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Does Health Insurance for the Poor Work for Indonesia? Does Health Insurance for the Poor Work for Indonesia? Indonesia Health Team 1 March 2011 Knowledge Series – Emerging Indonesia MC2-850 Structure of the presentation What is Jamkesmas How does it work? What is it achieving? Coverage Utilization Financial protection including incidence of catastrophic spending Discussion : How might it be improved? Performance based incentives? Targeting? What Is Jamkesmas? Jamkesmas provides health insurance for poor and near poor people in Indonesia Designed to improve access and provide financial protection Jamkesmas started as Health Insurance (Askeskin) in 2005 with target coverage of about 36.1 million and rapidly scaled up in 2008 to cover 76.4 million people It is the largest health insurance program in Indonesia and was a first bold step by GoI to achieve Universal Coverage (UC) How does it work? How is it financed and what is it financing The program is financed by Central taxes Budget in 2010 accounted for a quarter of Ministry of Health (MOH) total budget Payment to primary care at IDR 1,000 (or USD 0.1) and estimated inpatient payment of IDR 5,250 (or USD 0.57) Per Member Per Month Capitation based payment for basic health services, and DRGs to hospitals Targeting and Governance The number of the targeted beneficiaries are determined at the National level using the national Poverty Line which produces district-level quota. Districts determine individual beneficiaries based on the PSE05 list (BPS/NSO) or social welfare criteria set locally at the district No active enrollment ; The poor and the near poor are identified and given cards, they do not enroll themselves Centrally managed and funded, with program management teams at sub-national levels Grievances Redress System (GRS) at different levels but they are not necessarily linked and coordinated Membership and Provider Network Member Characteristics : Only 10% head of Jamkesmas households completed high school compared to 66% of those with Other Insurance. Almost 90% head of Jamkesmas HH are employed, but only 30% formally employed compared to almost 70% of those with Other Insurance There is no expiry date to membership Portability : The membership is valid for facilities in the network all over Indonesia Provider network comprises both public and private; primary care consists of public facilities only, and 30% network hospitals are private Benefit Package : JAMKESMAS provides the most comprehensive package but limited supply prevent the program from going bankrupt Characteristics Askes Jamsostek Jamkesmas Groups mandated Civil servants, retired civil servants, Employees of private employers with The poor and the near-poor (total 76.4 retired military staff, veterans >10 staff or wage bill >Rp.1mn/ month million targeted) Contribution (as share Employees:2% Single: 3% None of basic salary) Employer: 2% Married: 6% No ceiling Ceiling: Rp1mn / month Contributor Employer and employee Employer 100% Government 100% Carrier PT Askes, for profit PT Jamsostek, for profit Ministry of Health Benefits Comprehensive, with no specific Comprehensive, but excludes certain Comprehensive exclusions. catastrophic conditions. Drugs if within Generic drugs Drugs if within formulary. formulary. Cost-sharing Co-payments outside of the basic No co-payments No co-payments package Dependents covered Spouse and up to 2 children under 21 Spouse and up to 3 children under 21 All family members years, not working and not married. years, not working and not married Type of provider Public health centers and public Public and private providers Public health centers and hospitals (class hospitals within network Fees are negotiated III beds), and contracted private hospitals. Extra billing depending on negotiated fees Provider payment Negotiated fees Negotiated fees At health center: Rp. 1000/ month capitation payment At hospital level: negotiated fee with a ceiling What Is the Impact on Coverage? “About 60 to 70 percent of the total Govt to make 45,000 hospital beds free for poor people 64,441 third-class facility beds both in public and private hospitals have been The Jakarta Post, Jakarta | Fri, 01/21/2011 allocated for Jamkesmas and Jamkesda holders,” Endang said, adding that this The government plans to offer free showed that the country still lacked medical services for patients using third-class beds. third-class facilities at public hospitals this year, a move aimed at Private hospitals should expand the helping the large percentage of low- number of their third-class facilities due income and poor people who are to the high number of poor people, she added. uninsured. “They can arrange a kind of hospital Health Minister Endang Rahayu social responsibility scheme, so those Sedyaningsih said many patients who come from poor families can afford from low-income families were medical treatment even at private facing financial difficulties in hospitals,” Endang said. gaining access to adequate health services, and that those who were Citing the latest data from the Central covered by health insurance were Statistics Agency (BPS), she said that hampered by complex bureaucracy. 76.4 million out of 237.6 million Indonesian people belonged to the poor The government will expand third- and low-income brackets. class health facilities at 93 public hospitals, she said. The government has allocated Rp 5.13 trillion (US$564.3 million) for “We have agreed to universal Jamkesmas this year from a total health budget of Rp 27.66 trillion, which is an coverage. We have been troubled In the end Mariani and her family were increase from Rp 24.86 trillion in 2010 by various administrative Titik Purwasih, a 29-year-old housewife and Rp 20.17 trillion in 2009. procedures. So, it will be no and a member of the low-income bracket, able to raise the money for Titik’s problem for us to give free medical did not have access to public health operation, and Titik delivered the baby safely. Titik is now recovering in the third- Rieke Dyah Pitaloka, a member of treatment for patients using third- subsidy when she was pregnant. House of Representatives Commission class facilities,” Endang said. “It class wing of a hospital. IX, said the government should provide would be easier for us because we Titik suffered a severe premature rupture a clear definition of “poor people” who of the foetal membrane, which made To ease the financial burden, Mariani and don’t have to ask them to provide her family registered for government would be eligible for the subsidy. any documents anymore.” childbirth risky for her, necessitating a Caesarean section. subsidy for the operation. Citing BPS data, she said that 28 The public health insurance But the process was long and arduous, percent of Indonesian people got sick Titik’s mother-in-law, Mariani, said her every year, and that 3 percent suffered program (Jamkesmas), funded by family did not have the means to pay for involving a stack of documents and the state budget, and Jamkesda, several trips to several government from serious illnesses. Titik’s operation, but the situation left arranged by regional them with no choice. offices. administrations, both of which were “A clearer definition of poor people According to the Health Ministry, would guarantee that any insurance established in 2008, have not “We had neither the money nor health Indonesia has 1,523 hospitals — private program can be better distributed to the brought medical coverage to all insurance,” she told The Jakarta Post on targeted people,” she said. (ebf) low-income families. Thursday. “They asked me to think about and public — with a total of 151,000 beds. her baby and her own life first instead of About 45,000 of the 64,441 third-class “In many cases, patients from low- the medical expenses,” Mariani said. facility beds belong to public hospitals. income families are not members of the Jamkesmas or Jamkesda programs,” Endang said. In the Dark About Insurance, Mothers Give Health Care Is Failing Our Most Vulnerable Up Newborns to Pay Hospital Bills Nurfika Osman | July 09, 2010 It is distressing that after nearly 65 years of the poor — Jamkesmas at the national Two mothers who were left no option Usman Sumantri, the head of the Health independence, we are still finding cases level and Jamkesda in the regions — but but to sell their newborns to pay Ministry’s financing and insurance unit, told these schemes have been hindered by red where women who live in abject poverty hospital bills could have avoided their the Globe that parents who were not have no other option but to sell their tape and bureaucracy. plight had they been informed they covered by Jamkesmas, the national health newborn babies to pay their hospital bills. qualified for insurance and financing, insurance scheme for the poor, should have The government, as some officials point been covered by Jamkesda, the local First there was the case of Suparti, a out, has also failed miserably at effectively health officials said on Thursday. insurance plan. disseminating information about health woman from a poor district in Yogyakarta, Suparti, 41, a poor woman from Gunung who had to give away one of her twin baby insurance options and how citizens can go “There should have been another health about accessing them. Kidul district near Yogyakarta, said she girls to a member of staff at the state-run care scheme to help the parents,” Usman was forced to sell one of the twin girls hospital where she had just given birth in said. “Selling the babies is not the way to These cases point to an urgent need for to whom she had given birth to pay order to pay the Rp 6 million ($660) bill for solve the problem.” the authorities, including the central medical expenses for the deliveries at a her Caesarean section. government and local administrations, to state-owned hospital. Bondan Agus Suryanto, head of the Then there was Munawaroh, a improve their health services and health Yogyakarta Health Office, said patients had washerwomen in Bali, who said she would insurance coverage for the needy. Her husband, Sarimin, 50, who makes a options available to help pay hospital bills. have to sell her prematurely born daughter living doing odd jobs, failed to get a to cover her maternity costs. The government should be more proactive loan to pay the Rp 6 million ($660) bill. “We are also going to warn the hospital that in both promoting its health insurance She said a hospital staff member when there are patients who do not have schemes for the poor and in assuring that These cases highlight the fact that our offered to pay the bill if she allowed one insurance, it should give them information hard-won independence has failed to these schemes reach those who truly need of the twins to be adopted by another on other options.” them. improve the lives of many Indonesians. hospital employee. A hospital employee declined comment, In Suparti’s case, the story is even more The authorities should also be stricter in saying the press officer had left for the day. “I had to sell one of my twin girls, whom distressing because she gave birth in a admonishing health care institutions, I gave birth to only 10 days ago, state-owned hospital in Wonosari, a especially those owned and operated by Syahrul Aminullah, chairman of the the state, that refuse to treat poor people because I couldn’t pay the bill at medical facility operated by the very Indonesian Public Health Association government that is supposed to protect its or try to exact payments that they clearly Wonosari General Hospital,” Suparti (Iakmi), said hospitals could be sued if they told state news agency Antara on citizens — especially children, the elderly cannot afford. did not provide care to the poor. Wednesday. “On Tuesday, I was and the poor. Our Constitution clearly states that the allowed to go home. One of my babies Local governments are also responsible for state should protect its citizens and work And these two poor women are only the was taken by Mbak Rina [the staff providing health insurance to poor residents, latest to come to the public’s attention. for their well-being. How can we claim to member]. I was not allowed to see [my Syahrul said. be a modern, civilized society as long as child].” Long is the list of reports of infants being incidents such as these continue to occur? sold to cover medical costs, and there Munawaroh, a poor woman who gave Additional reporting from Made Arya In the cases of Suparti and Munawaroh, have been just as many cases of poor birth in Bali to a daughter with lung Kencana and Antara patients being virtually held hostage by we hope that it is clear to the authorities problems, was also faced with a Rp 6 their hospitals for failure to pay their bills. what their first course of action must be. million bill. Her husband, a laborer at a The children must be returned to their furniture store, had disappeared and True, the government does have a mothers. Immediately. her hospital bill grew by Rp 1.5 million dedicated health insurance scheme for per day. “I am willing to give up my baby if Jamkesmas has increased access to Health Insurance and constitutes the largest program in 2009 Household-level insurance coverage, 2004-2009 1 .8 .6 .4 .2 0 2004 2005 2006 2007 2008 2009 Jamkesmas/Askeskin/Health Card Askes Jamsostek Private Other No insurance Source: SUSENAS 2004-2009 Jamkesmas has Increased HI Coverage for the Poor Despite improvements in Targeting, Leakage of Benefits to the Non-Poor Remains Substantial Share of the top three deciles households receiving Jamkesmas benefits, 2009 Does Jamkesmas improve the utilization of health care services? Jamkesmas beneficiaries use more services than those without any health insurance coverage… Use of outpatient services by type of insurance, 2009 …the differences are more apparent in the use of inpatient services Use of inpatient services by type of insurance, 2009 Despite more generous benefit package, utilization of Jamkesmas is consistently lower than those with Other Insurance……. Inpatient utilization rate, 2004-2009 by insurance type All Bottom 3 deciles .04 .04 .035 .035 Other insurance .03 .03 .025 .025 Jamkesmas/Askeskin/Health Card Utilization rate Other insurance .02 .02 Jamkesmas/Askeskin/Health Card .015 .015 No insurance .01 .01 No insurance .005 .005 0 0 2003 2004 2005 2006 2007 2008 2009 2010 2003 2004 2005 2006 2007 2008 2009 2010 Year Year Source: SUSENAS 2004-2009 ….suggesting that non financial barriers to use health services persist The higher use of public facility may be more a reflection of availability of providers than choice Public- private mix in the use of inpatient services by type of insurance, 2009 Jamkesmas coverage has not been associated with a positive impact on skilled birth attendance rates Does Jamkesmas provide financial protection? Despite no co-payment, OOP for health spending remains substantial among Jamkesmas beneficiaries …large OOP is explained by Inpatient utilization Conditional on Inpatient Utilization Jamkesmas beneficiaries have a lower incidence and intensity of catastrophic expenditure Incidence Intensity Summary Program coverage has increased but leakages remain Jamkesmas has improved outpatient utilization, and inpatient utilization even more in comparison with no insurance However utilization rates are lower than those with other insurance; indicates other barriers for the poor to access service persist Skilled birth attendance among Jamkesmas users is no different compare to those without insurance Jamkesmas beneficiaries are somewhat better protected from shocks due to health payment However, OOP health expenditures remain significant among Jamkesmas beneficiaries What could be done to improve Jamkesmas Improvement in targeting by empowering the demand- side Include performance-based financial incentives for providers, sub-national managers, and the third party managing membership. Also include a feature at the demand side for choice to invoke competitiveness of providers for quality service Improve efficiency by improving the Program management including improve the implementation of DRG, HMIS, and provider payment mechanisms
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