Financing High-risk Pregnancy under Indonesia’s Jaminan Kesehatan Nasional (Badan Penyelenggara Jaminan Sosial): Kartu Skor Poedji Rochyati-driven Referrals, Case-mix Alignment, and Quality Assurance – A Systematic Review

Indonesia’s National Health Insurance scheme (Jaminan Kesehatan Nasional [JKN]) has expanded maternal health coverage nationwide, yet concerns persist regarding its capacity to support equitable, timely, and high-quality care for high-risk pregnancies. This systematic review synthesizes current evidence on how financing mechanisms, referral pathways, and governance structures under JKN influence the management of high-risk pregnancy across the health-system continuum. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 standards, a comprehensive search was conducted in PubMed, Scopus, Garuda, and institutional repositories for studies published between 2015 and 2025. A total of 1148 records were screened, with 36 full-text articles meeting the inclusion criteria. Twenty studies underwent methodological appraisal using Risk of Bias in Systematic Reviews, Risk of Bias in Non-Randomized Studies of Interventions, and the Newcastle–Ottawa scale. Findings indicate persistent misalignment between Indonesia Case-Based Groups’ reimbursement rates and actual costs of obstetric services, particularly for complications requiring intensive or multidisciplinary care. This financing gap contributes to cost-shifting practices and potential underprovision of essential services. Evidence also shows that the Kartu Skor Poedji Rochyati score has strengthened early risk identification and referral decision-making, although its application remains inconsistent in remote and resource-limited primary care settings. In addition, quality-assurance processes within Badan Penyelenggara Jaminan Sosial Health remain fragmented, with limited integration of clinical outcomes, financial incentives, and provider accountability. These systemic gaps constrain the ability of JKN to translate financial coverage into effective maternal health outcomes. The review underscores the need for risk-adjusted tariff reform, interoperable digital referral systems, and outcome-linked quality monitoring to advance maternal health equity. By integrating clinical, financial, and governance perspectives, this synthesis provides a comprehensive foundation for strengthening high-risk pregnancy management within Indonesia’s national insurance ecosystem.