Indonesia’s national health insurance program, JKN, now covers over 96 percent of the population. On paper, this sounds like a major success. However, a closer look at East Java Province home to 38 regencies and cities reveals a different story. Data from the 2025 BPS East Java publication shows that the average insurance ownership across these regions is only 24.58 percent, ranging from as low as 11.76 percent to just 33 percent. So, what truly determines whether a community signs up for health coverage? A recent study from ¶«¾©ÈÈ used an advanced statistical method called Penalized Multivariate Adaptive Regression Splines (PMARS) and found a surprising answer: it is not the number of hospitals that matters most, but access to basic sanitation and clean drinking water.
The research team analyzed five key factors: access to improved sanitation, access to clean drinking water, smoking habits, health complaints, and the number of healthcare facilities. The model they built was remarkably accurate, explaining over 94 percent of the differences in insurance coverage across East Java. Surprisingly, healthcare facilities ranked only fourth in importance. The top drivers were clean water, sanitation, and health complaints.
What does this mean for ordinary people? Simply put, when a household has a proper toilet and clean tap water, its members tend to be healthier and more aware of health risks. This awareness naturally encourages them to seek formal financial protection like JKN. In contrast, communities with poor sanitation often face recurring illnesses, but they may be too focused on daily survival to think about insurance. The study also found interesting interactions: good sanitation weakens the negative impact of health complaints, while access to clean water combined with adequate health facilities creates a powerful push toward enrollment.
Smoking and health complaints also play a role, but in a different way. People who experience frequent illnesses or live with smokers in the household face real, immediate health threats. This urgency drives them to obtain insurance as a shield against unexpected medical costs. However, without basic environmental infrastructure, even this motivation may not translate into actual enrollment.
The message for policymakers is clear. Building more hospitals and clinics is important, but it is not enough. To accelerate Universal Health Coverage and meet Sustainable Development Goal 3, the government must invest in foundational infrastructure: toilets and clean water at the household level. These basic amenities do more than prevent disease they raise health awareness, build community readiness, and create the conditions under which people actively want and use health insurance. For East Java and beyond, the journey to equitable health coverage begins not in a doctor’s office, but in every home’s bathroom and kitchen tap.
Author: Dita Amelia
Details of the study can be viewed at: https://journal.its.ac.id/index.php/inferensi/article/view/8747
