Does Health Insurance for the Poor Work
Does Health Insurance for the Poor
Work for Indonesia?
Indonesia Health Team
1 March 2011
Knowledge Series – Emerging Indonesia
Structure of the presentation
What is Jamkesmas
How does it work?
What is it achieving?
Financial protection including incidence of
Discussion : How might it be improved?
Performance based incentives?
What Is Jamkesmas?
Jamkesmas provides health insurance for poor and
near poor people in Indonesia
Designed to improve access and provide financial
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
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
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
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
Provider payment Negotiated fees Negotiated fees At health center: Rp. 1000/ month
At hospital level: negotiated fee with a
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
“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.
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
“I am willing to give up my baby if
Jamkesmas has increased access to Health
Insurance and constitutes the largest program
Household-level insurance coverage, 2004-2009
2004 2005 2006 2007 2008 2009
Jamkesmas/Askeskin/Health Card Askes
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
Share of the top three
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
Utilization rate Other insurance
2003 2004 2005 2006 2007 2008 2009 2010 2003 2004 2005 2006 2007 2008 2009 2010
Source: SUSENAS 2004-2009
….suggesting that non financial barriers to use health
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
Despite no co-payment, OOP for health
spending remains substantial among
…large OOP is explained by Inpatient
Conditional on Inpatient Utilization
Jamkesmas beneficiaries have a lower incidence
and intensity of catastrophic expenditure
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
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
What could be done to improve Jamkesmas
Improvement in targeting by empowering the demand-
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