Indonesia
During Indonesia’s colonial period, the Dutch established a mandatory health financing program for civil servants, which at the time, delivered comprehensive benefits through government facilities.[^1] Since the program’s inception in the late 1930s, it has undergone a number of changes, including the addition of a small copayment (3%), which was added in 1948.
During Indonesia’s colonial period, the Dutch established a mandatory health financing program for civil servants, which at the time, delivered comprehensive benefits through government facilities.1 Since the program’s inception in the late 1930s, it has undergone a number of changes, including the addition of a small copayment (3%), which was added in 1948. The various iterations of the scheme suffered from the same problems as modern day insurance schemes, including moral hazard, high costs to the public budget, high administrative costs, and non-coverage of retired officers.
The scheme evolved into Askes Persero, which was established in 1968 to finance and deliver health insurance services to both active and pensioned civil servants, including their direct family members. PT Askes, a state-owned and for-profit insurance company, was granted exclusive rights to manage its own insurance fund to support the administrative and functional operations. PT Askes started to broaden its market in 1991 to offer commercial health insurance programs to the public.
Formal sector workers became eligible for coverage in 1992, when Jamsostek was introduced. In a similar arrangement to Askes, Jamsostek is managed by PT Jamsostek.
In the early 1990s, the Indonesian government began to experiment with insurance for the poor. The first health card was introduced around 1994 and the second iteration of the health card came in response to the financial and economic crisis of 1997–98.2 New emphasis was placed on pro-poor financing and a number of efforts were undertaken to deal with the severe economic circumstances.
Donor funding increased sharply in 1998–99 so that the overall level of public funding remained close to the levels of the early to mid-1990s. The Government of Indonesia developed several targeted programs to cushion the economic shocks of the crisis on the poor and other vulnerable groups, collectively known as the Jaring Pengaman Sosial or JPS programs. JPS schemes included worker salaries, subsidized rice sales, targeted scholarships, health subsidies, and village block grants. Over this period of time, the Ministry of Health (MoH) was involved in encouraging various community-based and voluntary initiatives, including the promotion of village community development and community-managed health care.2 While these changes led to many important modifications in the health care delivery system and its financing, the MoH was unable to formally mandate a fundamental change in the delivery system which would have led to the creation of an HMO model of service delivery and financing.
In the early 2000s, two major reforms began to emerge: the decentralization reform of 2001, and the government’s dedication to universal health coverage reform. Since then, the country’s political system underwent a profound transformation from a centralized authoritarian regime to a decentralized democratic polity. Despite initial turbulence, a sense of political stability grew as democratic processes matured and achieved wider acceptance.
Decentralization, while still far from complete, has devolved substantial funds and authority to local governments, and new forms of decentralized participation in policy making have been created. Indonesia’s growing economy, political stability, and decentralization prospects have allowed the country to think about expanding health care coverage to the entire population, including those in the informal urban and rural economic sectors.
Leveraging the newly adopted decentralization policy and commitment to universal coverage, Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme in 2004. Askeskin (Asuransi Kesehatan Masyarakat Miskin) was implemented in 2005 and initially targeted the poorest 40 million people. Askeskin was renamed in 2008 to Jamkesmas (Jaminan Kesehatan Masyarakat) and coverage was expanded to cover the near poor, a total combined population of 76.4 million.
Recent reform efforts have been concentrated on integrating the major active insurance schemes in Indonesia into a national health insurance scheme for the entire nation. A series of laws underpins this movement, including the most recent which was passed in November 2011 and guarantees the formation of the social security administration agency (BPJS) by January 1, 2014.3
Table 2: Historical Evolution of Indonesia’s Health Insurance Programs up to 2012
| Year | Initiative |
|---|---|
| 1945 | Indonesian constitution mandated right to social security for every citizen |
| 1968 | Health insurance for civil servants – Askes |
| 1974-1990 | Promotion and experiments in CBHI – Dana Sehat |
| 1992 | Social security for private sector employees – Jamsostek, JPKM (HMOs), and CBHI |
| 1997 | Financial crisis |
| 1998 | Ministry of Health attempt to mandate HMOs fails |
| 1999 | JPS (Social Safety Net): financial assistance for the poor via ADB loan |
| 2000 | Comprehensive review of health insurance and amendment of constitution to prescribe the rights to health care |
| 2001 | Decentralization law implemented |
| 2004 | National Social Security (SJSN) Law mandated Social Health insurance for the entire population |
| 2004 | Introduction of Asuransi Kesehatan Masyarakat Miskin (Health Insurance for the Poor) |
| 2008 | Askeskin is renamed Jamkesmas and extended to the near poor |
| 2010 | Law No. 17: The National Development Middle Plan (RPJMN) reconfirmed Indonesia’s commitment to provide universal health coverage by 2014 |
| 2011 | Constitution No. 24: Social Security Providers Bill is passed, which mandates that the Social Security Agency (BPJS) would be operational by January 1, 2014 |
| Source: Adapted from Rokx C et al. 2009 |
-
Rokx C, Shieber G, Harimurti P, Tandon A, Somanathan A. Health Financing in Indonesia: A Reform Road Map. Jakarta. The World Bank. 2009. ↩
-
The World Bank. Jamkesmas Health Service Fee Waiver: Social Assistance Program and Public Expenditure Review. 2012. ↩
-
Coordinating Ministry for People's Welfare, National Council of Social Security, Ministry of Health, National Development Planning Agency, et al. Roadmap on Development of National Health Insurance 2012-2019, Republic of Indonesia. 2012;. ↩
Indonesia
Historical Context
During Indonesia’s colonial period, the Dutch established a mandatory health financing program for civil servants, which at the time, delivered comprehensive benefits through government facilities.1 Since the program’s inception in the late 1930s, it has undergone a number of changes, including the addition of a small copayment (3%), which was added in 1948. The various iterations of the scheme suffered from the same problems as modern day insurance schemes, including moral hazard, high costs to the public budget, high administrative costs, and non-coverage of retired officers.
The scheme evolved into Askes Persero, which was established in 1968 to finance and deliver health insurance services to both active and pensioned civil servants, including their direct family members. PT Askes, a state-owned and for-profit insurance company, was granted exclusive rights to manage its own insurance fund to support the administrative and functional operations. PT Askes started to broaden its market in 1991 to offer commercial health insurance programs to the public.
Formal sector workers became eligible for coverage in 1992, when Jamsostek was introduced. In a similar arrangement to Askes, Jamsostek is managed by PT Jamsostek.
In the early 1990s, the Indonesian government began to experiment with insurance for the poor. The first health card was introduced around 1994 and the second iteration of the health card came in response to the financial and economic crisis of 1997–98.2 New emphasis was placed on pro-poor financing and a number of efforts were undertaken to deal with the severe economic circumstances.
Donor funding increased sharply in 1998–99 so that the overall level of public funding remained close to the levels of the early to mid-1990s. The Government of Indonesia developed several targeted programs to cushion the economic shocks of the crisis on the poor and other vulnerable groups, collectively known as the Jaring Pengaman Sosial or JPS programs. JPS schemes included worker salaries, subsidized rice sales, targeted scholarships, health subsidies, and village block grants. Over this period of time, the Ministry of Health (MoH) was involved in encouraging various community-based and voluntary initiatives, including the promotion of village community development and community-managed health care.2 While these changes led to many important modifications in the health care delivery system and its financing, the MoH was unable to formally mandate a fundamental change in the delivery system which would have led to the creation of an HMO model of service delivery and financing.
In the early 2000s, two major reforms began to emerge: the decentralization reform of 2001, and the government’s dedication to universal health coverage reform. Since then, the country’s political system underwent a profound transformation from a centralized authoritarian regime to a decentralized democratic polity. Despite initial turbulence, a sense of political stability grew as democratic processes matured and achieved wider acceptance.
Decentralization, while still far from complete, has devolved substantial funds and authority to local governments, and new forms of decentralized participation in policy making have been created. Indonesia’s growing economy, political stability, and decentralization prospects have allowed the country to think about expanding health care coverage to the entire population, including those in the informal urban and rural economic sectors.
Leveraging the newly adopted decentralization policy and commitment to universal coverage, Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme in 2004. Askeskin (Asuransi Kesehatan Masyarakat Miskin) was implemented in 2005 and initially targeted the poorest 40 million people. Askeskin was renamed in 2008 to Jamkesmas (Jaminan Kesehatan Masyarakat) and coverage was expanded to cover the near poor, a total combined population of 76.4 million.
Recent reform efforts have been concentrated on integrating the major active insurance schemes in Indonesia into a national health insurance scheme for the entire nation. A series of laws underpins this movement, including the most recent which was passed in November 2011 and guarantees the formation of the social security administration agency (BPJS) by January 1, 2014.3
Table 2: Historical Evolution of Indonesia’s Health Insurance Programs up to 2012
| Year | Initiative |
|---|---|
| 1945 | Indonesian constitution mandated right to social security for every citizen |
| 1968 | Health insurance for civil servants – Askes |
| 1974-1990 | Promotion and experiments in CBHI – Dana Sehat |
| 1992 | Social security for private sector employees – Jamsostek, JPKM (HMOs), and CBHI |
| 1997 | Financial crisis |
| 1998 | Ministry of Health attempt to mandate HMOs fails |
| 1999 | JPS (Social Safety Net): financial assistance for the poor via ADB loan |
| 2000 | Comprehensive review of health insurance and amendment of constitution to prescribe the rights to health care |
| 2001 | Decentralization law implemented |
| 2004 | National Social Security (SJSN) Law mandated Social Health insurance for the entire population |
| 2004 | Introduction of Asuransi Kesehatan Masyarakat Miskin (Health Insurance for the Poor) |
| 2008 | Askeskin is renamed Jamkesmas and extended to the near poor |
| 2010 | Law No. 17: The National Development Middle Plan (RPJMN) reconfirmed Indonesia’s commitment to provide universal health coverage by 2014 |
| 2011 | Constitution No. 24: Social Security Providers Bill is passed, which mandates that the Social Security Agency (BPJS) would be operational by January 1, 2014 |
| Source: Adapted from Rokx C et al. 2009 |
-
Rokx C, Shieber G, Harimurti P, Tandon A, Somanathan A. Health Financing in Indonesia: A Reform Road Map. Jakarta. The World Bank. 2009. ↩
-
The World Bank. Jamkesmas Health Service Fee Waiver: Social Assistance Program and Public Expenditure Review. 2012. ↩
-
Coordinating Ministry for People's Welfare, National Council of Social Security, Ministry of Health, National Development Planning Agency, et al. Roadmap on Development of National Health Insurance 2012-2019, Republic of Indonesia. 2012;. ↩
Approximately 63% of the total population in Indonesia is covered by some form of insurance (as of 2012), which is up from 43% in 2010. The major insurers that provide this coverage include: Askes (civil servants and pensioners), Jamkesmas (poor and near poor), Jamsostek (formal sector workers), Jamkesda (district-level schemes), and private health insurance (most urban coverage).[^1] These are described in detail in Table 6 and listed below in order of total number of beneficiaries.
Approximately 63% of the total population in Indonesia is covered by some form of insurance (as of 2012), which is up from 43% in 2010. The major insurers that provide this coverage include: Askes (civil servants and pensioners), Jamkesmas (poor and near poor), Jamsostek (formal sector workers), Jamkesda (district-level schemes), and private health insurance (most urban coverage).1 These are described in detail in Table 6 and listed below in order of total number of beneficiaries.
**Jamkesmas – 76.4 million beneficiaries Jamkesmas currently covers over 76.4 million poor and near-poor Indonesians. As opposed to Askekin, which was managed fully by PT Askes, Jamkesmas is managed by the Ministry of Health (Depkes). PT Askes has a more limited role and manages the enrollment of members and the distribution of Jamkesmas cards. In addition, district health offices directly manage contracting and claims processing and Jamkesmas now contracts with many private hospitals, whereas Askeskin contracted with mainly public providers.
Jamkesda – 31.6 million beneficiaries Many district governments have followed the lead of Jamkesmas and established district-based insurance schemes (typically called Jamkesda/PJKMU) that cover the near poor or those not covered under Jamkesmas. Jamkesda schemes differ from community-based schemes in that they are often managed by the local government unit or attached to the local government institution, whereas the community-based schemes are managed by their own local community.
Some Jamkesda schemes are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas. Other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme. Jamkesda coverage has grown exponentially over the last few years. As of June 2012, it was estimated that at least 350 districts/cities have implemented some version of a local scheme, covering a total of 31.6 million individuals.23
Askes – 16.5 million beneficiaries Askes provides coverage for approximately 16.5 million civil servants and retired military and police.[^2] Askes individually contracts with private (mostly non-profit) hospitals. It is still administered by PT Askes, but according to Law 24 Year 2011 the para-statal entity will be transformed into the non-profit social security administration agency (BPJS) to run the integrated national health insurance scheme.
Active military and police are not eligible for Askes, but the military and police agencies offer a special program to cover their health costs. In addition, the Asabri program manages social security for the military including benefits like working injury, pension, old age and death. As Indonesia fulfills Law No. 24 (2011), active military and police will be eligible for a health insurance program that will be managed by BPJS Health.
Jamsostek – 2.5 million employees (5.6 million beneficiaries including dependents) Jamsostek is designed to cover all formal sector workers, but only 7% of those formal sector workers participate in Jamsostek. At the end of 2011, 2.5 million workers were covered (5.6 million when including dependents).5-7 Though Jamsostek coverage for accident, pension, old age and death are mandatory, membership is not mandatory for health and current regulation is such that only businesses with 10 or more employees are required to participate in the scheme. A number of small businesses have therefore decided to opt out. Additionally, medium and large private firms can offer their own insurance or a direct medical care provision program for workers if their benefits are superior to those offered in Jamsostek.[^2]
As a consequence, over 90% of formal sector workers and dependents are not currently enrolled in the Jamsostek program, but rather covered through their employers’ own programs. Due to the fact that formal sector Jamsostek enrollment has stalled, Jamsostek has been piloting programs to enroll informal sector workers.
Private Health Insurance – 8.8 million beneficiaries Indonesia introduced private health insurance in the early 1990s, relying on principles from Health Maintenance Organizations (HMOs). Over time, insurers have shifted away from the HMO model toward indemnity insurance. The private health insurance market is relatively small though, covering. [^2] 7% of the population. Ninety-five percent of those with private coverage receive it through an employee benefit program and the other 5 percent through individual enrollment.
| Enrollees (millions) | Scheme |
|---|---|
| 16.5 | Askes (current and retired government employees) |
| 1.1 | Taspen (Military and police) |
| 2.5 | Jamsostek (Private formal sector workers) |
| 8.8 | Private Schemes |
| 76.4 | Jamkesmas (poor) |
| 31.6 | Jamkesda (poor, rural) |
| 136.9 | Total Covered |
There are several important differences between the prior Askeskin program and the Jamkesmas program. Jamkesmas is managed by Depkes (Ministry of Health), whereas Askeskin was managed by a state-owned insurer, PT Askes, which received a block grant for the program. In addition, district health offices now directly manage contracting and claims processing. Finally, Jamkesmas now contracts with many private hospitals whereas Askeskin utilized mainly public providers.
Jamkesmas is financed entirely through general government revenues, with contributions made from both central and local governments. There are no required contributions by beneficiaries and care is free at the point-of-service. Jamkesmas offers a comprehensive package of care, including inpatient and outpatient care as well as maternal and preventive health services. Jamkesmas is administered in a largely decentralized fashion. While the central government plays an oversight role and partially finances the program, operations responsibilities fall largely with provincial and district governments.
Many district governments have followed the lead of Jamkesmas and established complementary district-based insurance schemes (typically called Jamkesda) that cover the near poor or those not covered under Jamkesmas. These schemes take different forms. Some Jamkesda are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas; other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme.
To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 million poor and near poor enrollees. In addition, total utilization has increased by 50% for ambulatory care and about 106% for inpatient care and the rates of service use between the most affluent and the poorest have nearly equalized. As of January 2010, the Jamkesmas program is being implemented throughout the country and will serve as one of the key building blocks of the government’s proposed universal coverage agenda, hopefully by 2014.
-
Center for Financing and Health Insurance, Ministry of Health. The Health Insurance Sector Data Analysis. Jakarta. 2010. ↩
-
Coordinating Ministry for People's Welfare, National Council of Social Security, Ministry of Health, National Development Planning Agency, et al. Roadmap on Development of National Health Insurance 2012-2019, Republic of Indonesia. 2012;. ↩
-
PT Jamsostek. Jamsostek Membership, http://www.jamsostek.co.id/content/i.php?mid=5&id=144;Accessed September 4, 2012. ↩
Indonesia
Summary of Reforms
Approximately 63% of the total population in Indonesia is covered by some form of insurance (as of 2012), which is up from 43% in 2010. The major insurers that provide this coverage include: Askes (civil servants and pensioners), Jamkesmas (poor and near poor), Jamsostek (formal sector workers), Jamkesda (district-level schemes), and private health insurance (most urban coverage).1 These are described in detail in Table 6 and listed below in order of total number of beneficiaries.
**Jamkesmas – 76.4 million beneficiaries Jamkesmas currently covers over 76.4 million poor and near-poor Indonesians. As opposed to Askekin, which was managed fully by PT Askes, Jamkesmas is managed by the Ministry of Health (Depkes). PT Askes has a more limited role and manages the enrollment of members and the distribution of Jamkesmas cards. In addition, district health offices directly manage contracting and claims processing and Jamkesmas now contracts with many private hospitals, whereas Askeskin contracted with mainly public providers.
Jamkesda – 31.6 million beneficiaries Many district governments have followed the lead of Jamkesmas and established district-based insurance schemes (typically called Jamkesda/PJKMU) that cover the near poor or those not covered under Jamkesmas. Jamkesda schemes differ from community-based schemes in that they are often managed by the local government unit or attached to the local government institution, whereas the community-based schemes are managed by their own local community.
Some Jamkesda schemes are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas. Other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme. Jamkesda coverage has grown exponentially over the last few years. As of June 2012, it was estimated that at least 350 districts/cities have implemented some version of a local scheme, covering a total of 31.6 million individuals.23
Askes – 16.5 million beneficiaries Askes provides coverage for approximately 16.5 million civil servants and retired military and police.[^2] Askes individually contracts with private (mostly non-profit) hospitals. It is still administered by PT Askes, but according to Law 24 Year 2011 the para-statal entity will be transformed into the non-profit social security administration agency (BPJS) to run the integrated national health insurance scheme.
Active military and police are not eligible for Askes, but the military and police agencies offer a special program to cover their health costs. In addition, the Asabri program manages social security for the military including benefits like working injury, pension, old age and death. As Indonesia fulfills Law No. 24 (2011), active military and police will be eligible for a health insurance program that will be managed by BPJS Health.
Jamsostek – 2.5 million employees (5.6 million beneficiaries including dependents) Jamsostek is designed to cover all formal sector workers, but only 7% of those formal sector workers participate in Jamsostek. At the end of 2011, 2.5 million workers were covered (5.6 million when including dependents).5-7 Though Jamsostek coverage for accident, pension, old age and death are mandatory, membership is not mandatory for health and current regulation is such that only businesses with 10 or more employees are required to participate in the scheme. A number of small businesses have therefore decided to opt out. Additionally, medium and large private firms can offer their own insurance or a direct medical care provision program for workers if their benefits are superior to those offered in Jamsostek.[^2]
As a consequence, over 90% of formal sector workers and dependents are not currently enrolled in the Jamsostek program, but rather covered through their employers’ own programs. Due to the fact that formal sector Jamsostek enrollment has stalled, Jamsostek has been piloting programs to enroll informal sector workers.
Private Health Insurance – 8.8 million beneficiaries Indonesia introduced private health insurance in the early 1990s, relying on principles from Health Maintenance Organizations (HMOs). Over time, insurers have shifted away from the HMO model toward indemnity insurance. The private health insurance market is relatively small though, covering. [^2] 7% of the population. Ninety-five percent of those with private coverage receive it through an employee benefit program and the other 5 percent through individual enrollment.
| Enrollees (millions) | Scheme |
|---|---|
| 16.5 | Askes (current and retired government employees) |
| 1.1 | Taspen (Military and police) |
| 2.5 | Jamsostek (Private formal sector workers) |
| 8.8 | Private Schemes |
| 76.4 | Jamkesmas (poor) |
| 31.6 | Jamkesda (poor, rural) |
| 136.9 | Total Covered |
There are several important differences between the prior Askeskin program and the Jamkesmas program. Jamkesmas is managed by Depkes (Ministry of Health), whereas Askeskin was managed by a state-owned insurer, PT Askes, which received a block grant for the program. In addition, district health offices now directly manage contracting and claims processing. Finally, Jamkesmas now contracts with many private hospitals whereas Askeskin utilized mainly public providers.
Jamkesmas is financed entirely through general government revenues, with contributions made from both central and local governments. There are no required contributions by beneficiaries and care is free at the point-of-service. Jamkesmas offers a comprehensive package of care, including inpatient and outpatient care as well as maternal and preventive health services. Jamkesmas is administered in a largely decentralized fashion. While the central government plays an oversight role and partially finances the program, operations responsibilities fall largely with provincial and district governments.
Many district governments have followed the lead of Jamkesmas and established complementary district-based insurance schemes (typically called Jamkesda) that cover the near poor or those not covered under Jamkesmas. These schemes take different forms. Some Jamkesda are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas; other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme.
To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 million poor and near poor enrollees. In addition, total utilization has increased by 50% for ambulatory care and about 106% for inpatient care and the rates of service use between the most affluent and the poorest have nearly equalized. As of January 2010, the Jamkesmas program is being implemented throughout the country and will serve as one of the key building blocks of the government’s proposed universal coverage agenda, hopefully by 2014.
-
Center for Financing and Health Insurance, Ministry of Health. The Health Insurance Sector Data Analysis. Jakarta. 2010. ↩
-
Coordinating Ministry for People's Welfare, National Council of Social Security, Ministry of Health, National Development Planning Agency, et al. Roadmap on Development of National Health Insurance 2012-2019, Republic of Indonesia. 2012;. ↩
-
PT Jamsostek. Jamsostek Membership, http://www.jamsostek.co.id/content/i.php?mid=5&id=144;Accessed September 4, 2012. ↩
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
At the policy level, all aspects of health financing reform in Indonesia are complicated by decentralization. Although the concept at first appears simple with districts responsible for implementing health services, the complexity of the flows of funds—some targeted to health and others not, and some payments made through insurance organizations and others made directly to public providers (hospitals, Puskesmas, and personnel)—make for an intricate and fragmented set of financing flows. Recent studies indicate that many poor districts are receiving much higher levels of funding than previously, but have been unable to spend these funds because of local capacity constraints. Capacity building is necessary to ensure the system can continue to build administrative expertise and capacity to expand coverage.
There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formularies). Neither government officials nor professional associations have really addressed how to ensure more rigorous clinical standards of treatment. Jamkesmas has a greater ability to enforce these standards—as they can apply controls over the release of funds in the form of reimbursements—than is possible by either the MoH or professional associations. To help address the issue of enforcing standards, provider payment and monitoring structures are being reassessed by the DJSN in their process of developing implementable guidelines. This assessment is reviewing how different provider payment systems might influence provider behavior, and how to enforce that providers adhere to treatment protocols, promote specific health services, and remove existing disincentives to adhere to protocol. Pilots of various payment methods are currently underway.
In addition, thorough actuarial analysis of the true cost of expanding coverage is necessary to ensure appropriate funds are allocated to achieving universal coverage. In the short run, it will also be necessary to develop reliable cost information on delivering services in all types of health facilities.
Finally, Jamkesmas may be a very useful tool for improving health outcomes and promoting the utilization of certain health services. Unfortunately, these levers are not being widely utilized by the program as yet, nor is there an operational research program in place within the program to engage in this type of exercise. There are two potential opportunities in this regard. First, Jamkesmas can encourage providers to target certain services by adjusting the reimbursement rates for various services. Family planning is one example where providers prefer to rely on short term methods, such as oral contraceptives and injectables, as the primary methods for promoting family planning. If Jamkesmas increased its reimbursement rate for longer-term methods, such as IUDs, to a level that motivates providers to provide the service, they may more actively offer it as alternatives to patients. Second, from the standpoint of public health programming, Jamkesmas may be useful for driving forward public health priorities. If Jamkesmas made minor changes in its payment/reimbursement policies on important health areas (e.g., maternal health, TB), there could be significant positive implications on how these diseases are treated by providers.
Indonesia
The Way Forward
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
At the policy level, all aspects of health financing reform in Indonesia are complicated by decentralization. Although the concept at first appears simple with districts responsible for implementing health services, the complexity of the flows of funds—some targeted to health and others not, and some payments made through insurance organizations and others made directly to public providers (hospitals, Puskesmas, and personnel)—make for an intricate and fragmented set of financing flows. Recent studies indicate that many poor districts are receiving much higher levels of funding than previously, but have been unable to spend these funds because of local capacity constraints. Capacity building is necessary to ensure the system can continue to build administrative expertise and capacity to expand coverage.
There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formularies). Neither government officials nor professional associations have really addressed how to ensure more rigorous clinical standards of treatment. Jamkesmas has a greater ability to enforce these standards—as they can apply controls over the release of funds in the form of reimbursements—than is possible by either the MoH or professional associations. To help address the issue of enforcing standards, provider payment and monitoring structures are being reassessed by the DJSN in their process of developing implementable guidelines. This assessment is reviewing how different provider payment systems might influence provider behavior, and how to enforce that providers adhere to treatment protocols, promote specific health services, and remove existing disincentives to adhere to protocol. Pilots of various payment methods are currently underway.
In addition, thorough actuarial analysis of the true cost of expanding coverage is necessary to ensure appropriate funds are allocated to achieving universal coverage. In the short run, it will also be necessary to develop reliable cost information on delivering services in all types of health facilities.
Finally, Jamkesmas may be a very useful tool for improving health outcomes and promoting the utilization of certain health services. Unfortunately, these levers are not being widely utilized by the program as yet, nor is there an operational research program in place within the program to engage in this type of exercise. There are two potential opportunities in this regard. First, Jamkesmas can encourage providers to target certain services by adjusting the reimbursement rates for various services. Family planning is one example where providers prefer to rely on short term methods, such as oral contraceptives and injectables, as the primary methods for promoting family planning. If Jamkesmas increased its reimbursement rate for longer-term methods, such as IUDs, to a level that motivates providers to provide the service, they may more actively offer it as alternatives to patients. Second, from the standpoint of public health programming, Jamkesmas may be useful for driving forward public health priorities. If Jamkesmas made minor changes in its payment/reimbursement policies on important health areas (e.g., maternal health, TB), there could be significant positive implications on how these diseases are treated by providers.