National Health Insurance Program Research Articles

Moving toward universal health coverage with a national health insurance program: A scoping review and narrative synthesis of experiences in eleven low- and lower-middle income countries.

Universal Health Coverage (UHC) aims to provide access to quality health services to all while avoiding financial hardship. Strategies can include establishing a national health insurance scheme (NHIS). However, variations in the progress exist among countries with an NHIS. This study assesses strategies adopted in low- and lower-middle-income countries (LLMICs) with an NHIS to expand UHC. The research entailed a descriptive, qualitative review of the literature on LLMICs that have implemented an NHIS. PRISMA guidelines were used to identify studies and reports. A total of 569 texts were identified from 4 databases. A total of 78 texts were included, spanning 7 countries from Sub-Saharan Africa and 4 from Asia. The search was conducted in March 2023 and updated in April 2024. An analytical framework was used to systematically collect, analyze, and synthesize key features to review healthcare financing mechanisms and coverage dimensions. Countries generate revenue through various public and private means, including taxes, premiums, and out-of-pocket payments. Some have consolidated revenue streams into a single pool for efficiency, while others maintain separate pools. Healthcare services are procured from public and private providers, differing by country. Fee-for-service is the prevalent payment method, but capitation systems have been attempted to control expenses. Population coverage depends on whether enrollment in an NHIS is mandatory or voluntary and on its enforcement. Service provision can be comprehensive and universal or can vary with specific schemes. Mechanisms to avoid financial hardship can involve premium exemptions or subsidies. Progressing toward UHC requires addressing issues of financial sustainability, cost-containment, enrollment expansion, financial protection, and health equity. While policy options are context-specific, this review showcased experiences for other LLMICs committed to UHC with an NHIS. Recommendations on health financing include increasing the allocation of tax revenues to the insurance scheme, merging risk pools, and adopting strategic purchasing.

Implementation of the National Health Insurance Programme in Achieving Universal Health Coverage in Indonesia

Many countries have agreed to and enforced the implementation of Universal Health Coverage (UHC), yet achieving it is only occasionally seen in certain countries. The National Health Insurance (JKN) Programme is an Indonesian government initiative aimed at providing health protection to all residents of Indonesia through the JKN Programme. The oversight of the Programme and its pivotal role in Indonesia's pursuit of Universal Health Coverage (UHC) is managed by the Social Health Insurance Administration Body (BPJS Kesehatan). The objective of the JKN Programme is to furnish the populace with healthcare services and monetary safety. In Indonesia, the JKN Programme represents a concrete endeavour towards realising universal health coverage through the facilitation of health accessibility, financial safeguards, and the enhancement of healthcare service quality for all individuals. Based on this paper's foundation, this study aims to assess how the JKN Programme in Indonesia has been utilised to achieve UHC and identify the factors contributing to its success through a Systematic Literature Review (SLR). The methodology utilised in this research is the literature review approach. This investigation analysed research results linked to the subject matter being studied. Recent journals published between 2019 and 2023 were identified as the data sources for the literature review.

Utilisation of Hospital Outpatient Services by Diabetes Mellitus Sufferers, Analysis of BPJS Kesehatan Sample Data

Diabetes mellitus is a catastrophic disease that burdens the financing of the National Health Insurance or Jaminan Kesehatan Nasional Program, and sufferers continue to increase. Specific participant segments still widely use access for participants with diabetes mellitus to utilise health services at advanced-level referral health facilities. Various factors also influence access to health services at advanced-level referral health facilities. This research aims to analyse utilisation based on membership type and examine the factors that affect the utilisation of advanced outpatient services by JKN participants with DM. This research uses secondary data from the 2022 DM contextual BPJS Health sample data. The data was analysed univariately, bivariately, and multivariately with the Zero Inflated Negative Binomial regression model. The results of statistical tests showed that in outpatient care, age, type of participant, gender, treatment class, and province of participants were significantly different in terms of health service utilisation. The influence of the type of participation in the JKN program significantly affects the utilisation of services in outpatient care; the utilisation of non-recipients of contribution assistance participants is 1.16 times greater than that of the recipient of contribution assistance participants in outpatient care.

Reform of the Calculation of Premium Contributions for State Administrator Participants

This study aims to assess the impact of the reform of the calculation of premium contributions from state administrators collecting based on Presidential Regulation Number 64 of 2020 with Local Government Contribution Reconciliation Application (ARIP), which involves a collaboration with stakeholders, namely the regional government, which is related to increasing the receipt of contributions from regional civil servants in revenue and stakeholder involvement for the sustainability of the National Health Insurance Program. ARIP is an information system that aims to ensure accountability in calculating contributions from regional officials through reconciling contributions between local governments and BPJS Kesehatan. The research used a population of 547 regional governments that used ARIP during 2020-2023. Each sample was analyzed before and after using ARIP quantitatively and descriptively based on receiving contributions from regional civil servants. The hypothesis was tested using paired samples t-test, with significance 0.001< 0.05 and value of t-count = 6.973> t-table = 1.964, then Ha was accepted. Thus, the acceptance of contributions from regional civil servants differs before and after the implementation of ARIP. According to the Cohen classification table, ARIP had a medium impact on accepting the receipt of contributions from regional civil servants, with an effect size of 0.298. Based on the analysis, implementing ARIP increases the receipt of contributions from regional officials, which was 41.303 billion rupiah and increased by 3.234 billion rupiah to 44.537 billion rupiah

Short and long-term mortality of spontaneous bacterial peritonitis in cirrhotic patients.

Spontaneous bacterial peritonitis (SBP) remains a significant concern for patients with cirrhosis. This study aims to reevaluate the trends in both short-term and long-term mortality rates associated with SBP. A retrospective cohort study was conducted using population data obtained from Taiwan's Health and Welfare Data Science Center, Ministry of Health and Welfare. The database, derived from Taiwan's National Health Insurance program, included information from 925 cirrhotic patients discharged after an episode of SBP between January 01, 2014 and December 31, 2015. Each patient's outcomes were tracked for up to 3 years following their initial hospitalization for SBP. The overall mortality rates for cirrhotic patients with SBP at 30 days, 90 days, 1 year, and 3 years were 10.8%, 23.0%, 44.0%, and 60.9%, respectively. Following Cox regression analysis with adjustments for patient age, gender, and underlying medical conditions, the short-term prognostic factors of significance were age (hazard ratio [HR] = 1.03, 95% confidence interval [CI] = 1.01-1.05, P = .001), concurrent sepsis (HR = 2.73, 95% CI = 1.82-4.08, P < .001), and renal function impairment (HR = 3.28, 95% CI = 2.07-5.18, P < .001). Although the 30-day mortality rate for SBP in cirrhotic patients is around 10%, the long-term mortality remains significantly high. Renal function impairment and the presence of concurrent sepsis serve as indicators of poor short-term prognosis in cirrhotic patients with SBP.

Public Health Insurance and Healthcare Utilisation Decisions of Young Adults.

This paper investigates the impact of a dependent coverage age-eligibility rule on young adults' health and healthcare utilisation under Indonesia's National Health Insurance (NHI) program. Employing a regression discontinuity design, analysis of the NHI administrative data documents a significant 14.6 to 20.9 percentage points drop in coverage among young adults at age 21, the age cut-off imposed by the rule. Using a large nationally representative household survey, this paper shows that the loss of insurance coverage does not change young adults' health status but markedly decreases the utilisation of outpatient care among those who are ill. Specifically, there is an abrupt 5.3 to 8.4 percentage points reduction in the probability of young adults having any outpatient visit in the past month, primarily driven by lower utilisation of primary care services. The study also finds an increased likelihood of self-treatment and the use of traditional healers, indicating a substitution effect. Further analysis shows a larger impact on those who are poor, less educated, and live in regions with higher healthcare costs.

Strategi Pemasaran Klinik Pratama Mutiara Bunda Tabanan berbasis SWOT untuk Meningkatkan Kunjungan Pasien

This study aims to evaluate the marketing strategy of Klinik Pratama Mutiara Bunda Tabanan to increase patient visits and strengthen the clinic's position in the local market. The clinic faces challenges in capitalizing on external opportunities despite having strong internal strengths and suboptimal marketing strategies. The research employs SWOT analysis, IFE and EFE matrix mapping, and interviews with clinic management and staff. Based on the SWOT analysis, the clinic is positioned in Quadrant II, indicating potential for growth if internal strengths are fully leveraged and challenges are addressed. The study recommends strategies to increase patient visits, including combining social media promotions with direct outreach, improving service quality by hiring specialist doctors, and forming partnerships with BPJS (the Indonesian National Health Insurance Program). These measures are expected to expand the market, enhance patient satisfaction, and strengthen the clinic's position in the local healthcare sector. The study concludes that Klinik Pratama Mutiara Bunda has the potential to overcome external challenges by improving service quality and implementing more effective marketing strategies, enabling the clinic to increase its competitiveness and long-term performance.

Association of herpes simplex virus infection and vitiligo: a nationwide retrospective cohort study.

Several studies have proposed viral infection with herpes simplex virus (HSV) as a probable cause of vitiligo. We aimed to examine the association between HSV infection and vitiligo. We used the National Health Insurance Research Database of Taiwan to perform a comparative analysis of the study population with or without a diagnosis of HSV infection. The study period was from January 1st, 2008, to December 31st, 2019. The primary outcome was the date of first vitiligo diagnosis, death, withdrawal from the National Health Insurance Program, or end of the study. We performed 1:1 propensity score matching based on age, sex, and comorbidities, resulting in 1,009,445 matched pairs of patients with and without HSV infections. The adjusted hazard ratio for developing vitiligo in the HSV cohort was 1.71 (95% confidence interval, 1.59 - 1.83; P < 0.001). An age-dependent pattern was also observed among HSV-infected patients with vitiligo (P for interaction < 0.001). Both sexes exhibited a significantly higher risk of developing vitiligo in the presence of HSV infection. The HSV cohort significantly increased cumulative vitiligo risk compared to the non-HSV cohort in a 12-year follow-up (log-rank P < 0.001). The result of sensitivity analysis was compatible with that of primary analysis. Patients with HSV infection had a considerably increased vitiligo risk within the 1-year follow-up than the non-HSV cohort (adjusted hazard ratio, 4.83; 95% confidence interval, 4.04 - 5.77, P < 0.001). This nationwide population-based study demonstrated an association between HSV infection and an increased risk of vitiligo. Further investigation of HSV DNA in the affected regions of vitiligo lesions may help to establish causality.

Correlation between the utilization of sodium-glucose cotransporter-2 (SGLT2) inhibitors and the risk of dementia: a nationwide population-based study in Taiwan.

The impact of sodium-glucose cotransporter 2 inhibitors (SLGT2i) usage on reducing the risk of dementia remains uncertain. Our research seeks to establish the association between dementia risk and SLGT2 inhibitors among individuals with diabetes.This study relied on data from the Taiwan National Health Insurance Database (NHIRD), which was established in 1995 coinciding with the launch of the National Health Insurance (NHI) program by the Taiwanese government. The NHI program was implemented to enhance the healthcare system and public health in Taiwan. Patients with type 2 diabetes mellitus (T2DM) administered SGLT2i between 2016 and 2019 were included in the SGLT2i cohort. The comparison cohort consisted of patients who did not receive SGLT2i, propensity score matching by sex, age (in 5-y intervals), index date year, insurance fee, urbanization, comorbidities, and medications, with a 1:1 ratio of the exposure group.SGLT2i users had a significantly lower risk of dementia than non-SGLT2i users after adjusting for age, sex, insurance fees, urbanization, comorbidities, and medications (adjusted HR = 0.53, 95%CI: 0.50-0.57).The results revealed that patients treated with SGLT2i have a lower risk of dementia in Taiwan.

Associations of paternal age with offspring under-five mortality and perinatal outcomes: a cohort study using claims data in Taiwan

BackgroundThe causal relationship between advanced paternal age and offspring health is unclear, owing to familial confounders. This study examined the association of paternal age with offspring’s under-five mortality and perinatal...

Monitoring, Evaluation, and Analysis of BPJS Referral Implementation at Primary Healthcare Facilities: Literature Review

The Social Security Administering Body (BPJS) is a social institution in Indonesia that organizes social security programs. The National Health Insurance Program (JKN) aims to improve community welfare through a capitation financing system at First Level Health Facilities (FKTP). The high number of referrals suggests that the referral system at Puskesmas has not been properly implemented, highlighting the need for monitoring and evaluation. This study aims to assess the implementation of BPJS referrals at FKTP. A literature review was conducted using Google Scholar to find relevant articles published from 2020 to 2024, resulting in the collection of seven journals. Findings indicate that while monitoring and evaluation of BPJS referrals are ongoing, implementation is not optimal and faces challenges.

Suicide-related risk among patients using branded and generic fluoxetine: a propensity score-matched, new‐user design in Taiwan

BackgroundTo date, the clinical equivalence between branded and generic medications remains debate and may sometimes be a reason why psychiatrists are hesitant to prescribe generic medications. Depression is recognized to exacerbate suicide risk globally and selective serotonin reuptake inhibitors, such as fluoxetine are common treatment options. Therefore, this study aimed to explores differences in suicidal risks between users of branded and generic fluoxetine in Taiwan.MethodsThis cohort study used Taiwan Longitudinal Health Insurance Database, encompassing 2 million individuals covered by National Health Insurance (NHI) program. The full cohort consisted of 32,298 fluoxetine new users. Then, 7,380 branded and 7,380 propensity score matched (PSM) generic fluoxetine new users were identified. The study further utilized Cox proportional hazards models to assess risk of 5-year suicidal ideation, suicide mortality, and all-cause mortality.ResultsThe study revealed that the adjusted hazard ratios (HRs) for suicidal ideation, suicide mortality and all-cause mortality in branded users were 0.766 (95% CI, 0.497 − 1.181), 0.660 (95% CI, 0.447 − 0.975), and 0.942 (95% CI, 0.849 − 1.045), respectively, when compared with matched generic fluoxetine users. Stratified and sensitivity analyses showed the lower risk of suicide mortality in specific subgroups, such as male (adjusted HRs = 0.536, 95% CI = 0.306–0.939) and young branded users (adjusted HRs = 0.549, 95% CI = 0.334–0.904).ConclusionThis study observed trends in the prevention effects of suicide-related risks. However, only suicide mortality was statistically significant, especially in males and those aged < 40 years. These insights may assist clinicians and policymakers in decision-making.Clinical trial numberNA (This study is a cohort study utilizing the national health insurance database, not a clinical trial).

Healthcare utilization among foreign beneficiaries of the National Health Insurance program in Korea.

To explore the factors related to healthcare utilization (both inpatient and outpatient services) among foreign beneficiaries of the National Health Insurance (NHI) in Korea. The total foreign beneficiaries of the NHI in Korea 2022 were included (n = 1,386,329). For the dependent variables, utilization and either hospital stays or count of visits were used. And the independent variables were selected guided by Andersen's behavioral framework: predisposing characteristics (e.g., sex, age, nationality), enabling characteristics (e.g., insurance premium ranking, residency status, residency period, place of residency, beneficiary type), and need characteristics (e.g., disability, CCI, chronic diseases). We conducted a two-part model analysis employing Andersen's behavioral framework, using health insurance claims data from 2022. The results indicated that individual need characteristics, such as disability, CCI, and chronic diseases, had the most significant impact on total healthcare utilization and its associated costs. The next significant characteristic was the residence period; the longer the period, the higher the likelihood of healthcare utilization, but the lower the associated costs. Among the predisposing characteristics, individuals aged 65 years and older had the most significant impact on healthcare costs. Additionally, among the enabling characteristics, residency period, residency status, and beneficiary type were most significant. Foreigners residing in Korea are eligible to use the Korean healthcare system by enrolling in NHI. As the foreign population is projected to grow even faster due to Korea's aging society and low birth rate, this study can assist public health administrators in formulating evidence-based policies.

Challenges And Strategies For Implementing Performance-Based Capitation In Indonesian Community Health Center : A Scoping Review

This study examines the implementation and challenges of performance-based capitation (KBK) at Community Health Centers (Puskesmas) in Indonesia, as a part of the National Health Insurance Program, aiming to improve the efficiency and quality of primary health services. Despite its potential, the implementation of KBK faces various challenges including inadequate human resources, limited infrastructure, and insufficient monitoring systems. The study uses a scoping review framework based on the Public Health Care Monitoring Conceptual Framework by WHO, analyzing 11 selected studies from 2021 to 2024. Findings indicate that internal factors such as management capacity, health worker competence, and organizational culture significantly impact the effectiveness of KBK. External factors like local government support, funding policies, and infrastructure availability also play crucial roles. Technological barriers, particularly in remote areas, hinder optimal policy implementation. The study emphasizes the need for clear regulations, consistent policy dissemination, and effective monitoring to ensure successful KBK implementation. Recommendations include strengthening leadership, training health workers, improving infrastructure, and enhancing digital health technology utilization. These strategies aim to optimize resource allocation, enhance service access, and improve patient satisfaction in Indonesia’s primary health care system.

Peran Hukum Kesehatan dalam Melindungi Peserta Program Badan Penyelenggara Jaminan Sosial Kesehatan Berdasarkan Undang-Undang Nomor 24 Tahun 2011

The role of health law is crucial in ensuring the protection of participants in the National Health Insurance (BPJS Kesehatan) program, as regulated by Law No. 24 of 2011. This law provides a legal basis for the implementation of the national health insurance program, which aims to promote the welfare of society by providing equitable access to quality healthcare services. Health law functions to protect the rights of BPJS participants by ensuring that they receive healthcare services that meet established standards without discrimination.Furthermore, this law mandates the state to provide comprehensive and inclusive health insurance. Through the role of BPJS Kesehatan, health law also regulates the supervision and enforcement of accountability from healthcare providers, both in terms of service quality and financial management. Healthcare institutions collaborating with BPJS are required to comply with professional standards and medical ethics, as well as being responsible for patient safety.In the event of violations, health law provides a mechanism for participants to file complaints and seek justice through legal channels. The application of administrative and criminal sanctions for violators is also part of the legal protection efforts for participants. Therefore, the role of health law not only ensures access to services but also guarantees that the rights of BPJS participants are fulfilled in receiving fair and quality healthcare services.

Mas'uliyah Society Brand Resonance: Enhancing Sustainable Marketing Performance of the National Health Insurance Program

Mas'uliyah Society Brand Resonance: Enhancing Sustainable Marketing Performance of the National Health Insurance Program

THE IMPACT OF DRUG COST ON MEDICATION ADHERENCE IN NIGERIA: A PERCEPTION AMONG PHARMACISTS

Background: Given Nigeria's huge economic instability, medication expenses may significantly impact medication adherence, creating a barrier to the treatment of various ailments. The study aimed to assess pharmacists' perceptions about the impact of drug costs on medication adherence in Nigeria. Methods: The study was cross-sectional among practicing pharmacists across Nigeria. The 25 items semi-structured questionnaire was administered online using simple random sampling with the snowballing technique to recruit the pharmacists for the study. The collected data was coded into Microsoft Excel 2016 and subsequently analyzed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were utilized to summarize the data, providing an overview of the demographic characteristics and key findings. Inferential statistics, specifically Pearson’s Chi-square test, were employed where applicable to determine the relationships between variables. Results: Total 161 pharmacists responded to the survey, giving an 80.5% response rate. The respondent rate was mainly young pharmacists (20–30 years old; 82.6%) and predominantly male (51.6%). Almost all the respondents possess only a bachelor of pharmacy degree (91.9%). Total 90% have practiced for 5 years or less, mostly in community settings (60.9%). Generic substitution has been cited as the most important technique to manage drug costs. Non-adherence due to cost was associated with practice settings, whereas adherence counseling was correlated with gender and setting of practice. All differences were not statistically significant at p&lt;0.05. Conclusions: Most participants believe that the cost of medication is a major barrier to accessing quality healthcare and drives massive non-adherence among those who can barely afford the medicines. Implementing a comprehensive national strategy to enhance the healthcare system, expand the reach of the national health insurance program, and promote cooperation among healthcare practitioners will result in improved clinical outcomes for patients. Peer Review History: Received 22 May 2024; Revised 11 July 2024; Accepted 26 August; Available online 15 September 2024 Academic Editor: Dr. A.A. Mgbahurike, University of Port Harcourt, Nigeria, amaka_mgbahurike@yahoo.com Average Peer review marks at initial stage: 5.5/10 Average Peer review marks at publication stage: 7.0/10 Reviewers: Prof. Hassan A.H. Al-Shamahy, Sana'a University, Yemen, shmahe@yemen.net.ye Dr. George Zhu, Tehran University of Medical Sciences, Tehran, Iran, sansan4240732@163.com

Maternal autoimmune disease and offspring risk of haematological malignancies: a case–control study

Autoimmune diseases are known to be associated with an increased risk of cancer. Whether maternal immune dysregulation can have an impact on the development of haematological malignancies in offspring remains uncertain. Therefore, we explored the association between offspring risk of haematological malignancies and maternal autoimmune disease using a real-world nationwide population-based study. In this case-control study, we identified 2172 children with haematological malignancies between 2004 and 2019 from Taiwan's National Health Insurance program and compared them with population-based controls without haematologic malignancies, who were matched with each individual at a ratio of 1:4. The medical information of the autoimmune mothers were obtained from the Taiwan Maternal and Child Health Database. Conditional logistic regression was used to estimate the odds ratio for haematologic malignancy in offspring. Furthermore, subgroup and stratified analyses were conducted. Among the rheumatologic diseases in our study, Crohn's disease was the most common disease both in the haematological malignancy group (1.1%) and the control group (0.9%). In multivariable analysis, the odds ratio for haematological malignancy in offspring with maternal autoimmune diseases was 1.2 (95% confidence interval [CI] 0.91-1.58). The overall risk of haematologic malignancy was not significantly higher when adjusted for specific risk factors, including neonatal age, maternal age, family income, urbanization, maternal occupation, birth weight, or maternal comorbidity, except for prematurity. When comparing different autoimmune diseases among haematological malignancies and the control group, maternal psoriatic arthritis/psoriasis had the highest adjusted overall risk for haematological malignancies (adjusted OR 2.11, CI 0.89-5), followed by ankylosing spondylitis (adjusted OR 1.45, CI 0.7-3), autoimmune thyroiditis (OR 1.26, CI 0.57-2.81), systemic lupus erythematosus (OR 1.21, CI 0.48-3.02), Crohn's disease (OR 1.19, CI 0.75-1.9), and Sjogren's syndrome (OR 1.18, CI 0.65-2.15), but no significance was reached in these analyses. Multivariable analysis of risk factors associated with haematological malignancy subtypes was done. It showed no associations between maternal autoimmune disease and childhood haematological malignancies. We found no significant relationship between maternal autoimmune disease and childhood haematological malignancies. The influence of maternal immune dysregulation on the next generation with respect to haematological malignancies development may be limited. There was no funding source for this study.

Citizens' rights in obtaining optimization of the implementation of the national health insurance program

This study aims to analyze the rights of citizens in obtaining optimization of the implementation of the national health insurance program. This research is in the form of normative or doctrinal legal research/library research, using a statutory approach and conceptual approach. The results of the study reveal that the implementation of the right to health based on the mandate of the 1945 Constitution in Indonesia has not been maximally implemented. This can be seen from the application in terms of facilities, health workers and the application in terms of the national health insurance system. Optimizing the implementation of the guarantee with the issuance of Presidential Instruction of the Republic of Indonesia Number 1 of 2022 concerning Optimizing the Implementation of the National Health Insurance Program was also found to be disharmonized with the principle of Portability and the non-fulfillment of the value of justice or equality of National Health Insurance participants, especially the rules on migrant workers. Therefore, it is necessary to conduct an evaluation related to the fulfillment of citizens' rights to health, as well as to review the Presidential Instruction of the Republic of Indonesia Number 1 of 2022 concerning Optimizing the Implementation of the National Health Insurance Program, especially regarding the obligations of pilgrims and migrant workers to remain active participants, so that the value of the principle of benefits can be obtained by all JKN participants fairly.

Analysis of the Governance System of National Health Insurance Referral Patients at the Outpatient Polyclinic of Dian Harapanjayapura Hospital, Papua

The National Health Insurance (JKN) program, which has been running since January 1, 2014, has been widely benefited by most of the community. This program makes it easy for the public to access health services. However, the implementation of JKN for nine years often faces problems and challenges, one of which is governance. Many parties involved in this JKN program include BPJS Kesehatan as the organizer, the Ministry of Health as a regulator, Health Facilities (hospitals) as service providers and Professional Associations. This research is a qualitative research with a type of program review (governance system). The data collection process is carried out by conducting observations, interviews, analysis and documentation. Data analysis is in the form of an explanation of the situation being studied, while the presentation is in the form of a story explanation. This is in accordance with descriptive research which is the study of observations on the object of research to obtain an overview and actual circumstances. This research has been conducted at Dian Harapan Jayapura Hospital in Papua in February 2024. Based on the results of the study, it was found that inputs, processes and outputs related to the governance of National Health Insurance referral patients at the Outpatient Polyclinic of Dian Harapan Jayapura Hospital Papua were based on an assessment of human resources, facilities and infrastructure, Standard Operational Procedures, constraints and problem solving processes. The results of the study based on the influence of Human Resources show that training related to BPJS has not been carried out evenly for all personnel, including the evaluation of services has not been carried out regularly. The Assessment of Facilities and Infrastructure is considered to have been fulfilled only due to disturbances in the queue machine, the V-Claim application and Scan Finger interference. The assessment of SPO is considered to be available and understood, but there has been no routine evaluation to assess the progress of SPO implementation. The assessment of the obstacles that are often experienced is the disruption of the V-Claim Application and the queue system is still offline because the patient has not used the Mobile JKN Application so that the patient comes early in the morning to take the queue number. In terms of handling problems in stages starting from internal, if necessary, coordination between units or coordination with management with higher authority will be carried out. The conclusion in this study is that Human Resources have a great influence on services, in terms of the number that has been fulfilled, it is still necessary to evaluate the progress of services such as obstacles to delays in the doctor's practice schedule to be corrected according to the agreement so as not to affect service satisfaction. Regarding Facilities and Infrastructure, it is still considered good, it only needs to be added to facilitate online registration by increasing the benefits of the Mobile JKN Application, including the Queue Display facility at the Polyclinic. The applicable Standard Operational Procedures have been implemented, but there has not been a routine evaluation of the implementation of the SPO has been carried out appropriately or still requires additional SPOs to support services. Regarding obstacles and the solution of obstacles, it is considered good. Each officer is already independent in handling problems.