Comprehensive Health Insurance Scheme Research Articles

Household economic burden of type-2 diabetes and hypertension comorbidity care in urban-poor Ghana: a mixed methods study

BackgroundNon-communicable diseases (NCDs) predispose households to exorbitant healthcare expenditures in health systems where there is no access to effective financial protection for healthcare. This study assessed the economic burden associated with the rising burden of type-2 diabetes (T2D) and hypertension comorbidity management, and its implications for healthcare seeking in urban Accra.MethodsA convergent parallel mixed-methods study design was used. Quantitative sociodemographic and cost data were collected through survey from a random community-based sample of 120 adults aged 25 years and older and living with comorbid T2D and hypertension in Ga Mashie, Accra, Ghana in November and December 2022. The monthly economic cost of T2D and hypertension comorbidity care was estimated using a descriptive cost-of-illness analysis technique from the perspective of patients. Thirteen focus group discussions (FGDs) were conducted among community members with and without comorbid T2D and hypertension. The FGDs were analysed using deductive and inductive thematic approaches. Findings from the survey and qualitative study were integrated in the discussion.ResultsOut of a total of 120 respondents who self-reported comorbid T2D and hypertension, 23 (19.2%) provided complete healthcare cost data. The direct cost of managing T2D and hypertension comorbidity constituted almost 94% of the monthly economic cost of care, and the median direct cost of care was US$19.30 (IQR:10.55–118.88). Almost a quarter of the respondents pay for their healthcare through co-payment and insurance jointly, and 42.9% pay out-of-pocket (OOP). Patients with lower socioeconomic status incurred a higher direct cost burden compared to those in the higher socioeconomic bracket. The implications of the high economic burden resulting from self-funding of healthcare were found from the qualitative study to be: 1) poor access to quality healthcare; (2) poor medication adherence; (3) aggravated direct non-medical and indirect cost; and (4) psychosocial support to help cope with the cost burden.ConclusionThe economic burden associated with healthcare in instances of comorbid T2D and hypertension can significantly impact household budget and cause financial difficulty or impoverishment. Policies targeted at effectively managing NCDs should focus on strengthening a comprehensive and reliable National Health Insurance Scheme coverage for care of chronic conditions.

Highlights of Chief Minister's Comprehensive Health Insurance Scheme with Special Reference to Tamil Nadu

Highlights of Chief Minister's Comprehensive Health Insurance Scheme with Special Reference to Tamil Nadu

Government Health Insurance Schemes and Their Benefits to The Indian Population: An Overview

In today’s scenario accelerating cost of health significantly impact the health of people and the populace creating a monetary burden on poor households. One of the key concerns while tackling healthcare disparities is out-of-pocket expenses (OOPE). Providing financial safety and provide universal coverage to the entire populace are the main goal of health schemes. Health policies in India are based on equity prioritising the needs of the poor and underprivileged. Likewise, there is a discrepancy in the consistency of information and knowledge regarding the scheme among the beneficiaries. A review was created to help medical and nursing professionals to gain comprehensive knowledge of various health schemes. We tried to give an overview of various health schemes including Ayushman Bharat Yojana, Aam Aadmi Bima Yojana (AABY), Pradhan Mantri Suraksha Bima Yojana (PMSBY), Rashtriya Swasthya BimaYojana (RSBY), Central Government Health Scheme (CGHS), Employees State Insurance Scheme (ESIC), Employee Health Scheme and various state-level health schemes. include, Yeshasvini Health Insurance Scheme, Mahatma Jyotiba Phule Jan Arogya Yojana, Chief Minister Comprehensive Health Insurance Scheme, Mukhyamantri Amrutum Yojana, Karunya Health Scheme, Awaz Health Insurance Scheme, Telangana State Govt Employees and Journalist Health Scheme, Dr Ysr Aarogyastri Health Care Trust, Mukhyamantri Chiranjeevi Yojana, Rajasthan Government Health Scheme (RGHS), and Aarogya Raksha.

Awareness among the beneficiaries on the features of Tamil Nadu Chief Ministers Comprehensive Health Insurance Scheme

Awareness among the beneficiaries on the features of Tamil Nadu Chief Ministers Comprehensive Health Insurance Scheme

Awareness and Enrolment of Chief Minister Comprehensive Health Insurance Scheme in Poor Cancer Patients in Coimbatore

The Government of India has started several healthcare schemes to provide best-in-class healthcare facilities to several low-income families in the country. Chief Minister’s (CM’s) Comprehensive Health Insurance Scheme (CMCHIS), additionally recognized as Amma Health Insurance, presents low-income households in Tamil Nadu get the right of entry to world-class healthcare services via cashless economic assistance.That way, these people do not have to suffer any financial burden when seeking medical backup. The research states that the government scheme succeeds in Tamil Nadu, particularly in poor cancer patients who took treatment from the government hospital in Coimbatore district and are aware of other life and general insurance companies.

Auditory performance and speech intelligibility among children with cochlear implant under a state-sponsored insurance scheme: a cross-sectional study

Background: Cochlear implant is the intervention for improving the auditory performance and speech ability for children between 6-12 years with congenital deafness under the Chief Minister’s Comprehensive Health Insurance Scheme, a state-sponsored insurance scheme in Tamil Nadu. Until 2020, 4107 children had been provided with a cochlear implant under the scheme. However, the outcome of this intervention was not studied so far. Hence, as a program evaluation auditory performance and speech intelligibility among patients who received cochlear implant under the scheme is studied.Methods: A cross-sectional study was conducted among 203 patients who had received a cochlear implant at least 1 year ago. Children were evaluated for auditory performance and speech intelligibility using revised Categories of Auditory Performance (CAP) and Speech Intelligibility Rating (SIR) scores by trained speech therapists in Government Medical College hospitals. The proportion of good scorers in CAP (level ≥7) and SIR (category ≥ 3) was computed. The difference in proportion between different demographics was tested using the Chi-square test and Fischer exact test.Results: The median CAP and SIR scores of the children were 8 (Interquartile Range – 4) and 3 (IQR – 2) respectively. Almost 2/3rd of the children had good auditory performance and speech intelligibility. Factors that were associated with good auditory performance and speech intelligibility were being a girl child, getting the implant before 3 years of age, and getting it in a private institution.Conclusions: Gender and age at implant influences auditory performance and speech intelligibility after cochlear implant. Hence, early screening for deafness should be made a routine to enable early detection and management, thereby preventing permanent disability.

Gender Inequity in Utilisation of Publicly Funded Health Insurance Schemes- Findings based on insurance data from a Southern Indian State

While Publicly Funded Health Insurance Schemes (PFHIS) can be an effective strategy to achieve Universal Health Coverage by offering financial protection, the extent to which they facilitate gender equity has been less explored. Women constitute one of the main vulnerable groups owing to a combination of health and economic vulnerabilities to access inpatient care services. Gender health equity requires that healthcare resources, such as PFHIS effectively reach women. This study investigates the gender differences in utilisation of Chief Ministers’ Comprehensive Health Insurance Scheme (CMCHIS) by looking at a large volume of claims data covering 2012 to 2014 in the southern Indian state, Tamil Nadu. Previous studies indicate that women in the state had a higher hospitalisation rate than men and are entitled equally to CMCHIS. By disaggregating the data on number of beneficiaries, claim status, average and total claim value, type of procedures based on gender on a random selection of 230265 cases, the paper points out that women’s utilization of CMCHIS is significantly lesser than men. Women constitute only 36% of all beneficiaries and received only half of the total claim value disbursed through the scheme. This pro-male bias was found to be statistically significant and consistent across the scheme years, age group and type of procedures. The study concludes that the gender inequity in utilization of CMCHIS is conspicuous and needs immediate attention from policy makers and administrators. With recent inclusion of COVID19 testing and treatment under PFHIS, the paper urges for further research lest more women are left behind.

A STUDY ON AWARENESS ON AB-PMJAY FOR TREATMENT OF DISEASES WITH SPECIAL REFERENCE TO CANCER CARE IN THANJAVUR DISTRICT OF TAMIL NADU

Ayushman Bharat or Modicare, the Central Government aims to provide a health insurance cover of Rs 5 lakh to 500 million Indians free of cost. This includes families from lower income groups that fall under the socio-economic caste census (SECC) data of 2011. PM-JAY envisions to help mitigate catastrophic expenditure on medical treatment which pushes nearly 6 crore Indians into poverty each year. In Tamil nadu a scheme called ‘Chief Minister Kalaignar’s Insurance Scheme for Life Saving Treatments’ (KHIS) was launched in the year 2009 to ensure that poor and low income groups who cannot afford costly treatment, are able to get free treatment in Government as well as private hospitals for serious ailments. Later this scheme was modified with extended coverage in the year 2011 and re-launched in the name of ‘Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS)’. Under this scheme, the sum assured for each is revised as Rs.1 lakh every year for a total period of four years and for a total value of Rs. 4 lakh. Now, a value addition is made to the exicting CMCHIS, after the launch of PM-JAY, providing an insurance cover upto Rs 5 lakh per family, per year for secondary and tertiary hospitalization

Why is women\u2019s utilization of a publicly funded health insurance low?: a qualitative study in Tamil Nadu, India

BackgroundThe continuing impetus for universal health coverage has given rise to publicly funded health insurance schemes in lower-middle income countries. However, there is insufficient understanding of how universal health coverage schemes impact gender equality and equity. This paper attempts to understand why utilization of a publicly funded health insurance scheme has been found to be lower among women compared to men in a southern Indian state. It aims to identify the gender barriers across various social institutions that thwart the policy objectives of providing financial protection and improved access to inpatient care for women.MethodsA qualitative study on the Chief Minister’s Comprehensive Health Insurance Scheme was carried out in urban and rural impoverished localities in Tamil Nadu, a southern state in India. Thirty-three women and 16 men who had a recent history of hospitalization and 14 stakeholders were purposefully interviewed. Transcribed interviews were content analyzed based on Naila Kabeer’s Social Relations Framework using gender as an analytical category.ResultsWhile unpacking the navigation pathways of women to utilize publicly funded health insurance to access inpatient care, gender barriers are found operating at the household, community, and programmatic levels. Unpaid care work, financial dependence, mobility constraints, and gender norms emerged as the major gender-specific barriers arising from the household. Exclusions from insurance enrollment activities at the community level were mediated by a variety of social inequities. Market ideologies in insurance and health, combined with poor governance by State, resulted in out-of-pocket health expenditures, acute information asymmetry, selective availability of care, and poor acceptability. These gender barriers were found to be mediated by all four institutions—household, community, market, and State—resulting in lower utilization of the scheme by women.ConclusionsHealth policies which aim to provide financial protection and improve access to healthcare services need to address gender as a crucial social determinant. A gender-blind health insurance can not only leave many pre-existing gender barriers unaddressed but also accentuate others. This paper stresses that universal health coverage policy and programs need to have an explicit focus on gender and other social determinants to promote access and equity.

Out-of-pocket expenditure and its predictors for illness of under-five children: A cross-sectional study in urban slums of Eastern India

Introduction:Out-of-pocket (OOP) expenditure influences the access to the healthcare of the marginalized and vulnerable population including under-five children (U5C). The aim of the study is to estimate the OOP expenditure and its predictors in Bhubaneswar, a region of eastern India.Methods:A cross-sectional study was conducted using a semi-structured interview schedule in 20 urban slums of Bhubaneswar. The survey was carried out by using the National Sample Survey Office (NSSO) health consumption schedule 25.0 in which mothers of U5C with illness (n = 530) were interviewed. For data analysis, the nonparametric Wilcoxon rank-sum test and Kruskal–Wallis test were used as tests of significance.Results:The study revealed that the mean OOP expenditure for outpatient department (OPD) care was ₹375.9 (₹219.48). The mean approximated expenditure was ₹1669.8 (₹1131.9) for inpatient department (IPD) care. In OPD care, doctors' fee and medicine cost constituted 65.01% and 50.46% of OOP expenditure, respectively. In IPD care, medicine cost and doctors' fee contributed to 36.62% and 30.54% of OOP expenditure, respectively. The major significant predictors that contributed to increased OOP were gender and delay in approaching the source of treatment in OPD, whereas in IPD no such predictors were observed.Conclusions:This study prominently sheds light on the issue of accessibility and affordability of health services without a comprehensive health insurance scheme for U5C illness among the vulnerable urban slum dwellers to achieve universal health coverage.

Cochlear implantation in different socioeconomic groups - bursting the myth

ObjectivesCochlear implantation does wonders for children suffering from severe to profound hearing loss, especially when the child is less than 12 months of age. However, most studies indicate that detection and implantation are done well beyond that age, owing to poor socioeconomic status, parental education, and income. Taking into account The Chief Minister's Comprehensive Health Insurance Scheme in Tamil Nadu, which provides cochlear implantation free of cost, this study aims to describe ages at presentation and nutritional factors among different socioeconomic classes. MethodsA randomized retrospective comparative study was done between two groups of children based on the socioeconomic status of the family. Group A included children with a parental income of less than Rs. 72,000 and the cost of surgery covered by the Tamil Nadu Chief Minister's Comprehensive Health Insurance Scheme and group B included children with a parental income of more than 72,000 and the cost of surgery covered by the family. Three parameters were considered and compared-the age at presentation to the hospital for diagnosis and management and the weight and hemoglobin. The results were computed, and statistical analysis done. ResultsThere was a negligible difference between the age at presentation between the two groups with the mean age for children belonging to group A being 2.906563 and the mean age for children belonging to group B being 3.540625. Weight among the two groups showed a significant difference with a p-value of 0.023664 at p < 0.05. The difference in hemoglobin values was found to be insignificant, with mean values being 11.0375 g/dl and 11.7375 g/dl for groups A and B respectively. ConclusionThis study has concluded sufficient awareness among different strata of society, despite economical differences, over cochlear implant programs owing to government initiatives of educating people and supporting them with necessary health benefits. Tamil Nadu, as a responsible state of a developing nation, has been proactive in ensuring the accessibility and reach of the health care system in this regard.

Does the Distribution of Empanelled Hospitals have an Impact on the Utilization of Services under State Insurance Scheme?

Context:Tamil Nadu's Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS) aims at reducing inequity by making the health service affordable and available by roping in both the public and private providers.Aims:This study aims to find if there exist any inter-district disparity in the distribution of hospitals empaneled and utilization of services under the CMCHIS scheme.Settings and Design:A secondary data analysis was done using the CMCHIS data on hospitals empanelled and number of claims made in the scheme for the year 2018.Subjects and Methods:The districts were classified into high-developed district (HDD), middle-developed district (MDD), and low-developed district (LDD) based on the Human Development Index. Availability of hospital services was calculated as the number of empanelled hospitals/100,000 families enrolled. Utilization was calculated as the number of claims made by people living in the district per one lakh families enrolled and number of claims made by hospitals under CMCHIS/100,000 enrolled.Statistical Analysis Used:The relationship between enrolment ratio, hospital availability, number of claims made, and Human Development Index across districts was examined using the Pearson's Correlation analysis.Results:Enrolment was highest in the LDDs (22.8%), followed by MDDs (21.9%) and HDDs (18.7%). The number of hospitals per 100,000 families enrolled was the highest in HDDs (8.0) and lowest in LDDs (4.6). The utilization was the highest in HDD followed by MDD and lowest in LDD.Conclusions:The disparity in the hospitals availability and utilization between districts should be addressed by adopting a targeting approach giving priorities to empanelling hospitals in the less-developed districts.

Burden of out-of-pocket health expenditure and its impoverishment impact in India: evidence from National Sample Survey

ABSTRACT In low- and middle-income countries like India, financing of health-care expenditure is predominantly characterized by out-of-pocket (OOP) spending. Given this context, the current study examined the economic burden of OOP health expenditure and resultant impoverishment in India. The study employed nationally representative survey on ‘Health and Morbidity’ conducted by National Sample Survey Organization (NSSO) in 2014 in India. Standard catastrophic, inequality and impoverishment measures were used to analyse the burden and impact of OOP health expenditure. Findings revealed that although the overall incidence and intensity of OOP health expenditure was concentrated among the richer consumption groups, in-depth study of the same in terms of inpatient and outpatient care showed that the incidence of outpatient care was highly concentrated towards the poorer consumption groups. Study also revealed that around 8% of the population fell below the poverty line due to OOP health expenditure in which outpatient care was the main contributing factor (5.8%). Among different socio-economic covariates, rural population, Muslims, Scheduled Castes and casual/agriculture labour were most affected and had higher impoverishment impact. Our findings suggest that there is a need to revisit the approach towards health-care financing in India. Abbreviations: OOP: Out-of-pocket; MPCE: Monthly per capita consumption expenditure; SCs: Scheduled Castes; STs: Scheduled Tribes; OBCs: Other Backward Castes; TCE: Total consumption expenditure; PFHI: Publicly financed health insurance; RSBY: Rashtriya Swasthya Bima Yojana; CMCHIS: Chief Minister’s Comprehensive Health Insurance Scheme; UHC: Universal health coverage

A Study of Experiences of Beneficiaries, Enrollees and Stakeholders of Tamil Nadu Chief Minister's Comprehensive Health Insurance Scheme (CMCHISTN): A Qualitative Study

Recently many states in India have rolled out publicly financed health insurance schemes owing to the poor public health infrastructure. Tamil Nadu Chief Minister's health insurance scheme is one such scheme launched in 2012. The qualitative design of the study pulls out some interesting themes vis the problems faced by the providers as well as beneficiaries with respect to the scheme, the plight of the enrollees. Eight in-depth interviews were conducted with the insurance enrollees and beneficiaries in The Nilgiris district in the state of Tamil Nadu, India. The findings revealed the hardships faced by the beneficiaries to procure smart card both financial and physical. Four formal interview were conducted to gain insight on provider's and other government officials perspective which revealed the problem of delayed reimbursements for the procedures performed to the providers and inputs on how the scheme could be improved based on population's health needs.

A sustainable model for cochlear implantation in the developing world: perspectives from the Indian subcontinent.

The overall prevalence of deafness in India is 0.2%, but the prevalence in the southern state of Tamil Nadu is much higher (around 0.6%) because of consanguinity. Especially in India, establishing cochlear implantation as a treatment modality for hearing loss has been a daunting task, but in the last decade, the cochlear implantation program has emerged as an unqualified success in many states, with over 20 000 cochlear implantations done till date. Several states are sponsoring free implants to children under the age of 6 years and below poverty line. Nearly 3000 cochlear implantations have been performed in Tamil Nadu under the Chief Minister's Comprehensive Health Insurance Scheme, with the goal to have a 'deafness free Tamil Nadu' by 2025. This scheme covers nearly 40 million people in rural areas. Valuable lessons have been learnt from this social experiment. One of the cornerstones of this scheme is the method to deliver habilitation via satellite centers in rural areas at the doorstep of the patient. The outcomes in peripheral centers were found to be statistically similar to those in the main center and correlated well with duration of habilitation. Opening up satellite centers for habilitation across the state of Tamil Nadu has greatly helped to improve the attendance and outcomes. The Indian model has been hugely successful and has helped start similar cochlear implantation programs in neighboring countries such as Nepal, Sri Lanka and Bangladesh.

Determinants of out-of-pocket spending on health among the poor population served by public health services in Peru, 2010-2014Determinantes da despesa por conta própria em saúde da população pobre atendida em serviços públicos de saúde, Peru, 2010-2014

RESUMENObjetivoEl objetivo de este estudio fue averiguar qué factores afectan el gasto de bolsillo en servicios de salud prestados por el MINSA y los gobiernos regionales a la población en condiciones de pobreza monetaria relativa entre 2010 y 2014.Materiales y métodosEstudio transversal descriptivo econométrico con cortes anuales (2010-2014) a nivel nacional con información de encuestas de hogares. La variable dependiente fue el gasto de bolsillo en salud de las personas en situación de pobreza monetaria relativa para costear su atención médica en servicios de salud públicos. Las variables independientes fueron la afiliación al Seguro Integral de Salud (SIS), el nivel de gasto familiar per capita, el grupo de edad (0-5 años), ser mujer en edad fértil (15-49 años), ser persona adulta mayor (mayor de 60 años)), la carga familiar (cuyo indicador proxy fue el número de miembros en el hogar), y el nivel de complejidad del prestador de servicios.ResultadosSólo 5% de la población rural objeto de estudio fue atendida en centros de mayor nivel de complejidad (hospital) frente a 16% de la del medio urbano. Los medicamentos concentraron el mayor gasto de hogares: 44% en los asegurados en el SIS y 62% en los no asegurados (2014). El gasto de bolsillo en salud se asoció positivamente con no estar afiliado en el SIS, el mayor nivel de complejidad del prestador, el nivel del gasto familiar per capita y ser adulto mayor.ConclusionesLa afiliación al SIS es una variable de política relevante para disminuir el gasto de bolsillo en hogares pobres. El menor gasto de bolsillo de la población rural pobre, especialmente vulnerable, está fuertemente asociado con el uso casi exclusivo de servicios provistos por prestadores del primer nivel de atención. Se necesitan políticas específicas de protección de la población adulta mayor en condiciones de pobreza. Para lograr la cobertura universal en salud, Perú necesita políticas más intensivas de protección financiera y de reestructuración de su oferta pública.

Are we are equipped to handle an epidemic of chronic kidney diseases?

Background: The utilization pattern under Tamil Nadu state health insurance program, namely The Chief Minister’s Comprehensive Health Insurance Scheme (CMCHISTN) reveals that chronic kidney disease (CKD) is one of the high expenditure elements and this study explores need and availability of facilities to handle the CKD in the state. The objectives of the study were to estimate the requirement of renal replacement therapy (RRT) including haemodialysis and renal transplant surgery in the population; to compute the available facility and measure the shortfall if any, so as to create an evidence-based comprehensive strategy to handle CKD in Tamil Nadu. Methods: Based on the existing data, the estimated prevalence of CKD is calculated and it is matched with a utilization of services under CMCHISTN so as to arrive the requirements and gaps in RRT. Results: The existing system is able to cover only around 3% of the estimated population needing RRT and projected shortfall is around 68% in HD machines. Conclusions: The government needs to create RRT facility in the public sector covering both MHD and RT along with the suitable preventive strategy to reduce the risk factors and promote an early screening of diabetes and hypertension.

Chief Minister's Comprehensive Health Insurance Scheme Tamil Nadu (CMCHISTN) tool towards Universal Health Coverage (UHC) in Tamil Nadu, India

Background: The state of Tamil Nadu in India is one of the states with better health indicators in the country. With an ambition to provide still better health care to the residents of the state, the possibilities of the journey towards UHC are analyzed. Objectives: To explore the possibilities of using the existing Chief Minister's Comprehensive Health Insurance Scheme (CMCHISTN) as base to reach Universal Health Coverage (UHC) in Tamil Nadu. Methods: The various dimensions of UHC namely people, benefit, and financial protection are analyzed considering the present status in the state particularly the Chief Minister's Comprehensive Health Insurance Scheme and matched with future needs to reach UHC in Tamil Nadu. This provides the vital indications in success towards UHC. Results and conclusion: The gap between the existing modalities under CMCHSITN and requirements for UHC are within the reachable level. With additional resources and effort, it is possible to reach UHC in Tamil Nadu in the near future. CMCHISTN is one of the best available options for reaching UHC in Tamil Nadu.

Health insurance a predominant medium for achieving universal healthcare in India ? A farfetched dream?

In India, there are two kinds of insurances - Social Health Insurance (e.g. Employees State Insurance Scheme) & Voluntary Health Insurance. Even after years of grappling with health insurances, 71% of the healthcare costs are borne by the households. CGHS (Central Government Health Scheme), ESI (Employees State Insurance) and private insurance providers are major participants but they often ignore the population that needs the healthcare insurance the most. Self Help Groups and NGOs extend a number of Community based health insurance schemes. However, this covers only less than 1% of the country?s population. ESIS and CGHS taken together constituted 41% of total spending on insurance. The government has rolled out various schemes like RSBY (Rashtriya Swasthya Bima Yojna) that cover population in informal sector but only the BPL (Below Poverty Line) and marginalized population. Still a large non-formal sector is there that is above the BPL but in dire need of health insurance as they are most susceptible to catastrophic health expenditures and fall below poverty line due to health expenditures. However, achieving universal coverage through compulsory health insurance has several roadblocks like a huge informal sector, uneven income levels, large rural population and variability in government policies. When it comes to healthcare service delivery, private providers account for majority of healthcare expenditure (76.74%). While in the public sector, the major providers are public hospitals, outreach centres, medical education, research and training institutes. A comprehensive health insurance scheme is needed instead of fragmented schemes to provide universal health coverage to the whole population. This short commentary tries to throw light on the inequity of healthcare insurance and service delivery in a complicated healthcare system of urban areas.

Indonesia's road to universal health coverage: a political journey.

In 2013 Indonesia, the world's fourth most populous country, declared that it would provide affordable health care for all its citizens within seven years. This crystallised an ambition first enshrined in law over five decades earlier, but never previously realised. This paper explores Indonesia's journey towards universal health coverage (UHC) from independence to the launch of a comprehensive health insurance scheme in January 2014. We find that Indonesia's path has been determined largely by domestic political concerns – different groups obtained access to healthcare as their socio-political importance grew.A major inflection point occurred following the Asian financial crisis of 1997. To stave off social unrest, the government provided health coverage for the poor for the first time, creating a path dependency that influenced later policy choices. The end of this programme coincided with decentralisation, leading to experimentation with several different models of health provision at the local level. When direct elections for local leaders were introduced in 2005, popular health schemes led to success at the polls. UHC became an electoral asset, moving up the political agenda. It also became contested, with national policy-makers appropriating health insurance programmes that were first developed locally, and taking credit for them.The Indonesian experience underlines the value of policy experimentation, and of a close understanding of the contextual and political factors that drive successful UHC models at the local level. Specific drivers of success and failure should be taken into account when scaling UHC to the national level. In the Indonesian example, UHC became possible when the interests of politically and economically influential groups were either satisfied or neutralised. While technical considerations took a back seat to political priorities in developing the structures for health coverage nationally, they will have to be addressed going forward to achieve sustainable UHC in Indonesia.