HEALTH FINANCING :
revenue collection,
pooling and purchasing
Yulita Hendrartini
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
Financing is More Than Mobilize Money
Mobilize
& collect
Pool the Risk
Funds
Allocate
Resources
Fungsi dan Tujuan Pembiayaan
Fungsi dan Tujuan Pembiayaan
Kesehatan
Kesehatan
Fungsi
Tujuan
Revenue
Collection
Pooling
Purchasing
& Payment
Meningkatkan dana untuk
kesehatan secara cukup dan
berkesinambungan. Dana ini
untuk membiayai pelayanan
paket esensial dasar dan
perlindungan keuangan dari
penyakit dan biaya katastropik
berdasarkan aspek
pemerataan
Mengelola dana-dana tersebut
dalam pool risiko kesehatan
yang efisien dan merata
Menjamin pembelian/
pemerolehan dan
pembayaran pelayanan
kesehatan yang efisien
secara teknis dan alokatif
Mekanisme Revenue Collection
Melalui mekanisme pemerintah/lembaga asuransi kuasi pemerintah
•
Pajak langsung atau tidak
langsung
•
Pendapatan pemerintah yang
berasal dari bukan pajak
•
Kontribusi asuransi wajib dan
potongan gaji
•
Pembayaran premi ke
pemerintah
•
Grant dan pinjaman
luar-negeri
Dari masyarakat
•
Dari kantong pasien
perorangan
•
Yayasan-yayasan
kemanusiaan
Apa yang terjadi dalam
Pengumpulan dana
Kesehatan
APBN
BPJS
Paja
k
Pendapatan Negara bukan Pajak Non-PBI MandiriPelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll
dll
Kemenkes
Dana dari Masyarakat langsung
Kementerian lain PBI Pemda 7 Pendapatan Asli DaerahAskes
Swasta
(67,5 T)NHA 2009 (dana masyarakat langsung) (18 T)
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.
Pooling dana kesehatan
9
1. APBN
•
Kemenkes (47,5 T)—termasuk
PBI
•
Kementrian Lain (13,5 T)
•
Pemda (6.5 T dari APBN)
2. BPJS Kesehatan
•
PBI (19,9 T) plus
•
Non PBI-ex Askes,Jamsostek
(18.89T)
•
Non PBI-Mandiri (2.24T)
Dua Pool
besar:
Apa yang terjadi
dalam Pooling
APBN
BPJS
Pajak
Pendapatan Negara bukan Pajak
Non-PBI
Mandiri
Pelayanan
Primer:
Pelayanan
Rujukan
Non-PBi PNS,
Jamsostek dll
dll
Kemenkes
Dana dari Masyarakat
langsung
Kementerian lain
PBI
Pemda
10
Pendapatan Asli Daerah
Askes
Swasta
Pooling & Purchasing Functions Not Separated by Revenue
Health Purchaser or Purchasers
Unified or Coordinated Benefits Package
Unified or Coordinated Provider Payment Systems National
Budget
Local Budget
Payroll Tax
Donor Funds
Private Funds
Pooling of Funds Pooled
or not Pooled Revenue
Collection
Pooling of Funds
Health Purchasing
Providers
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
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
RASIO KLAIM 2014 - PELAYANAN (DIKURANGI BIAYA OPERASIONAL BPJS )
(JUTA RUPIAH)
IURAN PELKES KLAIMRASIO
40.719.862 46.665.539 114,60 % 38.242.870 46.665.539 122,02 %
LAPORAN BOA, CPR & KEUANGAN DIOLAH
•
Rasio klaim berdasarkan bulan
pelayanan sebesar 114,60 %
dengan beban klaim 12 bulan
•
Bila dikurangi biaya operasional
maka rasio klaim akumulasi
122,02%.
•
Berdasarkan bulan pelayanan
iuran POPB : 27.198 dan Biaya
manfaat POPB : 30.486
•
Bila tanpa peserta PBPU, rasio
klaim 84,29%
RASIO KLAIM 2014 - PEMBEBANAN
(JUTA RUPIAH)
IURAN PELKES KLAIMRASIO
40.719.862 42.658.702 104,76 % 38.242.870 42.658.702 111,55 %
LAPORAN AKUNTANSI AUDITED
Purchasing dalam JKN
Biaya manfaat 2014
42.658.702 *
Peserta 133.273.918
Biaya Pelayanan Primer
Rp. 8.347.850
Biaya Pelayanan
Rujukan
Rp. 30.439.572
Jlh faskes primer :
17.492
Puskesmas : 9.788
DPP : 3.984
Klinik pratama : 2.388
Faskes TNI-POLRI : 1.324
RS pratama : 8
Jlh Faskes Rujukan : 1. 681 RS Pemerintah : 776
RS TNI-POLRI : 143
RS Swasta : 652
RS BUMN : 42
Klinik Utama : 68
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 3.871.280
PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688 PBPU : 9.050424
Rata rata biaya per
faskes Rp.39.77
juta/bulan
Rata rata biaya per
faskes
Rp. 1,509 M/bulan
Biaya manfaat sd Juni 2015 27.178.466 *
Peserta 147.675.544
Biaya Pelayanan Primer
Rp. 4.953.108
Biaya Pelayanan Rujukan Rp. 22.270.069
Jlh Faskes Rujukan : 1.783 RS Pemerintah : 692 RS TNI-POLRI : 147 RS Swasta : 903
RS BUMN : 41
Biaya Non
Kapitasi
Non CBG’s,
promprev
Rp. 816.879
PBI –N :86.426.543 10.613.788PBI-D : PPU swasta 18.347.445 19.534.154Eks Askes : 12.753.614PBPU :
Rata rata biaya per
faskes Rp.44,99
juta/bulan
Rata rata biaya per faskes Rp. 2,081 M/bulan Jlh faskes primer : 18.347
Puskesmas : 9.814 DPP : 4.314 Klinik pratama : 2.923 Faskes TNI-POLRI : 1.288 RS pratama : 8
17
Fund Collection Indicators
Indicators
Purpose
•The formal sector share of GDP
•Natural resources revenue as a share of total public budget
• Total health expenditure % GDP
• Potential resources available to finance public health spending
• Public sector spending as % GDP •External health sector aid as % of GDP
•To measure resources specially available to the public sector
•The share of public health to total public expenditures
•Per capita total and public health expenditures
•To measure public sector allocation decisions, additional resources, and potential constraints
•The share of total health expenditures
18
Pooling Indicators
Indicators
Purpose
Means and distribution measure
of:
•Share of co-payments to total
health expenditures in each pool
•Membership in each pool
•Per capita spending in each
pool
•Measures of the scale, depth of
financial coverage, and existence
of compensatory mechanisms
across pools
•Share of administration
expenses out of total spending in
each pool
•Average ratio of transfers to
estimated shortfall (or surplus)
•To measure the efficiency of
pool management and
19
Purchasing Indicators
Indicators
Purpose
•Share of expenditures accounted
for by “strategic” purchasing
•Characterizing the pool-purchaser
relationship
•Number of purchasers
•Mean and distribution of total
expenditures across purchasers
•Mean and distribution of the
number of providers who are
contracted or hired by each
purchaser
•To characterize the structure of
interaction between purchasers and
providers
•Share of total funds spent with
different payment mechanisms (e.g.
salaries, fee-for-service, capitation)
Health Financing Schemes
Health
care
services
Tax-based
financing
Social health
insurance
Other
prepayment
schemes
Out-of-pocket
payments
1. General tax or other revenue
2.Payroll tax
3.Contribution or
premium
4. Direct payment
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?
