Moving Toward Universal Health Coverage

I N D O N E S I A1
I. II. III. IV. V. VI. VII. VIII. IX. X. TheEvolutionofInsuranceReforminIndonesia AnOverviewofInsuranceSchemesinIndonesiaToday Funding PopulationCoverage,Enrollment,andCommunication BenefitsPackages ServiceDeliverySystem ProviderPaymentSystems InstitutionalStructures MonitoringandEvaluation TheWayForward

BasicDemographicandHealthStatistics ThefollowingtablepresentsabriefoverviewofsomekeyhealthanddemographicstatisticsinIndonesia i : Table1:SelectedDemographicandHealthStatistics,Indonesia,2006: Indonesia(2006) Grossnationalincomepercapita(PPPinternational$) 3,310 Population(inthousands)total 228,864 Percapitatotalexpenditureonhealth(PPPint.$) 87 Privateexpenditureonhealthaspercentageoftotalexpenditureonhealth 49.6 Infantmortalityrate(per1000livebirths)bothsexes 26 Lifeexpectancyatbirth(years)female 69 Lifeexpectancyatbirth(years)male 66 Maternalmortalityratio(per100000livebirths) 420 TheEvolutionofInsuranceReforminIndonesia IndonesiasfirsthealthfinancingsystembeganinthecolonialperiodwhentheDutchestablishedamandatoryhealth insuranceschemeforcivilservants.Sinceitsinceptioninthelate1930s,thatcivilservantsschemewentthroughmany [Link] tosuffer,includingmoralhazard,highcoststothepublicbudget,highadministrativecosts,andnoncoverageofretired officers. In1968,AskesPerserowasestablishedtofinanceanddeliverhealthinsuranceservicestobothactiveandpensioned civilservants,[Link],[Link](astateownedinsurancecompany)was [Link] in1991,[Link] programstothepublic. In1992,theJamsostek,asocialsecurityprogramforprivateemployeesandemployers,[Link] noteworthyattributeoftheJamsostekprogramwasthatmediumandlargeprivatefirmsweregrantedtheoptionto [Link],over90%of formalsectorworkersanddependentsarenotcurrentlyenrolledintheJamsostekprogram,butrathercoveredthrough [Link],Jamsostekhas

[Link](GTZIndonesia),[Link](Dean,SchoolofPublic Health,UniversityofIndonesia),[Link](Dean,FacultyofMedicine,GadjahMadaUniversity).

[Link] meetingwithanysubstantialsuccess. Inresponsetothefinancialandeconomiccrisisof199798,newemphasiswasplacedonpropoorfinancinganda [Link] [Link] governmentofIndonesiadevelopedseveraltargetedprogramstocushiontheeconomicshocksofthecrisisonthepoor [Link]. JPSschemesincludedworkersalaries,subsidizedricesales,targetedscholarships,healthsubsidies,andvillageblock [Link],theMinistryofHealth(MoH)wasinvolvedinencouragingvariouscommunitybasedand voluntaryinitiatives,includingthepromotionofvillagecommunitydevelopmentandcommunitymanagedhealthcare. Whilethesechangesledtomanyimportantmodificationsinthehealthcaredeliverysystemanditsfinancing,theMoH wasunabletoformallymandateafundamentalchangeinthedeliverysystemwhichwouldhaveledtothecreationof anHMOmodelofservicedeliveryandfinancing. Intheearly2000s,twomajorreformsbegantoemerge:(i)thedecentralizationreformof2001,and(ii)the [Link],thecountryspoliticalsystemunderwenta profoundtransformation:[Link] turbulence,asenseofpoliticalstabilityhasgrownasdemocraticprocesseshavematuredandachievedwider acceptance. Decentralization,whilestillfarfromcomplete,hasdevolvedsubstantialfundsandauthoritytolocalgovernments,and [Link],political stability,anddecentralizationprospectshaveallowedthecountrytothinkaboutexpandinghealthcarecoveragetothe entirepopulation,includingthoseintheinformalurbanandruraleconomicsectors. ThetablebelowprovidesasummarytimelineoftheevolutionofhealthinsuranceprogramsinIndonesiaupto2001. Table2:HistoricalEvolutionofIndonesiasHealthInsuranceProgramsupto2004: Year Initiative 1968 HealthinsuranceforcivilservantsAskes 19741990 1992 1997 1998 1999 2000 2001 2004 PromotionandexperimentsinCBHIDanaSehat SocialsecurityforprivatesectoremployeesJamsostek,JPKM(HMOs),and CBHI Financialcrisis MinistryofHealthattempttomandateHMOsfails JPS(SocialSafetyNet):financialassistanceforthepoorviaADBloan Comprehensivereviewofhealthinsuranceandamendmentofconstitutionto prescribetherightstohealthcare Decentralizationlawimplemented NationalSocialSecurity(SJSN)LawmandatedSocialHealthinsuranceforthe entirepopulation

AnOverviewofInsuranceSchemesinIndonesiaToday Leveragingthenewlyadopteddecentralizationpolicyandcommitmenttouniversalcoverage,Indonesiaintroducedthe firstphaseofitsplantoachieveuniversalhealthcoveragethroughamandatorypublichealthinsuranceschemein2004. AsuransiKesehatanMasyarakatMiskin,orAskeskin,wastargetedtothepoorandhasincreasedaccesstocareand [Link] providersintwoways:(i)acapitationpaymentprovidedtoPuskesmas(healthcenters)basedonthenumberof registeredpoor;and(ii)[Link](a stateownedinsurer).Allpublichospitalswereautomaticallyqualifiedasproviders,whileAskescontractedwithprivate (mostlynonprofit)hospitalsindividually.

Askeskinimplementedin2005,differedfromthepreviousprogramsforthepoorintwomajorways:First,ratherthan beingapurelygovernmentrunprogram,[Link],whichthentargetedthepoorwith Askeskincardsandreimbursedhospitalclaims;second,thebeneficiarycardsinAskeskinwereindividuallytargeted ratherthanhouseholdcardsusedinpreviousprograms. By2008Askeskinhadexpandedenrollmenttocoverover70millionpeople.Thenin2008,Askeskinevolvedinto JaminanKesehatanMasyarakat,orJamkesmas,whichisaMoHruninsuranceprogramwhichnowcoversover76.4 millionpoorandnearpoorIndonesians. ManydistrictgovernmentshavefollowedtheleadofJamkesmasandestablisheddistrictbasedinsuranceschemes (typicallycalledJamkesda)[Link] [Link],withthegoalofcoveringanadditional populationofnearpoor,ontopofthosecoveredbyJamkesmas;otherschemesfocusonspecificservices,suchasin Yogyakarta,wherematernalandchildhealthservicesfor104,500childrenandpregnantwomenarecoveredundera districtledscheme. [Link] ismanagedbyDepkes(MinistryofHealth)andPTAskesisnolongerinvolved,exceptinmanagingtheenrollmentof [Link],districthealthofficesnowdirectlymanagecontracting [Link] publicproviders. AsofJanuary2010,theJamkesmasprogramisbeingimplementedthroughoutthecountryandwillserveasoneofthe keybuildingblocksofthegovernmentsproposeduniversalcoverageagenda,hopefullyby2014. To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 [Link],totalutilizationhasincreasedby50%forambulatorycareandabout 106%forinpatientcare2andtheratesofserviceusebetweenthemostaffluentandthepooresthavenearlyequalized. Funding [Link] andpricingforthevariousprograms: Table3:FundingandTargetPopulationsofVariousHealthInsuranceSchemesinIndonesia,2010: Target Scheme FundingSource(s) EffectivePremium Population Activecivilservantsand Membercontributionof2%of Askes dependents,civilservice& salaryplusgovernmentmatchof DependsonSalary militaryretirees 2% Militaryworkersandpolice Taspen andtheiruncovered Outofpocket Varies dependents Membercontributionof3%of Privateformalsector salaryforsingles,6%forfamilies employees(anddependents) Jamsostek (LimitRp1million(USD110)if Dependsonsalary offirmswithtenormore minimumwageisgreaterthan1 employees million) PrivateHealth Privateformalsector Outofpocket Varies Insurance employeesanddependents Communitybased Informalsectorworkersand Outofpocket Varies HealthInsurance studentsinselected
2

SeeAppendix1ofClaudiaRokxetal.,HealthFinancinginIndonesia:[Link].C.:WorldBank,2009.

Jamkesmas (Askeskin)

Jamkesda

universities,andcertain otherschools Poorandnearpoor,based onindividualandhousehold targeting Poorandnearpoor, homeless,orphans,and noncivilserviceteachers Someschemestarget differentpopulations

Generalrevenues(100%funded bycentralgovernment.)

Rp5,000(USD0.50) percapitapermonth

Districtgovernmentsforthose whocannotpay Variesbylocality Outofpocketforthosethat canpay,basedonasliding scaledefinedlocally

[Link] healthcareisgoingtoincreasethecostofhealthinsurance,particularlyforthepoorestpopulationscoveredby [Link] hasincreased,thecapacityoflocalservicedeliverymaynotbeabletokeeppacewithincreasingdemandswithout furthercollaborationwithprivateprimaryhealthcareproviders. Currently,itistheresponsibilityofthelocalgovernmenttofinancethegapbetweentheactualcostofinsuringits [Link] poorestlocalities,[Link] problem,andinordertocontinuetostrivetowardsuniversalcoverage,itisconsideringhowitmightintroduce strategiestodevelopfurtherapproachestocofinanceservicedeliveryatthelocallevel. Theproposedfundingrequirementsfortheoperationalcostsofpreventiveandpromotiveservicedeliveryisunder activeconsiderationwithintheparliamentatthistimeandknownastheBOKfund. PopulationCoverage,Enrollment,andCommunication [Link] approximately46%ofthepopulation,upfromabout10%15%[Link] [Link] [Link],notethatthedataontheenrollmentofJamkesda(sub nationalschemes)underrepresentsactualcoverageasitisbasedona2008studywhentherewerereportedlyabout35 Jamkesdaprograms.AsofJanuary2010,therearenearlyfivetimesmoreJamkesdathanin2008,butthenumberof coveredpersonsisunknown. Table4:TotalInsuranceCoverageJanuary2010: Scheme [Link],inMillions Askes(currentandretiredgovernmentemployees) Taspen(Militaryandpolice) Jamsostek(Privateformalsectorworkers) PrivateSchemes Jamkesmas(poor) Jamkesda (poor,rural) TotalCovered PopulationNotCoveredattheendof2009
3

15.2 1.1 4.2 7.0 76.4 2.3 106.2 123.8

3 TheseestimatesarebasedonastudyofsubnationalschemesconductedbyAscobatGani,etalin2008.Asoftheendof2009,therewereabout
80to90additionalschemeswhichmayhaveenrolledanother2to3millionmemberswhicharenotincludedinthesefigures.

TheJamkesmastargetpopulationisdefinedwiththeuseofanannuallyadministerednationalsurveyknownasthe [Link] [Link],thetotalnumberofpoor [Link]. PTAskesremainstheadministratorofmembershipintheJamkesmasprogramsinceithasoperatedtheprogramsince [Link] [Link] isapartofBappenas(thenationalplanningagency).PTAskesthendistributesthecardsandregistersenrolleesintothe program. TheMinistryofHomeAffairs(MoHA)isresponsibleforthedevelopmentofanationalidentitycardtobedistributed [Link],itwillbecomethebasisforenrollmentintothe nationalhealthinsuranceprogram. Jamkesmasisnotbeingformallymarketed,asithasbeenoversubscribedsinceitsinceptionin2008. BenefitPackage ThebenefitsprovidedbyvariouspubliclyimplementedinsuranceschemesinIndonesiavary.Table4belowoutlinesthe benefitsprovidedbyeachscheme. Table5:BenefitPackagesofPublicInsuranceSchemesinIndonesia,2010: Scheme Benefits Exclusions Cosmeticsurgery,alternativemedicine,dental Comprehensive(inandoutpatient),including prostheses,fertilitytreatment,nonbasic Askes maternity,annualphysicals,andpreventive immunizations,hemodialysis,andsecondary healthcare cancertherapy Healthconditionsdirectlycausedbynatural disaster,selfinflictedproblems,extreme Comprehensive(inpatientandoutpatient), sports,generalcheckups,cancertreatments, Jamsostek includingmaternity,annualphysicals,and heartsurgery,renaldialysis,andlifelong preventivehealthcare treatmentforcongenitaldiseases,prostheses, nonbasicimmunizations,transplantation,and fertilitytreatment Comprehensive(inpatientandoutpatient), Varybyplantherearemorethan50private PrivateHealth includingmaternity,annualphysicals,and carriers,thoughPTAskeshasthelargest Insurance preventivehealthcare marketshare Cosmeticsurgery,annualphysicalcheckups, Comprehensive(inpatientandoutpatient), alternativemedicine,dentalprosthesis, Jamkesmas includingmaternityandpreventivehealthcare [Link], asareheartrelatedproblems Communitybased Primarilyoutpatientservices,including DependsonSchememanyexcludespecialist HIandJamkesda [Link] andinpatientservices,annualphysicalcheck schemes schemescoverinpatientcare ups [Link],Jamkesmasenrolleesareonlyentitledto [Link] verystrictondruguse,dispensingonlygenericsandinsomehospitalsmaintainingtheirownpharmacyforAskes patients. 4
4

Askescollectsdataondrugdispensingandcostsandareabletoshowthattheyhavereduceddrugcostsfromapproximately45%ofexpenditureto25%of expenditureoverthelast5yearsorso.

Overall,freeaccesstomanyprovidersbothprivateandpublicandacomprehensivebenefitspackagemake JamkesmasmoreattractivetothemajorityofthepopulationeventhosecoveredunderAskesandJamsostek.A recentsurveyinearly2008entitledStudyonBenefitPackageBasedonCommunitysPreferenceconductedbyCenter forHealthFinancingPolicyandHealthInsuranceManagementattheUniversityofGadjahMadahasshownthat79.8% ofpeoplewhowerealreadyenrolledwithhealthinsuranceschemes,suchasAskesandJamsostek,preferredtobe entitledwithJamkesmasbenefitsastheyfeltthecoverageprovidedunderJamkesmaswassuperiortothatprovided undertheirexistingplan. ServiceDeliverySystem Healthservicesacrosseachschemearedeliveredbyamixofproviders,withmostschemesrelyingheavilyonthepublic sectorfordeliveryofcare.Table6outlinesthetypesofservicedeliveryoutletscoveredeachscheme. Table6:HealthCareDeliveryOutlets,IndonesianHealthInsuranceSchemes,2010: Scheme Ambulatoryservices Inpatientservices Publicandsomeprivateprovidersare Askes Publiconly included Jamsostek Publicandprivate Publicandprivateinnetwork PrivateHealth Privatepublicwhereprivatecareis Privateandpublicwhereprivatecareis Insurance notavailable notavailable Publicandsomeprivateprovidersare Jamkesmas(Askeskin) Public included CommunitybasedHI Publiconly Dependsonscheme andJamkesda [Link] bothpublicandprivateproviders(e.g.,Jamsostek),whereasothersrequirebeneficiariestoobtainservicesfromthe largelypublicnetworkofproviders(e.g.,AskesandJamkesmas)formostservices,withaccesstoprivateprovidersfora smallerrangeofcare. TherearesignificantoutofpocketcostsforJamsostekandAskesbeneficiaries(estimatedatupto40%)whoselect [Link]/orfinancialprotection providedbythoseinsuranceschemesmaybelimited. Jamkesmascontractswith926hospitalstoprovideservices,including220privatehospitalsforcertaintypesofcare. Askesalsocontractswithalargenumberofprivateprovidersforthecivilserviceprogram. ProviderPaymentMechanisms Aswithrevenueraising,targetpopulations,andbenefits,providerpaymentandcontractingmechanismsvarywitheach scheme.Table7providesasummaryoftheproviderpaymentmodelsusedbyeachgovernmentschemebasedonthe typeofcaredelivered: Table7:ProviderPaymentMechanismsEmployedinIndonesia,2010: Scheme InpatientCare PrimaryCare Askes Feeschedules Capitation Jamsostek Capitationandfeeforservice Capitation Historicallyfeeforserviceto CapitationtoPuskesmasbased publichospitals;transitioning Jamkesmas(Askeskin) onnumberofpoorinthe toaDRGsystembeginningin catchmentarea 2009 ForJamkesmas,whilethebenefitpackageisthesamenationally,districtssetthereimbursementratesforvarious servicesbasedonlocalconditions,aslocaldistrictgovernmentshavejurisdictiontoestablishhospitalfees.Until2009, reimbursementwasbasedonservicesprovided(feeforservice),althoughtherearemaximumreimbursementratesby

typeofservices.Beginning2009,Jamkesmaswasintheprocessoftransitioningitsreimbursementsystemfromfeefor servicetoonebasedondiagnosisrelatedgroups(DRGs).AllhospitalsarebeingincorporatedintotheDRGpayment processin2010. [Link] [Link] [Link] [Link],itbeginsthereimbursement processtoproviders. Whiletherehasbeenbroadexperiencewithcontractingpublicandprivateprovidersthroughthepublicallyfunded schemes,thecontractmechanismshavenotusedreimbursementorpaymentpoliciesstrategicallytodrive [Link] byJamkesmashascreatedthewrongincentivesforproviders,suchasnotreimbursingmidwivesforpredeliverycareif [Link],onceapatientisreferredtothehospital,thehospitalreceivesafull reimbursementfordelivery,whilethemidwifereceivesnofee,therebydiscouragingmidwivesfromreferringpatientsto hospitalsforcomplicationsastheywouldloseincome. InstitutionalStructure ArevisedinstitutionalstructureofIndonesiasJamkesmasschemeiscurrentlybeingdeveloped. Currently,therearefivemainactorsinvolvedintheinsuranceadministrativeprocessesforthisprogram:(1)the NationalSocialSecurityCouncil(knownasDJSN);(2)nationalgovernmentagenciesincludingDepkes(MoH),the MinistryofFinance(MoF),theMinistryofHomeAffairs(MoHA)whichadministersthedecentralizationprocess,the coordinatingMinistryforSocialAffairs(Menkokesra),andtheplanningministry(Bappenas);(3)provincialanddistrict governments;(4)publicandprivateprovidersofcare;and(5)theinsurer/thirdpartyadministrator(PT Askes/Jamsostek).Thetablebelowsummarizestherolesandresponsibilitiesofalloftheorganizationsinvolvedin implementingnationalhealthinsurance,includingJamkesmas: Table8:CurrentInstitutionalStructureoftheIndonesianNationalHealthInsuranceSystem,2010 LR=longrun;SR=shortrun National government NationalSoc agencies Provincialand Insurer/TPA Providersof CharacteristicsoftheScheme SecCouncil (MoH,MoF, district (Askes/ Care (DJSN) MoHA, Governments Jamsostek) Menkokesra, Bappenas) Oversightofscheme X(LR) X(SR) Financingscheme X X Settingparameters(benefits package,definitionsofpoor, X(LR) X(SR) etc.) Accreditation/Empanelmentof X X providers Enrollment X X X Financial X(LR) X(SR) management/planning Actuarialanalysis X(LR) Settingrateschedulesfor X(LR) X(SR) services/reimbursementrates X(Under X(District Claimsprocessingandpayment X Review) level)

Outreach,Marketingto X beneficiaries Servicedelivery X Developingclinicalinformation X(LR) X(SR) systemformonitoring/eval Monitoringlocallevel utilizationandotherpatient X(LR) X(SR) information Monitoringnationalaggregate X(LR) information Customerservice X X [Link] actuarialcapacityavailablewhenrequired. MonitoringandEvaluation WhiletherearenoformalevaluationsoftheJamkesmasscheme,theIndonesiangovernmentandmanyinternational organizations,includingtheWorldBankandGTZ,arecollaboratingtoimprovetheprogramtoaddressbothpolicyand implementationchallenges. [Link] achievedwithinlessthan2years,[Link] increasedby50%forambulatorycareandabout106%forinpatientcare 5andtheratesofserviceusebetweenthemost affluentandthepooresthavenearlyequalized. TheWayForward Atthepolicylevel,[Link] conceptatfirstappearssimplewithdistrictsresponsibleforimplementinghealthservices,thecomplexityoftheflowsof fundssometargetedtohealth,othersnotandsomepaymentsmadethroughinsuranceorganizations,andothers madedirectlytopublicproviders(hospitals,Puskesmas,andpersonnel)makeforanintricateandfragmentedsetof [Link] previously,[Link] necessarytoensurethesystemcancontinuetobuildadministrativeexpertiseandcapacitytoexpandcoverage. Inaddition,thoroughactuarialanalysisofthetruecostofexpandingcoverageisnecessarytoensureappropriatefunds [Link],itwillalsobenecessarytodevelopreliablecost informationondeliveringservicesinalltypesofhealthfacilities. ThereisalsoalackofenforcementofthemanyexistingstandardsinIndonesia(e.g.,clinicaltreatmentstandards, hospitalstandards,standarddrugformularies).Neithergovernmentofficialsnorprofessionalassociationshavereally [Link] thesestandardsastheycanapplycontrolsoverthereleaseoffundsintheformofreimbursementsthanispossible [Link],providerpaymentand [Link] assessmentisreviewinghowdifferentproviderpaymentsystemsmightinfluenceproviderbehavior,howtoenforce thatprovidersadheretotreatmentprotocols,promotespecifichealthservices,andremoveexistingdisincentivesto [Link]. Finally,Jamkesmasmaybeaveryusefultoolforimprovinghealthoutcomesandpromotingtheutilizationofcertain [Link],theseleversarenotbeingwidelyutilizedbytheprogramasyet,noristherean [Link],
5

SeeAppendix1ofClaudiaRokxetal.,HealthFinancinginIndonesia:AReformRoadmap,(WashingtonD.C.:WorldBank,2009).

Jamkesmascanencourageproviderstotargetcertainservicesbyadjustingthereimbursementratesforvariousservices. Familyplanningisoneexamplewhereprovidersprefertorelyonshorttermmethods,suchasoralcontraceptivesand injectables,[Link] longertermmethods,suchasIUDs,toalevelthatmotivatesproviderstoprovidetheservice,theymaymoreactively [Link],fromthestandpointofpublichealthprogramming,Jamkesmasmaybe [Link]/reimbursement policiesonimportanthealthproblemareas(e.g.,maternalhealth,TB),therecouldbesignificantpositiveimplicationson howthesediseasesaretreatedbyproviders.

WorldHealthOrganizationNationalHealthAccounts.Indonesia2006.