The scale of the challenge is stark when the numbers are laid side by side. Indonesia carries the world’s second-largest tuberculosis epidemic, with approximately one million cases and 130,000 deaths each year, many from diseases with known cures. Stroke and other non-communicable diseases have become the leading causes of death, while maternal mortality remains stubbornly high at around 144 deaths per 100,000 live births nationally. Yet those national averages conceal a geography of inequality that is among the most dramatic in the world. Across Nusa Tenggara, Maluku and Papua, maternal mortality reaches 317 per 100,000 live births, close to three times the 114 recorded across Java and Bali. Infant mortality follows the same gradient: 9 deaths per 1,000 live births in Jakarta compared with 37 per 1,000 in the Papua Pegunungan highlands, meaning infants there are almost four times less likely to survive simply because of where they were born.

The Commission’s authors describe how these disparities pull the system in two directions at once. In Java’s crowded cities, the binding constraint is congestion: long waits, full wards and overstretched staff. In the eastern islands and highlands, the constraint is distance itself. A woman in obstructed labour may face a sea crossing to reach the nearest hospital, and the limiting factors are transport, workforce and unreliable basic infrastructure rather than the availability of clinical protocols. Between these extremes lies a third, quieter failure: patients across the country often lack access to integrated, continuous care that connects primary care, hospital services and post-acute or long-term support into a single pathway. Any system designed for Indonesia must answer for the urban patient in a crowded waiting room and the highland patient cut off by water and terrain simultaneously.

On paper, Indonesia has already built one of the most ambitious instruments for universal coverage anywhere in the world. The Jaminan Kesehatan Nasional, administered by BPJS Kesehatan, is the largest single-payer health insurance scheme in existence, and by 2024 roughly 98 percent of the formal identification-holding population was registered. The Commission is careful, however, to draw a distinction that has become central to global health policy debates: coverage is not access. A card cannot be used where facilities are absent, distant or overwhelmed. Disparities in who is actually reached, and in the quality of care once reached, persist across geographic and socioeconomic gradients. The financial sustainability of JKN also bears directly on the quality and reach of services, making the interplay between the public scheme and private systems a core question for reform rather than a technical afterthought.

The timing of the Commission is dictated by demography. Indonesia faces a double burden of disease in which persistent communicable illness coincides with a rapid rise in non-communicable disease, all against the backdrop of an ageing population and an epidemiological transition that demands a pivot from curative medicine towards preventative and geriatric care. Climate-related disasters and conflict add a compounding layer of risk. Layered over all of this is a narrow demographic window: the period around 2030 to 2035, when the working-age share of the population is projected to peak. This is the limited interval in which demographic structure can still be converted into durable economic and social gains. Reforms that arrive after that window closes will yield less, as the ageing population grows and the dependency ratio shifts. The evidence needed to guide those reforms, the authors argue, must be produced now.

Some of the most revealing findings in the Commission’s framing concern the blind spots of the data systems themselves. When Indonesia first assembled its national suicide data, the true toll proved to be many times what official records had shown, concentrated in provinces and rural communities that the aggregate picture had rendered invisible. This is not an isolated artefact. Routine systems poorly capture the experiences of the poorest, most marginalised and most remote populations, so national averages systematically conceal who is being left behind. Health-system data remain fragmented across institutions and administrative levels, with uneven quality that limits rigorous benchmarking. And, perhaps most fundamentally, there is as yet no agreed, measurable definition of what a health system for a high-income Indonesia should actually deliver.

The Commission’s organising concept is what it calls the Centennial Gap: the distance between the health system as it performs today and the system a prosperous, high-income Indonesia will require by 2045. The gap is to be measured across four dimensions: access and coverage, quality and outcomes, efficiency and financial sustainability, and equity and resilience. Defining that gap rigorously, identifying where it most threatens the national ambition, and charting how it can be closed constitutes the Commission’s core mandate. The work is organised into seven interconnected working groups spanning the entire system, from benchmarking current performance to equity and cultural safety, primary care redesign within a decentralised system, hospitals as hubs within people-centred networks, equitable technology adoption across uneven infrastructure, care that withstands climate disaster and conflict, and sustainable financing through revenue mobilisation and insurance reform together.

Methodologically, the Commission commits to harmonised indicators, a consistent standard of method, and case studies that capture subnational realities, with a national narrative that deliberately disaggregates data to expose the inequalities that aggregate figures hide. It is explicitly Indonesia-led, bringing together researchers, clinicians, policy makers and people with lived experience alongside international collaborators, and it positions itself as a partner to reform rather than a substitute for it. The authors note that the government has already set measurable national targets through its medium-term development plan, RPJMN 2025–2029, pursued through an active health-transformation agenda. What is needed now, they argue, is not another vision but independent, rigorous evidence to judge what is working, identify where course-correction is required, and measure progress against a coherent long-term standard.

Beyond the report itself, the Commission intends to strengthen Indonesia’s research and publication ecosystem through partnerships with universities and research institutes across the archipelago, building capacity in the country’s periphery so that local researchers can articulate the challenges of their own regions. This capacity-building dimension reflects a broader recognition that the evidence gap is not merely technical but structural: the institutions best placed to document the realities of remote eastern provinces have historically had the least access to international publication channels and the funding that flows through them.

The case for acting, the authors conclude, is at once moral and economic. Leaving inequity, fragmented evidence and constrained financing unaddressed perpetuates preventable suffering among those already least served while weakening the foundations of Indonesia’s prosperity, since sustained, broad-based growth is impossible without a healthy, productive population and ill health across the life course erodes the human capital on which the Indonesia Emas 2045 vision rests. The Commission began its launch with a single question that frames everything that follows: how can Indonesia develop a healthcare system that provides quality healthcare for the poorest, most remote and most marginalised people in the country? The answer, delivered as evidence-based, actionable recommendations over the coming years, will carry lessons far beyond the archipelago for every nation pursuing universal coverage across difficult terrain.

Subject of Research: Health system reform and universal health coverage in Indonesia ahead of its 2045 centenary

Article Title: Reimagining healthcare in Indonesia for 2045: a Lancet Regional Health – Western Pacific Commission

Article References: Onie, S., Irmansyah, Agustina, R., Nugraheni, W. P., Idris, H., Padmawati, R. S., Balqis, Fuady, A., Dhamanti, I., Hendrartini, J., Dartanto, T., Maharani, A., Haedar, A., Nurdiati, D. S., Ferdiana, A., Good, B. J., Asnawi, A., & Thabrany, H. (2026). Reimagining healthcare in Indonesia for 2045: a Lancet Regional Health – Western Pacific Commission. The Lancet Regional Health – Western Pacific, Article 101992. https://doi.org/10.1016/j.lanwpc.2026.101992

Image Credits: AI Generated

DOI: 10.1016/j.lanwpc.2026.101992

Keywords: Indonesia, universal health coverage, JKN, health equity, maternal mortality, tuberculosis, non-communicable diseases, demographic dividend, health financing, The Lancet Regional Health Western Pacific, Indonesia Emas 2045, primary care