UNIVERSAL HEALTH COVERAGE (UHC)

CHALLENGES & SOLUTIONS,

WHAT CAN WE LEARN FROM INDONESIA?

ASIH EKA PUTRI

aeputrishi@cbn.net.id
The National Social Security Council of Rep. Indonesia
2-day Seminar:
Designing Effective Social Security System in Asian Countries
MOF & ADBI, Yogyakarta 20 March 2018
 OUTLINES

Social Security Reform & NHIP

Current Achievement

CHALLANGES & SOLUTIONS

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 Brief Overview
SOCIAL SECURITY REFORM &
NATIONAL HEALTH INSURANCE PROGRAM (NHIP)

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 THE NATIONAL SOCIAL
SECURITY COUNCIL

• Social Security Reform has been taken place in 2004 as

ordered by the Constitution, amended in 2002.
• The Council was established to implement the National
Social Security System (Law no 40/2004) – Tripartite &
Public Institution for policy formulation and supervision.
• The law stipulates:
– Health care coverage for all citizens,
– Occupational health for all employees,
– Provident fund for all employees,
– Pension for all employees,
– Death benefits (life insurance) for all employees.

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 The Indonesian Health System
(the Law no 36/2009)

Public Health Programs Personal Health Care

• Administered by Ministry • Administered by BPJS

of Health and the Local Kesehatan, the National Health
Government Health Insurance Corporation
Offices • Focus on individual health care
(screening, diagnosis, treatment
• Focus on public health , and rehabilitation)
promotion and • Funded by public contribution &
prevention government subsidy for the
• Funded by the indigents (Social Health
Government Budgets Insurance scheme)
(National & Local) • Delivered by Contracted Public
and Private Health Care
• Delivered by Puskesmas Providers.
(Public Health Centers)

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 Landmarks of UHC Indonesia
Social Health Insurance Scheme Started
50 years ago, NOT 5 years!!

ASKES Safety Nets NHIP

1997-2013
Various social safety integration of
1968

2014
SHI for all civil net programs /social previous systems into
servants and their assistances, in a single National
family members reaction to Asian Health Insurance
was started Financial Crisis were Program, administere
implemented d by the BPJS
Kesehatan.

SHI for private The law of the National

employees, with Social Security System
passed, but
opt out. By
implementation was
1993

2013, only 5%
2004
delayed until 2014 due to
employees were political reasons.
registered.
JAMSOSTEK Social Security
Reform
 Main Characteristics of NHIP,
UHC Indonesia
SYSTEM COVERAGE BENEFITS PROVISION
• NHIP is integral • Single payer • In-country • By Contracted
part of national provision Providers, both
for all
social security • Comprehensive public and
citizens, inclu benefits, all
system & private
ding necessary but
established • uses a gate
through social foreigners most cost-
effective health keeper system
security reform working and pay HC
care.
• Personal above 180 • Commission on providers on
health care is days. Health prospective
Technology payments
a part of Assessment was
nat.health (capitation and
established to casemix base
system consider a new
groups, CBG)
medical
technology is
covered only if it
is proven cost-
effective
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 NHIP
PERSONAL
HEALTH CARE
FOR ALL:

Publicly
financed,

Privately
provision
(market
mechanism)

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 CONTINUING REFORM
Triggered from the external of Health system (2004-2017)

SOCIAL SECURITY
HEALTH SYSTEM REFORM
REFORM:
Moving towards integrative
193,53 Milions Members
system of public health &
(74,4% population)
health services with
Mandatory membership to
decentralized health policy
all citizens by 2019
 law harmonization
Social solidarity principle
NATIONAL Accountable structure of
Constitutional Right
HEALTH governance
Government subsidy for the
INSURANCE Stonger public
indigents through
participation in decision-
membership contribution
making .
Government’s contigency
fund to cover deficit HEALTH SERVICE
PAYMENT REFORM REFORM
Single Pool of fund creating Monopsony power Moving towards:
26.862 providers Structural & integrative
delivery
(clinics, optics, laboratoriums, pharmacies,hospitals)
Standardized services
All public providers - mandatory (40%) Regulated healthcare market
Private providers (60%)
 GENERAL POLICY
• RAPID EXPANSION OF COVERAGE to all citizens
of 260 millions in 5 years (2014-2019):
– LOW PREMIUM – regressive in nature
– COMPREHENSIVE BENEFITS WITH FREE OF CARE AT
THE POINT OF SERVICES; cost sharing is limited to
prevent moral hazzard of members.
– LOW TARRIFs WITH PROSPECTIVE PAYMENT
MECHANISM
– MASSIVE GOVERNMENT SUBSIDY for paying the
contribution of the indigents and contigency funds.
– OPEN REGISTRATION for all citizens since the first
day of NHIP implementation with limited period of
waiting time and minimal compliance risk
management.
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 The Prospective Payments
• Payment modelling & Price setting:
– By MoH; final price with very limited space for provider-payer
negotiation.
• Primary care (puskesmas, solo practices, and private clinics):
– are paid IDR 3,000 – 8,000 per member per month.
– The capitation covers doctor’s consultation, simple
lab, medicines for acute care. Inherently, the primary care
facilities are pushed to provide individual health prevention
• Sencondary care & Hospital Care:
– The CBG system pays outpatients and inpatients care based on
fixed payment determined by the Ministry of Health
– Currently there are 1,076 groups of outpatients and inpatients
distributed for five regions and four 11 classes of hospitals
– The CBG covers all resources needed for acute care hospital
services
– Drugs for chronic diseases and cancers are paid separately

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 Drugs Managements

• MOH plays central role in drug management for NHIP:

– Setting up a National Formulary, listed generic name of
drugs that health care providers must provide
– ensuring competitive prices, the MoH and the LKPP
(National Procurement Agency) conduct tender of
framework prices at the National Level. However, the drug
prices are at provincial levels. It is called e-catalog
– negotiating patented drugs and cancer medicines
separately with Pharma industries
– The lowest price winners must supply drugs to public
health care providers. There are still debates and
complaints about access to e-catalog.
• BPJS Kesehatan plays passive role.

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 Source: Suwondo & Yussi, 2016

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 2014-2017

CURRENT ACHIEVEMENTS
Indonesia has made significant
progress on the commitment to
achieve UHC by 2019

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 Trend of Registered
Coverage, Millions of People by
Group Members Trends of the Average per Capita
Contributions and Claim Costs of the
JKN
200
180 2014 2015 2016
160
Contribution per
capita/month, IDR 25,432 28,052 34,734
140
Claim per capita/month,
120 IDR 26,356 28,613 36,818
100 Per cent Increased of
80 contribution, % 10.3% 23.8%
60 Avg xchange US$1 = 13,400
40 Source : AE Putri & H Thabrany
20
0 Coverage is
2014 2015 2016 2017 expanding, utilization is
Low Inc Nat Low Inc Loc increasing, and cost per
Waged (Formal) Non Waged (informal)
member is increasing.
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 Distribution of Hospitals Contracted by
the BPJS by Ownership, 2017
MoH Military Police
2% 5% 2% Provincial
All public hospitals are Gov't
6%
mandated to serve the
JKN members. Private
hospitals may contract
if they accept the District Gov't
25%
levels of payment. Private
About 75% private 60%
hospitals are making
contract

Source : AE Putri & H Thabrany

Previous maldistributions of health facilities and human

resources inhibit access to some services.
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Health Care Cost Distributions of the JKN

HEALTH CARE COST (IDR B & %) 2014 HEALTH CARE COST (IDR B & %) 2015
CBGs Capitation Non-CBGs & Non Kapitasi CBGs Capitation Non-CBGs & Non Kapitasi

4.314 5.449
9% 9%
8.348 10.543
18% 17%

33.838 45.535
73% 74%
Source : AE Putri & H Thabrany

One of the problems of NHIP is spending less than 20% of the total
fund for primpary care (capitation). ...allocative inefficiency?
Data source: Ministry of Health and BPJS Health data)
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 Increasing Access to Medical care.
Rates Per 1,000 members

Services 2014 2015 2016

Primary 42 53 62
OP hosp 13 21 25
Inpatients 3 3 4
Source : AE Putri & H Thabrany

Increasing access and consumption resulted in higher claim

costs. But, the Government has been hesitated to raise
contribution for political reasons.

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 JKN/NHIS has Improved Equity in Inpatient
Rates significantly
JKN

Evaluation of 1

the
.8

Indonesian
Family Life
.6

Survey data of
2007 (before
.4

JKN) and 2014

(agter JKN)
.2

shows the
concentration
0

curves moving 0 .2 .4 .6 .8 1

toward equity Cencentration Curve

Distribusi ofkonsumsi
kumulatif Admission
perkapita
Cencentration Curve of Admission
line. 2007
2014
Garis equality

Age ≥ 40 Year Age ≥ 15 Year

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Source: Nugrahani, 2017
 The WHO Cube of UHC
The JKN Figure of 2017 Shows share of the JKN fund to the
Total Health Expenditure is Predicted only 18%. Too low to
Ensure Good Quality of care

45-47% OOP
Current financial
share 18% of the THE
75 % population covered
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 2014-2017

CHALLENGES FOR NHIP

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Brief Activity Report on Social Security Funds
2014 – 1st Semester 2017 (in Billion Rupiah):
Indonesia’s UHC is approaching SUSTAINABILITY CROSSROAD

Total Net Revenue Total Expense Deficit Due to

80000
70260,28
inappropriate
70000
61267,68
63940,82 contribution
60000
52896,54 regulation, benefit,
50000 42211,07
41051 payment & tarrifs
38901,96
40000
34320,71 and heavily
30000 politics, the NHIP
20000 has been suffering
10000 from STRUCTURAL
0 DEFICIT in 2014-
-10000
-3309,11
-8371,14
-6319,46 -6730,29 2017.
-20000
2014 2015 2016 1st Semester 2017
Source : DJSN Report, 2017

IT BECOMES TOO POLITICS: decision of contributions and

payments is heavily political, not economical.
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 WEAK ACCOUNTABILITY OF SYSTEM
• UNFINISHED REFORM AGENDA CREATES POWER CONFLICT IN THE
ARRANGEMENT OF NHIP – ANOMALY in implementation of the
Social Security Act of 2004
– unclear central role of BPJS Kesehatan as fund manager &
strategic purchaser, &
– malfunctioning supervisory arrangement of the National Social
Security Council (NSSC)
• MALFUNCTIONING OF NSSC led to diminishing role of public in
regulating and supervising the implementation of NHIP and
increasing the complexity of decision making process.
• Incomplete power shift from MOH to NHIC, led to diminishing
power & responsibility of NHIC as strategic purchaser (become
passive).
• Integration of NHIP with local health policy remains weak and some
local government established local health schemes parallely to
NHIP.

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 Diversities of the Country:
Economic, Social, Infrastructures:
Like Sky and Earth Inadequacy of
contribution
payment and
geographical
imbalance in
service
provision
remain
challenged the
sustainability of
the NHIP.

High income
people are not
happy, normally
at the beginning.
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 CHANGING & CHALLENGING STATUS QUO
TO CREATE NEW VALUES
MAJOR CHANGES at OPERATIONAL LEVEL OF PURCASING: Securing
Incentives work effectively at primary clinics & hospitals remais ineffective.
Rupiah

Rupiah
Loss
Profit Fixed tariff

Volume of services Volume of Services

Cost + Profit = Tariff Tariff – Cost = Profit

Doctors and other health professionals are not happy due to low
payments (below the market prices)
 But, We Cannot Wait
Act
Now!

Wait until
Act now, with providers are
inequity of distributed equally
providers

55% of the population live in urban, distant to any

health care providers within one hour of travel time 26
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 Political Mindset: Covers Comprensive
instead of Rationing Benefits
Compre
hensive

Providing potential Cover only partial

access comprehensive services, adequate
services to everyone fund for everyone

Covering partial benefits to ensure everyone get HC they need, or

covering comprehensive and lets some one do not use their right?
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When will they get health protection?
Current UHC Certainly Does not Work
for them!
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 CONCLUSION:
NHIP is moving toward
providing better access to
health care, yet the level of
financial protection remain
low.

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 SOLUTIONS
• Revision of Law & Regulation
– 2017-2018: Revision of Implementing Rules &
Regulation of NHI to be harmonized with Social
Security Act & the President’s Agenda on Regulatory
Reform,
– 2009: Revision of the NSS Law & BPJS Law to
strengthen the NSS Council & to improve the
governance of BPJS Kesehatan.
– 2018-2019: selecting the governance arrangements
and distribution of purchasing functions that is
appropriate for Indonesia.
– 2017-2018: Restucturing contribution, benefits, tarrifs

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 SOLUTIONS
• Use strategic health purchasing wisely
– to balance efficiency gains with improved health service delivery
and better quality.
– to assign the function of payment rate-setting to the purchaser
(BPJS Kesehatan).
• Optimize resource mobilization for financing the NHIP
– Moving toward progressive contribution rate supported by
strong social insurance culture/understanding of the citizens.
– Strengthening the use of IT solutions for strengthening the
accountability of the system & the compliance of members &
providers.

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 SOLUTIONS

The is More Money in the Ministry and Health Offices than in

NHIC (BPJS Kesehatan):
Budget reallocation is necessary to strengthen the NHIP e.g shifting budget
allocation for hospitals operation to premium subsidy and let hospital
operational costs including salaries paid by claim revenues from NHIP .
Reducing duplication of tasks/unnecessary tasks of MOH by fully delegating
the tasks to NHIP & NSSC.
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Terima Kasih
THANK YOU

Asih Eka Putri - DJSN 33