The Dilemma of Efficiency and Quality: Organizational Strategies of Public Hospitals in the Era of National Health Insurance

Abstract

The implementation of the National Health Insurance (JKN) through the INA-CBGs payment scheme has posed significant challenges for public hospitals in Indonesia in balancing cost efficiency and service quality. The mismatch between claim tariffs and the actual cost of care, along with increasing demands for quality accreditation, has created complex structural and managerial pressures. This study aims to analyze the organizational strategies of public hospitals in responding to the efficiency–quality dilemma in the JKN era. This study adopts a qualitative-descriptive approach based on phenomenology. Data were collected through in-depth interviews, non-participant observation, and document analysis involving hospital directors, heads of quality units, heads of finance divisions, and senior healthcare professionals. Thematic analysis was conducted to identify patterns of organizational strategies in responding to the limitations of a fixed-payment system. The findings reveal that the success of hospitals in addressing the efficiency–quality dilemma is strongly influenced by the flexibility of organizational structures, integration of quality management systems, and transformational leadership styles. Hospitals that adopt value-based efficiency strategies, decentralize managerial functions, and embed a culture of quality tend to be more adaptive to external pressures. This study underscores the importance of a holistic organizational approach to ensure the sustainability of public healthcare services in the increasingly challenging context of JKN policy.