the ‘change team’ was more diffuse, compared to Thailand, but a number of similar strategies are highlighted by the case study, such as the importance of evidence generation, facilitation of policy dialogue between stakeholders, generating support from influential donors, and creating legitimacy through a rights-based approach, grounded in the safe motherhood movement (Table 6). Indonesia’s reform underscores the strategic influence of the executive, as well as organized civil society in supporting political momentum of reform.

In Thailand, the critical role of the reformist group at the heart of the change team emerges (Table 7). This change team identified the political opportunity for the reform and then mobilised essential resources, at the bureaucratic, political and social levels, and put in place effective strategies to ensure progress of the reform [69]. The strategy used by the change team has been called “the triangle that moves the mountain”, because of the synergistic and interlinked mobilisation of civil society and public support, political support and use of evidence and technical experience [28, 73, 74].

Another strategic approach used by the change team was the rapid pace of the decision-making processes. This “blitzkrieg strategy” allowed the change team to gain an advantage against opponents of the reform (for example, the medical profession) as their opposition would only come during the legislative process. Strategic choices and compromises also had to made to ensure the political and technical feasibility of reforms, including maintaining a generous benefits package (to reduce ‘losers’ from the new policy), maintaining the separate SSS scheme, agreeing on funding the new UCS policy from general taxes [28, 52]. When tensions emerged with opposition groups, they were managed through the change team’s strong political leadership and a change in tone towards collective problem-solving. In this sense, encouraging participation, transparency and accountability was also a key strategy to manage tensions with different constituencies (e.g., the private sector and medical professions) and to muster the support of others (e.g., civil society organisations, patients’ groups, etc.). In other occasions, the change team made a strategic use of evidence, explicitly drawing on it to inform or support design choices and mobilising international support through personal networks and publication of results of the UCS, creating a narrative of success that would help protect achievements.

The Indonesian case study highlights a number of similar strategies to those deployed in Thailand and Nepal, including the key importance of mobilising political support, including from the President but also key parliamentary groups. Comprehensive generation of evidence by diverse stakeholders, supported by international organisations was also important, building on earlier reform experiences (Mboi 2015). Other strategies (Table 8) including coordination with diverse groups, establishing policy dialogues, public awareness raising, and use of legal challenges when implementation under President Yudhoyono was lagging. The policy design also drew on national values of mutual support and took urgency from the public exposure to risks highlighted during the 1997/1998 AFC. Engagement of civil society, notably through the KAJS, and its alliance with parliamentarians, were key: during the law-making process, KAJS closely monitored the special session in the parliaments, attended almost every meeting, had a special seat in the discussion room and could comment and send feedback directly to Committee IX members who were present in the discussions [11].