Introduction
Globalization has accelerated the flow of labor across borders, making international migration an integral component of economic and social development1). Japan, as one of the major destinations for foreign workers in Asia, has experienced substantial growth in its migrant workforce. In 2023, Vietnamese nationals represented the largest group of migrant workers in Japan, accounting for approximately 24.8% of the total number (570,000 workers), followed by migrant workers from China (400,000) and the Philippines (240,000). Although these countries dominate in terms of overall numbers of workers, Indonesia ranks among the fastest-growing sources of labor, with a 39.5% year-on-year increase, alongside Myanmar (61.0%) and Sri Lanka (33.7%). By industry, foreign workers are concentrated in the manufacturing (26.0%), services (15.4%), and wholesale and retail (13.0%) sectors, with notable expansions in healthcare and social welfare (28.1%), construction (22.7%), and hospitality (16.9%), such as hotels, restaurants, and tourism-related services2).
Indonesia has a long history of labor migration and is becoming an increasingly vital partner in Japan’s workforce strategy. In November 2023, Indonesia’s Ministry of Manpower and the Japan International Cooperation Agency announced plans to send 100,000 Indonesian workers to Japan over the next 5 years3). This large-scale initiative operates through a strong domestic infrastructure in Indonesia comprising 547 organizations sending technical interns and specified skilled workers (SSWs)4).
Through these channels, Indonesian workers are deployed primarily under Japan’s Technical Intern Training Program (TITP) and SSW program. The TITP provides opportunities for migrants to acquire technical skills and on-the-job training for up to 5 years, whereas the SSW program, established in 2019, allows qualified workers with proven skills and Japanese language proficiency to work independently in sectors such as nursing care, agriculture, construction, and manufacturing. This structured pathway enables Indonesian workers to advance from trainees to skilled professionals, contributing substantially to Japan’s labor market and Indonesia’s economic development5).
In accordance with Article 67 of the Industrial Safety and Health Act of Japan, the Japanese government must provide any workers who are engaged in work that has the potential for serious health consequences, such as cancer, a Notebook of Personal Health Record (nPHR) after they finish their work. As part of their rights and government obligation, workers receive follow-up health measures related to their exposure to hazardous materials6). Since 1991, these requirements have applied equally to Japanese and foreign workers. However, Indonesia’s workers face challenges in using the nPHR after they have left Japan.
In this study, we highlight the preparedness of local policies, facilities, and other resources in implementing a standardized health checkup system for Indonesian migrant workers with an nPHR returning from Japan. Data collected from hospitals in Jakarta’s greater area representative sources to illustrate on-the-ground conditions and institutional readiness. Based on these findings, we discuss the feasibility of integrating the nPHR system into Indonesia’s healthcare system. Establishing such a framework would not only safeguard the health of returning migrant workers but also contribute to long-term public health resilience. We emphasize the principal strengths and notable shortcomings, as observed from an academic medical standpoint. We are engaged in the Overseas Health Check-up Initiative (OHCI) Project, which is supported by the Ministry of Health, Labour and Welfare of Japan7).
Results
General information
Indonesia is a tropical archipelagic nation in Southeast Asia bordered by Malaysia, Papua New Guinea, and Timor-Leste and surrounded by the Indian and Pacific oceans. With a total land area of approximately 1.9 million km2, Indonesia is the largest archipelagic nation in the world, comprising more than 17,000 islands. Administratively, the country is divided into 38 provinces, each with its own local governance system. Geographically, Indonesia is often categorized into five major island regions: Sumatra, Java, Kalimantan (Borneo), Sulawesi, and Papua, along with numerous smaller island groups. Jakarta, located on the island of Java, serves as the capital and economic hub of the country, with Surabaya, Medan, Bandung, and Makassar representing other major urban centers8).
As of 2023, Indonesia’s population exceeded 278 million, making it the fourth most populous nation globally9). The country is highly diverse, home to more than 1,300 recognized ethnic groups and over 700 local languages, with Javanese, Sundanese, and Malay being the largest ethnic communities. The population distribution is uneven, with Java alone accounting for nearly 56% of the total population of Indonesia8). As of 2024, it was estimated that Indonesia’s urban population was at 158.8 million, with 119.2 million people residing in rural areas, reflecting the ongoing but uneven urbanization trends8,9).
In 2025, Indonesia’s labor force included 153 million people aged ≥15 years. The agriculture, fisheries, and forestry industries employ approximately 40% of workers, with the services and manufacturing sectors experiencing substantial growth in recent decades10). Among the five major island regions, Java and Sumatra together account for most of the workforce, reflecting both population concentration and industrial activity. However, other provinces, such as Kalimantan and Papua, although less densely populated, remain central to Indonesia’s resource-based economy through mining, oil, and gas production.
Since its transition from an oil-dependent economy in the 1970s to a diversified middle-income economy, Indonesia has become one of the largest emerging markets in Asia. Sustained reforms and integration into the global economy have positioned Indonesia as a member of the G20. The real gross domestic product (GDP) per capita at current prices reached United States dollars ＄4,919 in 2023, continuing its upward trajectory despite external economic challenges. Today, Indonesia is recognized as one of the most dynamic economies in the Asia-Pacific region, with strong growth prospects supported by its demographic dividend and expanding domestic market8,10).
Healthcare system
Indonesia’s healthcare system functions as a decentralized public–private model organized under a three-tiered structure (national, provincial, and district/city), with primary/public healthcare services (puskesmas) forming the foundation of service delivery. District/city health offices have direct control of puskesmas as frontline health services. There is no direct control from central to provincial health offices, or from provincial to district health offices, or from district health offices to hospitals. At the central level, the Ministry of Health sets strategic directions, manages tertiary and specialized hospitals, and oversees standards and resources. Provincial health offices coordinate programs across districts, whereas district and municipal governments manage local hospitals and the puskesmas networks, supported by subdistrict facilities along with village maternity and integrated health posts11).
In Indonesia, hospitals are classified into four categories (Types A, B, C, and D) on the basis of their service capacity, facilities, and specialist availability (Figure 1)12). Type A hospitals serve as national and regional referral centers, are equipped with the most comprehensive facilities, and have a wide range of medical specialists and subspecialists. Type B hospitals function as provincial referral hospitals, providing broader specialist services but fewer subspecialities than Type A hospitals. Type C hospitals operate at the district or regional level, offering essential specialist care, such as internal medicine, pediatrics, obstetrics and gynecology, and general surgery. Type D hospitals are at the most basic level, typically serving smaller communities; they have limited specialist availability and focus mainly on general medical services. This tiered classification ensures an organized referral system, allowing patients to access appropriate levels of care according to their medical needs. Alongside the public sector, private hospitals, clinics, and individual healthcare practitioners play important roles in healthcare provision. Changes in hospital category can occur with changes in the capacity and competency of specific medical services.
Fig. 1. The healthcare system in Indonesia. MoH, Ministry of Health
Since 2014, Indonesia has implemented a national social health insurance program (see Healthcare financing below).
Primary healthcare delivery is provided largely through the puskesmas and community-based programs, which serve as the backbone of the Indonesian healthcare system, focusing on health promotion and preventive services, in addition to curative and rehabilitative care. Secondary and tertiary care are concentrated in district, provincial, and national referral hospitals, supported by a structured referral system. To strengthen integration, Indonesia has adopted referral guidelines and technical supervision frameworks that link higher- and lower-level institutions, ensuring coordination across the healthcare system.
Healthcare facilities and resources
As of 2023, Indonesia had an extensive healthcare network consisting of 3,100 hospitals (~65% public and 35% private), alongside more than 10,000 puskesmas and their auxiliary posts. These facilities are unevenly distributed across Indonesia’s 38 provinces, with the island of Java — home to over half the population — having the highest concentration of hospitals, physicians, and hospital beds. By comparison, remote regions, such as eastern Indonesia (Maluku and Papua), continue to face critical shortages in healthcare resources. Indonesia had an estimated 1.7 hospital beds per 1,000 people in 2022, substantially lower than many neighboring countries and reflecting ongoing infrastructure challenges11,12).
The public sector remains the backbone of healthcare provision, although the private sector is expanding rapidly, particularly in urban centers, such as Jakarta, Surabaya, and Medan. However, disparities in distribution persist, with urban populations having greater access to modern facilities, advanced diagnostics, and specialist care than rural and remote communities. The uneven ratio of health professionals mirrors this divide: Indonesia had 0.47 physicians per 1,000 people in 2021, with urban centers often having three- to fourfold more physicians than remote provinces12).
The availability of medical technology remains limited in Indonesia. Only some hospitals are at least equipped with spirometry, audiometry, and radiology (including International Labour Organization [ILO]-certified chest X-rays standard), along with computed tomography (CT), magnetic resonance imaging (MRI), and angiography systems concentrated in large referral (ie, Type A and B) hospitals. And, the implementation of a unified health management information system remains fragmented, with many facilities still relying on paper records. Efforts are underway to strengthen the use of electronic health records, but adoption rates vary markedly by region.
Our observations of two Type A hospitals located in areas around Jakarta show that both hospitals are equipped with advanced tools for health screening. Both hospitals have the ability to perform CT scans, MRI, and digital chest X-rays, and both have relevant experts on staff, such as pulmonologists, internal medicine specialists and subspecialists, clinical pathologists, and occupational medicine specialists along with toxicologist subspecialty though the number is very limited. However, attributing a detected cancer to prior occupational chemical exposure requires detailed exposure history including work-related exposure, exposure-specific biomarker assays, and sometimes molecular/pathological analyses that are not routinely collected in the assessed facilities.
Healthcare quality control
Indonesia has introduced multiple reforms to improve the quality of healthcare, most prominently through the Komisi Akreditasi Rumah Sakit (Hospital Accreditation Commission), which conducts mandatory assessments of public and private hospitals. Hospitals are evaluated on the basis of multiple criteria, such as patient safety, infection control, professional competence, infrastructure, and continuous quality improvement. A hospital’s accreditation status affects its eligibility to contract with the National Health Insurance Agency, thus providing financial incentives for compliance13). Several large hospitals in Jakarta, Surabaya, and Bandung have also received Joint Commission International accreditation, aligning with global quality standards.
Despite these reforms, disparities in quality persist, particularly between urban referral hospitals and rural health centers, where shortages of qualified personnel, limited equipment, and weaker supervision remain major challenges. Patient satisfaction surveys conducted by the Ministry of Health report on gradual improvements, but public trust remains lower in local puskesmas than in higher-level hospital14).
Healthcare financing
Indonesia’s healthcare financing is anchored by the National Health Insurance Program or Jaminan Kesehatan Nasional (JKN). By July 2023, over 90% of Indonesians had enrolled in the JKN, establishing it as one of the world’s largest single-payer health insurance programs. Funding is derived from a mix of employer contributions, self-payments, and government subsidies for the poor. Primary care facilities (including puskesmas) are reimbursed via capitation, whereas hospitals receive payment through the Indonesian Case Base Groups (INA-CBG) system11,12). Compliance with accreditation standards from the Ministry of Health is required for facilities to contract with the JKN.
Parallel to this, workers are covered by social insurance programs administered by BPJS Ketenagakerjaan (for general workers), Taspen (for civil servants), and Asabri (for military and police personnel), offering cover for occupational accidents (including occupational diseases), a pension scheme, and job-loss protection. Formal sector companies are required to register their employees as members, whereas informal enterprises are only encouraged to participate11).
Governance of OHS
Indonesia’s OHS system is grounded in Law No. 1 of 1970 on Occupational Safety and in Government Regulation No. 88 of 2019 on Occupational Health15). Responsibility is divided among several bodies, including the Ministry of Manpower, which oversees workplace safety, and the Ministry of Health, which provides occupational health services (Figure 2). Additional roles in the OHS system are played by trade unions, employer associations, and industry-specific ministries (eg, Ministry of Industry, Ministry of Transportation, and Ministry of Public Works). Regarding the safety and health of migrant workers, Indonesia has a Ministry of Protection of Indonesian Migrant Workers, which is responsible for overseeing all matters related to migrant workers.
Fig. 2. National insurance system scheme for workers in Indonesia. MoH, Ministry of Health. OHS, Occupational Health and Safety. MoM, Ministry of Manpower.
A distinctive feature of Indonesia’s OHS system is the integration of basic occupational health services into puskesmas. This integration is operationalized through combining occupational health service posts, or Pos Upaya Kesehatan Kerja (Pos UKK), which are community-based initiatives established under Ministry of Health Decree No. 100 year 2015 with the daily activity of puskesmas11,16). Pos UKK primarily target informal workers (who make up over 60% of Indonesia’s workforce), offering health promotion and preventive services, such as health education, hazard identification, personal protective equipment, early diagnosis of occupational disease, and simple curative and rehabilitative measures. Across 32 provinces, 1,610 Pos UKK units had been established by 2016; in Jakarta alone, 181 active Pos UKK units were reported in 202311).
Community contributions and support from puskesmas provide funding for Pos UKK activities. Puskesmas staff annually train health cadres — typically drawn from the informal workforce — in health promotion, hazard prevention, and emergency responses. We identified this community–government partnership as a key strength of Indonesia’s OHS framework, enabling outreach to sector where formal occupational health services are scarce11).
OHS regulation
The Indonesian legal system is structured hierarchically, with the constitution and laws (Undang-Undang) at the top, followed by government regulations (Peraturan Pemerintah), presidential decrees, and ministerial regulations. The principal legislation for occupational safety is Law No. 1 of 1970 on Occupational Safety, which remains the cornerstone of Indonesia’s OSH framework. More recently, Government Regulation No. 88 of 2019 on Occupational Health was enacted to expand the scope of health protection in the workplace14). These laws mandate employers to provide a safe working environment and ensure workers’ access to preventive and curative occupational health services.
OHS regulations require employers to implement four essential occupational health functions: disease prevention, health promotion, disease management, and rehabilitation. Employers are obliged to provide annual health checkups for workers exposed to occupational hazards, with costs borne by the employer. Health surveillance is performed in accredited medical facilities, typically puskesmas or designated hospitals. The Ministry of Health also issues regulations that define lists of compensable occupational diseases and the medical procedures for their diagnosis, including chest X-rays, spirometry, CT scans, and laboratory testing, depending on the suspected disease.
In parallel, the Workers’ Social Security Agency (BPJS Ketenagakerjaan) manages the occupational accident program. This scheme provides compensation and medical coverage for occupational accidents and diseases. Premiums are calculated on the basis of industry-specific risk categories and are paid by employers.
Facilities and resources for health checkups
Indonesia has introduced a free health check-up program aimed at expanding preventive health services and encouraging the public to monitor their well-being regularly. This broader commitment to preventive care also aligns with improvements in occupational health services, particularly for workers exposed to dust hazards. In Indonesia, medical facilities and resources related to the health surveillance of dust-exposed workers, including diagnostic tools relevant to the nPHR system of Japan (eg, ILO-standard chest X-rays, CT scans, and lung function tests like spirometry), are increasingly available across multiple levels of healthcare. Puskesmas and other primary healthcare facilities can perform basic healthcare monitoring and preliminary screening, whereas secondary care clinics and hospitals typically provide digital radiography (X-ray) services for the detection of pneumoconiosis in accordance with ILO classification standards and other laboratory tests. More advanced diagnostic modalities, such as high-resolution CT scans, and advanced occupational health laboratory services, are primarily available at tertiary referral hospitals and occupational health centers.
Interpreting the radiographic signs of pneumoconiosis is challenging owing to subjectivity and inconsistency among readers; this led the ILO to develop the ILO International Classification of Radiographs of Pneumoconioses in 1950 to ensure uniform and comparable reporting. In Indonesia, training in radiograph interpretation according to ILO standards was first hosted in 2012 (B-reader program by United States National Institute of Occupational Safety and Health) and then again in 2018 and 2023 (AIR-Pneumo program); by 2023, a total of 153 professionals had successfully completed the certification program17,18,19,20,21). These developments support the integration of standardized occupational lung disease surveillance into national digital health record systems, thus advancing interoperability and data consistency in line with international standards, such as Japan’s nPHR initiative. Moreover, some Type B hospitals are further supported by diagnostic and imaging physician experts relevant to health checkups, such as radiologists and clinical pathologists. Some Type B hospitals are also supported by occupational medicine specialists to ensure the provision of specific diagnostic services to workers.
Discussion
A healthcare system encompasses organizations, institutions, resources, and individuals whose collective objective is to safeguard and improve population health. In Indonesia, the decentralized governance of health has enabled hospitals and public health facilities to deliver healthcare services that include health checkups for workers, as well as for prospective and current migrant workers. However, there are no formal systems to make these activities easier to execute nationwide.
The adequacy of health checkup systems for workers, including migrant workers, therefore carries significant preventive and surveillance value. For returning migrant workers, health checkups are crucial for detecting occupational diseases such as pneumoconiosis, chronic bronchitis, chemical intoxications, and cancers linked to long-term exposures. They also serve as an early warning system for infectious diseases that workers may bring back from abroad, such as tuberculosis or meningitis. From the worker’s perspective, these examinations offer reassurance, enable early treatment, and support fairness, particularly when occupational diseases qualify them for compensation through the Workers’ Social Security Agency. For hospitals, primary objective of providing health checkups and occupational health services is to safeguard and enhance the health and wellbeing of patients and employees by facilitating early identification, suitable referral, and prompt management of health concerns. Healthcare facilities may also derive secondary institutional benefits, such as enhanced reputation, increased service utilization, or supplementary revenue streams; however, these should be regarded as incidental outcomes resulting from the provision of high-quality, patient-centered care rather than primary rationales for the implementation of these services. Despite these benefits, clarity regarding financing and standardized protocols remains lacking in Indonesia, reducing the perceived feasibility of implementing comprehensive examinations for returning migrant workers on a national scale.
Indonesian hospitals already provide a wide range of health services, from general health checks to occupation-specific examinations such as spirometry, audiometry, and radiology (including ILO-certified chest X-rays and CT scans). Type A and B hospitals typically have comprehensive diagnostic facilities, whereas Type C and D hospitals often rely on collaboration with external laboratories to conduct laboratory tests (eg, for heavy metals or chemical exposure). On-site examinations at companies and industrial areas are increasingly common, and some hospitals have started initiatives such as “on-site services” programs, by bringing mobile equipment and healthcare professional to the companies and electronic health checkup database systems. In terms of migrant workers, most of these services remain oriented towards predeparture checks, whereas examinations for returning migrant workers are rare and lack standardized guidelines.
These gaps are further compounded by several structural and operational challenges. First, there is a shortage of experts, especially occupational medicine specialists and radiologists — outside major urban centers, leading many hospitals to rely primarily on general practitioners. Second, overlapping regulations among the Ministry of Health, Ministry of Manpower, and Ministry of Protection of Indonesian Migrant Workers, combined with licensing bottlenecks for occupational health physicians and service providers, result in the absence of clear, unified regulations governing health checkups for returning migrant workers. Third, logistical constraints, including limited access to portable X-ray equipment, an insufficient number of radiologists, and the lack of advanced laboratories in provincial areas, hinder the implementation of comprehensive surveillance. Hospitals do not bear these costs for returning migrant workers. Instead, individuals usually have to pay for them themselves unless a specific third-party payer, like a recruitment agency, an employer, bilateral program financing, or an applicable insurance scheme, is official named.
In response to these challenges, several concrete recommendations have emerged. First, the standardization of health checkup protocols is essential, with clear differentiation among pre-employment, periodic, and migrant worker–specific examinations, both for departure and return. These protocols should be risk-based and incorporate detailed job histories and exposure data. Second, financing responsibilities must be clearly allocated among recruitment agencies, employers, the government, and potentially destination countries to prevent undue financial burdens on workers. Integration with Indonesia’s national social security system (BPJS Ketenagakerjaan) may offer one feasible pathway. Additionally, Indonesia’s free health checkup program (Pemeriksaan Kesehatan Gratis), currently available to all citizens, could serve as a key mechanism by mandating returning migrant workers to undergo basic screening at primary care facilities, with referrals to hospitals when necessary. Third, substantial investment is required to strengthen human resource capacity, particularly occupational physicians, radiologists, and toxicologists, supported by hospital stratification that ensures clear referral pathways. Finally, digital platforms with integrated electronic health checkup systems should be scaled up to ensure interoperability, transparency, and efficient health record tracking. The recommended interoperability should primarily ensure national compatibility across Indonesian healthcare providers’ information systems. If there is already bilateral cooperation in place, interoperability can be expanded to allow safe, consented cross-border data exchange while still following legal, ethical, and governance rules.
Conclusion
In summary, Indonesia has made considerable progress in expanding its healthcare capacity and embedding occupational health within its decentralized healthcare system. Hospitals across the country are increasingly being equipped with diagnostic facilities and initiatives, such as digital chest X-rays, CT scans, MRI, and the use of digital platforms, which demonstrate innovative approaches to reaching workers, including migrant workers. Nevertheless, standardization gaps, a limited number of experts (including occupational medicine specialists), and unclear financing responsibilities continue to undermine the effectiveness of health checks for migrant workers — especially those returning from abroad.
To address these challenges, we recommend that the Indonesian Government should prioritize:
• the establishment of clear and standardized health checkup protocols for migrant workers, including those returning from abroad
• the strengthening of financing frameworks, with shared responsibility among employers, state agencies, workers’ insurance companies, and destination countries (when possible)
• the expansion of expert training, including the training and certification of occupational medicine specialists
• the creation of electronic health records and monitoring systems for migrant workers, and the integration of these systems at the national level.
