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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

       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

 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
  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
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
                                                                                                       capitation payment
                                                                                                       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.
  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

         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

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


                        Other insurance


                           Jamkesmas/Askeskin/Health Card
                                          Utilization rate                                     Other insurance

                                                                                       Jamkesmas/Askeskin/Health Card

                               No insurance

                                                                                                No insurance


              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
Despite no co-payment, OOP for health
spending remains substantial among
Jamkesmas beneficiaries
…large OOP is explained by Inpatient
Conditional on Inpatient Utilization
Jamkesmas beneficiaries have a lower incidence
and intensity of catastrophic expenditure
   Incidence                   Intensity
 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-

 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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