HEALTH FINANCING :

revenue collection, pooling and

purchasing

Yulita Hendrartini
Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan
Universitas Gadjah Mada
Agents in health care financing
 Definition of health care
financing
Definition of health care financing
• mobilization of funds for health care
• allocation of funds to the regions and
population groups and for specific
types of health care
• mechanisms for paying health care

(Hsaio, W and Liu, Y, 2001)

Financing is More Than Mobilize Money

Mobilize
& collect
Pool the Risk
Funds
Allocate
Resources
Purchaser
Fungsi dan Tujuan Pembiayaan Kesehatan
Fungsi Tujuan
Meningkatkan dana untuk
Revenue kesehatan secara cukup dan
berkesinambungan. Dana ini untuk
Collection membiayai pelayanan paket
esensial dasar dan perlindungan
keuangan dari penyakit dan biaya
katastropik berdasarkan aspek
pemerataan

Mengelola dana-dana tersebut

Pooling dalam pool risiko kesehatan yang
efisien dan merata

Purchasing Menjamin pembelian/

pemerolehan dan pembayaran
& Payment pelayanan kesehatan yang
efisien secara teknis dan alokatif
Hsiao 2013
 Mekanisme Revenue Collection
Melalui mekanisme
pemerintah/lembaga asuransi Dari masyarakat
kuasi pemerintah
• Pajak langsung atau tidak • Dari kantong pasien
langsung perorangan
• Pendapatan pemerintah yang • Yayasan-yayasan
berasal dari bukan pajak kemanusiaan
• Kontribusi asuransi wajib dan
potongan gaji
• Pembayaran premi ke
pemerintah
• Grant dan pinjaman luar-
negeri
6
 Pendapatan Apa yang terjadi dalam
Negara
Paja
k
bukan Pajak Pengumpulan dana
Kesehatan
Non-PBi PNS,
18.89T
Jamsostek dll
APBN (67,5 T) dll
Non-PBI
PBI
BPJS Mandiri
2.24T
Kemenkes 19.93T
Askes
Swasta
Kementerian
Kab/K lain Pelayanan Pelayanan
ota 489 NHA 2009 (dana
( 72.9 Primer: Rujukan masyarakat
T) Pemda langsung) (18 T)

Pendapatan Dana dari Masyarakat langsung

Asli Daerah Trisnantoro, 2014
7
 Pooling
• Pooling yaitu bagaimana pengumpulan dana
dibagikan yang mempunyai risiko kesehatan diantara
pengumpul dana /atau anggota kelompok (pool
member) (World Bank, 2014).
• Dana yang dikumpulkan untuk kesehatan akan
dibayarkan ke provider kesehatan,
• tempat penampungan (pools) dana bisa berbagai
macam, seperti anggaran pemerintah pusat dan
pemerintah daerah, asuransi kesehatan publik dan
swasta, dan asuransi kesehatan berbasis masyarakat.

8
 Pooling dana kesehatan

1. APBN
Dua Pool • Kemenkes (47,5 T)—termasuk
PBI
besar: • Kementrian Lain (13,5 T)
1. APBN • Pemda (6.5 T dari APBN)
2. BPJS
2. BPJS Kesehatan
• PBI (19,9 T) plus
• Non PBI-ex Askes,Jamsostek
(18.89T)
• Non PBI-Mandiri (2.24T)
9
 Pajak
Pendapatan
Negara
bukan Pajak
Apa yang terjadi
dalam Pooling
Non-PBi PNS,
Jamsostek dll
APBN dll

PBI Non-PBI
BPJS Mandiri
Kemenkes
Askes
Swasta
Kementerian
lain Pelayanan Pelayanan
Primer: Rujukan
Pemda

Pendapatan Dana dari Masyarakat

Asli Daerah langsung Trisnantoro, 2014
10
 Pooling & Purchasing Functions Not Separated by Revenue

National Local Payroll Donor Private

Revenue Budget Budget Tax Funds Funds
Collection

Pooling of Funds Pooled

Pooling or not
of Funds Health Purchaser or Purchasers
Pooled

Unified or Coordinated Benefits Package

Health
Purchasing
Unified or Coordinated Provider Payment Systems

Providers

Population
Purchasing with Health Budget Funds
• Input-based line item budgets funding public facilities
can be problematic if low budget level doesn’t fund all
services provided in health facility
– Not clear to provider what services funded and what not
funded
• Health budget purchasing better targeting or
matching priority services & poor populations
– Output-based provider payment systems
• Key is unit of service—not building but services for people
– Financial incentives for desired service delivery
improvements
– Align rather than fragment health purchasing
– Better targeting budget funds to priority services opens
space or clear role for private funds
 Pemahaman Purchasing
Purchasing:
•Mekanisme pembayaran ke fasilitas kesehatan
dan penyedia layanan kesehatan
•3 komponen yaitu alokasi sumber daya, paket
manfaat dan mekanisme pembayaran provider
(Preker and Langenbrunner, 2005)

Desain ini merupakan komponen kunci yang sangat penting

untuk pemerataan akses yang adil dan perlindungan terhadap
resiko keuangan. 13
 Purchasing dalam JKN
RASIO KLAIM 2014 - PEMBEBANAN • Rasio klaim berdasarkan bulan
(JUTA RUPIAH)

RASIO pelayanan sebesar 114,60 %

IURAN PELKES
KLAIM dengan beban klaim 12 bulan
40.719.862 42.658.702 104,76 % • Bila dikurangi biaya
38.242.870 42.658.702 111,55 % operasional maka rasio klaim
LAPORAN AKUNTANSI AUDITED
akumulasi 122,02%.
RASIO KLAIM 2014 - PELAYANAN • Berdasarkan bulan pelayanan
(DIKURANGI BIAYA OPERASIONAL BPJS ) iuran POPB : 27.198 dan Biaya
(JUTA RUPIAH)
manfaat POPB : 30.486
RASIO
IURAN PELKES
KLAIM • Bila tanpa peserta PBPU, rasio
40.719.862 46.665.539 114,60 % klaim 84,29%
38.242.870 46.665.539 122,02 %
LAPORAN BOA, CPR & KEUANGAN DIOLAH

14
 Biaya manfaat 2014
42.658.702 *

Peserta 133.273.918
PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688 PBPU : 9.050424

Biaya Pelayanan Primer Biaya Pelayanan

Rp. 8.347.850 Rujukan
Rp. 30.439.572
Biaya Non
Jlh Faskes Rujukan : 1. 681
Jlh faskes primer : Kapitasi RS Pemerintah : 776
17.492 Non CBG’s, RS TNI-POLRI : 143
Puskesmas : 9.788 promprev RS Swasta : 652
DPP : 3.984 Rp. 3.871.280 RS BUMN : 42
Klinik pratama : 2.388 Klinik Utama : 68
Faskes TNI-POLRI : 1.324
RS Rata
pratama : per8
rata biaya Rata rata biaya per
faskes Rp.39.77 * Cash basis
faskes
juta/bulan Rp. 1,509 M/bulan
 Biaya manfaat sd Juni 2015
27.178.466 *

Peserta 147.675.544
PBI –N : PBI-D : PPU swasta Eks Askes : PBPU :
86.426.543 10.613.788 18.347.445 19.534.154 12.753.614

Biaya Pelayanan Primer Biaya Pelayanan Rujukan

Rp. 4.953.108 Rp. 22.270.069
Biaya Non
Jlh faskes primer : 18.347 Jlh Faskes Rujukan : 1.783
Kapitasi
Puskesmas : 9.814 RS Pemerintah : 692
DPP : 4.314 Non CBG’s,
RS TNI-POLRI : 147
Klinik pratama : 2.923 promprev RS Swasta : 903
Faskes TNI-POLRI : 1.288 Rp. 816.879 RS BUMN : 41
RS pratama : 8

Rata rata biaya per Rata rata biaya per faskes

faskes Rp.44,99 Rp. 2,081 M/bulan
* Cash basis
juta/bulan
 Fund Collection Indicators
Indicators Purpose
•The formal sector share of GDP • Potential resources available to
•Natural resources revenue as a share finance public health spending
of total public budget
• Total health expenditure % GDP

• Public sector spending as % GDP •To measure resources specially

•External health sector aid as % of available to the public sector
GDP

•The share of public health to total
public expenditures
•Per capita total and public health
expenditures
•The share of total health
expenditures that are prepaid
•To measure public sector allocation
decisions, additional resources, and
potential constraints
•A broad measure of financial protection
against out-of-pocket expenses

17
 Pooling Indicators
Indicators Purpose
Means and distribution measure •Measures of the scale, depth of
of: financial coverage, and existence
•Share of co-payments to total of compensatory mechanisms
health expenditures in each pool across pools
•Membership in each pool
•Per capita spending in each pool

•Share of administration •To measure the efficiency of

expenses out of total spending in pool management and
each pool effectiveness of compensatory
•Average ratio of transfers to mechanisms
estimated shortfall (or surplus)
18
 Purchasing Indicators
Indicators Purpose
•Share of expenditures accounted •Characterizing the pool-purchaser
for by “strategic” purchasing relationship

•Number of purchasers •To characterize the structure of

•Mean and distribution of total interaction between purchasers and
expenditures across purchasers providers
•Mean and distribution of the
number of providers who are
contracted or hired by each
purchaser
•Share of total funds spent with •To measure the financial incentives
different payment mechanisms (e.g. embedded in payments to providers
salaries, fee-for-service, capitation)

19
 Health Financing Schemes

Financing mechanisms Financing sources

Tax-based 1. General tax or

Natural
financing other revenue resource
revenue

Social health 2.Payroll tax

Health insurance
Household
care Other 3.Contribution or
services prepayment premium
schemes External
resource

Out-of-
4. Direct payment
pocket
payments
 Issues in Health Financing

What's the nation's ethical foundation for

health care? Is equity a priority over efficiency?
For whom you allocate resources and for what
services/drugs?
How much would the program cost? Who
pays?
Can the nation's transform money into effective
and efficient services?
Is financing scheme sustainable?