Institutional Learning and Sustainable Performance in Public Healthcare Systems: A Moderated Mediation Analysis from Indonesia’s National Health Insurance Context

This study investigates how institutional learning capacity contributes to the sustainable performance of public healthcare services through two workforce-related mechanisms—organizational commitment and organizational citizenship behavior (OCB)—and whether governance-related leadership practices condition these relationships. Using a cross-sectional survey of nurses from seven healthcare institutions operating under Indonesia’s National Health Insurance System (BPJS), 176 valid responses were analyzed using partial least squares structural equation modeling (PLS-SEM). The results indicate that institutional learning exerts a significant direct effect on workforce performance and indirectly enhances service sustainability through strengthened commitment and citizenship behavior. Organizational commitment and OCB both function as mediating mechanisms that translate learning into improved performance outcomes. Transformational leadership strengthens the effect of commitment on performance but weakens the contribution of OCB, suggesting that highly salient managerial interventions may reduce the voluntary and self-initiated nature of citizenship behaviors. The model explains a substantial proportion of variance in performance (R² = 0.845) and demonstrates predictive relevance. From a planning and policy perspective, the findings highlight the importance of investing in institutional learning systems, leadership development, and governance design to support sustainable public service delivery in healthcare. The study contributes to the sustainable development literature by demonstrating how organizational learning and human capital mechanisms interact to shape the long-term effectiveness and resilience of public healthcare systems.