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

MC2-850

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

protection

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 people

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, retired military staff, veterans

Employees of private employers with >10 staff or wage bill >Rp.1mn/ month

The poor and the near-poor (total 76.4 million targeted)

Contribution (as share of basic salary)

Employees:2% Employer: 2%No ceiling

Single: 3% Married: 6% Ceiling: Rp1mn / month

None

Contributor Employer and employee Employer 100% Government 100%Carrier PT Askes, for profit PT Jamsostek, for profit Ministry of HealthBenefits Comprehensive, with no specific

exclusions. Drugs if within formulary.

Comprehensive, but excludes certain catastrophic conditions. Drugs if within formulary.

ComprehensiveGeneric drugs

Cost-sharing Co-payments outside of the basic package

No co-payments No co-payments

Dependents covered Spouse and up to 2 children under 21 years, not working and not married.

Spouse and up to 3 children under 21 years, not working and not married

All family members

Type of provider Public health centers and public hospitals within network

Public and private providersFees are negotiatedExtra billing depending on negotiated fees

Public health centers and hospitals (class III beds), and contracted private hospitals.

Provider payment Negotiated fees Negotiated fees At health center: Rp. 1000/ month capitation paymentAt hospital level: negotiated fee with a ceiling

What Is the Impact on Coverage?

The government plans to offer free medical services for patients using third-class facilities at public hospitals this year, a move aimed at helping the large percentage of low-income and poor people who are uninsured.

Health Minister Endang Rahayu Sedyaningsih said many patients from low-income families were facing financial difficulties in gaining access to adequate health services, and that those who were covered by health insurance were hampered by complex bureaucracy.

The government will expand third-class health facilities at 93 public hospitals, she said.

“We have agreed to universal coverage. We have been troubled by various administrative procedures. So, it will be no problem for us to give free medical treatment for patients using third-class facilities,” Endang said. “It would be easier for us because we don’t have to ask them to provide any documents anymore.”

The public health insurance program (Jamkesmas), funded by the state budget, and Jamkesda, arranged by regional administrations, both of which were established in 2008, have not brought medical coverage to all low-income families.

“In many cases, patients from low-income families are not members of the Jamkesmas or Jamkesda programs,” Endang said.

Titik Purwasih, a 29-year-old housewife and a member of the low-income bracket, did not have access to public health subsidy when she was pregnant.

Titik suffered a severe premature rupture of the foetal membrane, which made childbirth risky for her, necessitating a Caesarean section.

Titik’s mother-in-law, Mariani, said her family did not have the means to pay for Titik’s operation, but the situation left them with no choice.

“We had neither the money nor health insurance,” she told The Jakarta Post on Thursday. “They asked me to think about her baby and her own life first instead of the medical expenses,” Mariani said.

“About 60 to 70 percent of the total 64,441 third-class facility beds both in public and private hospitals have been allocated for Jamkesmas and Jamkesda holders,” Endang said, adding that this showed that the country still lacked third-class beds.

Private hospitals should expand the number of their third-class facilities due to the high number of poor people, she added.

“They can arrange a kind of hospital social responsibility scheme, so those who come from poor families can afford medical treatment even at private hospitals,” Endang said.

Citing the latest data from the Central Statistics Agency (BPS), she said that 76.4 million out of 237.6 million Indonesian people belonged to the poor and low-income brackets.

The government has allocated Rp 5.13 trillion (US$564.3 million) for Jamkesmas this year from a total health budget of Rp 27.66 trillion, which is an increase from Rp 24.86 trillion in 2010 and Rp 20.17 trillion in 2009.

Rieke Dyah Pitaloka, a member of House of Representatives Commission IX, said the government should provide a clear definition of “poor people” who would be eligible for the subsidy.

Citing BPS data, she said that 28 percent of Indonesian people got sick every year, and that 3 percent suffered from serious illnesses.

“A clearer definition of poor people would guarantee that any insurance program can be better distributed to the targeted people,” she said. (ebf)

In the end Mariani and her family were able to raise the money for Titik’s operation, and Titik delivered the baby safely. Titik is now recovering in the third-class wing of a hospital.

To ease the financial burden, Mariani and her family registered for government subsidy for the operation.

But the process was long and arduous, involving a stack of documents and several trips to several government offices.

According to the Health Ministry, Indonesia has 1,523 hospitals — private and public — with a total of 151,000 beds. About 45,000 of the 64,441 third-class facility beds belong to public hospitals.

The Jakarta Post, Jakarta | Fri, 01/21/2011

Govt to make 45,000 hospital beds free for poor people

Two mothers who were left no option but to sell their newborns to pay hospital bills could have avoided their plight had they been informed they qualified for insurance and financing, health officials said on Thursday.

Suparti, 41, a poor woman from Gunung Kidul district near Yogyakarta, said she was forced to sell one of the twin girls to whom she had given birth to pay medical expenses for the deliveries at a state-owned hospital.

Her husband, Sarimin, 50, who makes a living doing odd jobs, failed to get a loan to pay the Rp 6 million ($660) bill. She said a hospital staff member offered to pay the bill if she allowed one of the twins to be adopted by another hospital employee.

“I had to sell one of my twin girls, whom I gave birth to only 10 days ago, because I couldn’t pay the bill at Wonosari General Hospital,” Suparti told state news agency Antara on Wednesday. “On Tuesday, I was allowed to go home. One of my babies was taken by Mbak Rina [the staff member]. I was not allowed to see [my child].”

Munawaroh, a poor woman who gave birth in Bali to a daughter with lung problems, was also faced with a Rp 6 million bill. Her husband, a laborer at a furniture store, had disappeared and her hospital bill grew by Rp 1.5 million per day.

“I am willing to give up my baby if someone wants to buy it, as long as I can get out of the hospital,” she told the Jakarta Globe.

Usman Sumantri, the head of the Health Ministry’s financing and insurance unit, told the Globe that parents who were not covered by Jamkesmas, the national health insurance scheme for the poor, should have been covered by Jamkesda, the local insurance plan.

“There should have been another health care scheme to help the parents,” Usman said. “Selling the babies is not the way to solve the problem.”

Bondan Agus Suryanto, head of the Yogyakarta Health Office, said patients had options available to help pay hospital bills.

“We are also going to warn the hospital that when there are patients who do not have insurance, it should give them information on other options.”

A hospital employee declined comment, saying the press officer had left for the day.

Syahrul Aminullah, chairman of the Indonesian Public Health Association (Iakmi), said hospitals could be sued if they did not provide care to the poor.

Local governments are also responsible for providing health insurance to poor residents, Syahrul said.

Additional reporting from Made Arya Kencana and Antara

It is distressing that after nearly 65 years of independence, we are still finding cases where women who live in abject poverty have no other option but to sell their newborn babies to pay their hospital bills.

First there was the case of Suparti, a woman from a poor district in Yogyakarta, who had to give away one of her twin baby girls to a member of staff at the state-run hospital where she had just given birth in order to pay the Rp 6 million ($660) bill for her Caesarean section.

Then there was Munawaroh, a washerwomen in Bali, who said she would have to sell her prematurely born daughter to cover her maternity costs.

These cases highlight the fact that our hard-won independence has failed to improve the lives of many Indonesians.

In Suparti’s case, the story is even more distressing because she gave birth in a state-owned hospital in Wonosari, a medical facility operated by the very government that is supposed to protect its citizens — especially children, the elderly and the poor.

And these two poor women are only the latest to come to the public’s attention.

Long is the list of reports of infants being sold to cover medical costs, and there have been just as many cases of poor patients being virtually held hostage by their hospitals for failure to pay their bills.

True, the government does have a dedicated health insurance scheme for

the poor — Jamkesmas at the national level and Jamkesda in the regions — but these schemes have been hindered by red tape and bureaucracy.

The government, as some officials point out, has also failed miserably at effectively disseminating information about health insurance options and how citizens can go about accessing them.

These cases point to an urgent need for the authorities, including the central government and local administrations, to improve their health services and health insurance coverage for the needy.

The government should be more proactive in both promoting its health insurance schemes for the poor and in assuring that these schemes reach those who truly need them.

The authorities should also be stricter in admonishing health care institutions, especially those owned and operated by the state, that refuse to treat poor people or try to exact payments that they clearly cannot afford.

Our Constitution clearly states that the state should protect its citizens and work for their well-being. How can we claim to be a modern, civilized society as long as incidents such as these continue to occur?

In the cases of Suparti and Munawaroh, we hope that it is clear to the authorities what their first course of action must be. The children must be returned to their mothers. Immediately.

Health Care Is Failing Our Most Vulnerable

In the Dark About Insurance, Mothers Give Up Newborns to Pay Hospital BillsNurfika Osman | July 09, 2010

Jamkesmas has increased access to Health Insurance and constitutes the largest program in 2009

0.2

.4.6

.81

Pro

po

rtio

n

2004 2005 2006 2007 2008 2009

Source: SUSENAS 2004-2009

Household-level insurance coverage, 2004-2009

Jamkesmas/Askeskin/Health Card AskesJamsostek Private

Other No insurance

Jamkesmas has Increased HI Coverage for the Poor

Despite improvements in Targeting, Leakage of Benefits to the Non-Poor Remains Substantial

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

….suggesting that non financial barriers to use health services persist

Despite more generous benefit package, utilization of Jamkesmas is consistently lower than those with Other Insurance…….

No insurance

Jamkesmas/Askeskin/Health Card

Other insurance

0.0

05

.01

.015

.02

.025

.03

.035

.04

Utilization r

ate

2003 2004 2005 2006 2007 2008 2009 2010Year

All

No insurance

Jamkesmas/Askeskin/Health Card

Other insurance

0.0

05

.01

.015

.02

.025

.03

.035

.04

Utilization r

ate

2003 2004 2005 2006 2007 2008 2009 2010Year

Bottom 3 deciles

Source: SUSENAS 2004-2009

Inpatient utilization rate, 2004-2009by insurance type

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 protection?

Despite no co-payment, OOP for health spending remains substantial among Jamkesmas beneficiaries

…large OOP is explained by Inpatient utilization

Conditional on Inpatient Utilization

Jamkesmas beneficiaries have a lower incidence and intensity of catastrophic expenditure

Incidence Intensity

Summary

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-side

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