Kebijakan Strategis untuk mengurangi ketidak adilan dalam mencapai Universal Health Coverage

(1)

Kebijakan

Strategis untuk

mengurangi

ketidak adilan

dalam mencapai

Universal Health

Coverage

Laksono Trisnantoro Universitas Gadjah Mada

InaHEA 2nd National Meeting, Jakarta, 9th April 2015 1

Strategic Policy

for narrowing

inequity in

Universal Health

Coverage

programs

(2)

What Happened in 2014

• JKN dimulai 1 Januari

2014

• Situasi supply-side dalam

keadaan tidak seimbang.

- SDM dokter dan kesehatan tidak merata

- Pelayanan kesehatan tidak merata • Di awal tahun 2015, berbagai sumber menyatakan bahwa BPJS kekurangan 2 – 5 Triliun • JKN started in January 2014

• Supply side is extremely

not well distributed across Indonesia - Human resources - Health facilities - In 2015 some report shows that BPJS is shortage of 2-4 Triliun 2

(3)

The Shortage of BPJS

• Pardede, 2015 ₃

(4)

Who Gets What in 2014?

• Siapa yang mendapatkan dana BPJS? • Apakah masyarakat yang membutuhkan?Ataukah justru masyarakat menengah ke atas di kota-kota besar?

• Who get what from

BPJS expenditure?

• Whether the poor or the better of

community?

• Whether people in the remote area or in the big cities

(5)

In more specific, which member

group?

• Kelompok masyarakat

miskin yang dibayar melalui PBI?

• Kelompok Non-PBI eks PT

Askes Indonesia dan PT Jamsostek?

• Kelompok Non-PBI

Mandiri (Pekerja Bukan Penerima Upah)?

Bagaimana isu Ketidak adilan?

• Poor community paid by

central government budget (PBI)?

• The ex PT Askes and PT

Jamsostek members and formal sector?

• The Non-PBI Mandiri?

How is equity issue is managed?

(6)

The Analysis

• Revenue Collection • Pooling

• Purchasing

(7)

Health Financing

(simplified)

APBN BPJS Tax Income Non-tax Income Non-PBI Mandiri Primary

Care Referral Care

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 7 Local Gov Private Insuran ce (19.93 T) NHA 2009 : (18 T) 489 ( 72.9 T) l.K 20 T 4 T (67,5 T)

(8)

Revenue Colelection

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 8 Local Gov Private Insuran ce (67,5 T) NHA 2009 : (18 T) 489 ( 72.9 T) 4 T (19.93 T) +-20 T

(9)

Pooling

9

1. APBN

1. MoH (47,5 T)—incl. PBI • Other Ministries (13,5 T)

• Local Government (6.5 T of APBN)

2. BPJS Kesehatan

• PBI (19,8 T) plus

• Non PBI-ex PT Askes • Non PBI-Mandiri

Two Big

Pools

1. Ministry

of Health

1. BPJS

(10)

What happened in the

two Big Pools?

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 10 Local Gov Private Insuran ce

(11)

Ministry of Health

In 2014:

• Small Budget for

Hospital Investment

• Human Resources

budget stagnant Pada tahun 2014

• Dana investasi kecil untuk penambahan pelayanan kesehatan dan sumber daya

kesehatan

(12)

Kemkes Pemprov Pemkab Pemko Kementeri_{an lain} TNI POLRI _{non profit}Swasta Swasta BUMN 2012 32 85 411 86 3 105 29 654 237 77 2013 32 89 447 88 3 115 39 727 468 75 2014 33 96 455 92 3 118 41 724 599 67 Updated 34 97 459 92 5 127 43 733 694 66 -100 200 300 400 500 600 700 800 RS

The new Hospital financed by private

sector

(13)

(14)

BPJS:

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 14 Local Gov Private Insuran ce More Sick Members in the Voluntary Group Kelompok

(15)

Adverse Selection

problems in Non-PBI

Mandiri

APBN BPJS Pajak Pendapatan Negara bukan Pajak Non-PBI Mandiri Pelayanan

Primer: PelayananRujukan

Non-PBi

PNS, Jamsostek dll dll

Kemenkes

Dana dari Masyarakat langsung

Kementerian lain PBI Pemda 15 Pendapatan Asli Daerah Kelompok

sakit Kelompok_sehat

Askes Swasta

(16)

The health risk in BPJS pool

• Non-PBI-Mandiri

(Voluntary Group)

Not poor, some rich .

• PBI members (poor member)

• Non-PBI (ex PT Askes )More Healthy

members Kelompok sakit Kelompok sehat Kelompok

sakit Kelompok_sehat Kelompok

sakit Kelompok_sehat

(17)

What Happened in

Purchasing?

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 17 Local Gov Private Insuran ce 489 ( 72.9 T)

(18)

BPJS, Purchasing and Payment

Mechanism

• Kapitasi untuk

pelayanan kesehatan primer, dan

• Klaim untuk pelayanan kesehatan rujukan

berbasis INA-CBG.

• Capitation for Primary Care

• Claim, based on INA-CBG (DRG) type of payment

(19)

The facts in 2014

• Kapitasi tidak terkait kinerja FKTP

• Tidak ada batas atas (plafond) di RS dalam melakukan klaim.

• Sistem Pencegahan dan Penindakan Fraud belum berjalan

• Daerah dengan SDM lengkap, RS

banyak, teknologi tinggi akan menyerap dana BPJS banyak

• Capitation is not linked with performance indicators

• There is no upper limit for hospital in claiming the services

• Fraud

Prevention, Detection, dete rrence, and prosecution system is not yet

established

• Regions which have many doctors, health

services, and high

technology equipment get the fund more

(20)

The Risk of this current condition of

financing

• Health facilities in remote areas become more lagged behind

• The distribution of human resources for health will suffer • Not efficient primary care

• Fraud will be uncontrollable and make the use of resources become less efficient

• Adverse selection problems • PBI budget is used by the

middle and higher income group

• Pembangunan RS dan faskes di daerah terpencil tidak dapat mengejar ketinggalan

• SDM kesehatan semakin tidak merata

• FKTP tidak efisien

• Klaim INA-CBGs tidak dijamin efisiensinya karena fraud tidak terkendali

• Problem Adverse Selection semakin meningkat

• PBI (APBN) disinyalir

menanggung biaya pelayanan kesehatan Non PBI (mandiri)

(21)

Who get the most from

BPJS

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 21 Local Gov Private Insuran ce In Nov _2014: Claim Ratio is around 1300% Claim Ratio Less than 90% (Nov 2014)

(22)

The possibility:

PBI Budget is used by Non-PBI Mandiri (Pekerja Bukan

Penerima Upah) APBN BPJS Tax Income Non-tax Income Non-PBI Mandiri Primary

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 22 Local Gov Private Insuran ce In Nov _2014: Claim Ratio is around 1300% Claim Ratio Less than 90%

(23)

• Wheter UHC can be

achieved in 2019?

(24)

Scenario 1: Optimistic Scenario 2: Pessimistic.

(25)

UHC pessimistic scenario

2014 2015 2016 2017 2018 2019 DIY NTT Zero JKN increases geographical inequity,

and also socio-economic inequity

(26)

Proposed Strategic Policy to reduce

inequity

1. Using more reform

approach in JKN; Not only

Financing;

2. Short term

recommendation in

Financing Policy (Revenue

Collection, Pooling and

Purchasing).

(27)

More Strategic Policy using

Health Sector Reform Concept

Access Quality Efficiency • Pembiayaan/Fin ancing • Pembayaran/Payme nt • Pengorganisasian/O rganizing • Regulasi/Regulation • Promosi/Promotion Status Kesehatan/ Health Status Kepuasan Publik/ Public Satisfaction Perlindungan Resiko/ Risk Protection Cost Goal Control Knobs 27 Equity? (Harvard University-WB)

(28)

Proposed Strategic Policies in

Financing to reduce in-equity

(29)

Short-term Policy

recommendation in

Financing

Non-PBi

Kemenkes

Kementerian lain PBI Pemda 29 Askes Swasta

(30)

More Budget for MoH

to improve the supply

side

Non-PBI ex PT Askes

MoH

Out pof pocket

(31)

Kemkes Pemprov Pemkab Pemko Kementeri_{an lain} TNI POLRI _{non profit}Swasta Swasta BUMN 2012 32 85 411 86 3 105 29 654 237 77 2013 32 89 447 88 3 115 39 727 468 75 2014 33 96 455 92 3 118 41 724 599 67 Updated 34 97 459 92 5 127 43 733 694 66 -100 200 300 400 500 600 700 800 RS

More MoH and local government budget to finance new health services and hospitals

(32)

(33)

Do not increase the

premium for PBI

Non-PBI ex PT Askes

MoH

Out pof pocket

(34)

Increase the premium

for the middle and rich

members

Non-PBI ex PT Askes

MoH

Out pof pocket

Other Ministries PBI Pemda 34 Local Gov Private Insuran ce Aim:_{To reduce} Claim Ratio

(35)

To reduce in-equity: there

should be fundamental

change in BPJS

(36)

Needs compartment in BPJS

• In BPJS there

should be

compartment

based on source

of income and

expenditure

Aim:

• To prevent the budget from PBI to be used by Non-PBI-mandiri

members

(State budget for the poor should be used by the

poor)

(37)

Compartment in

BPJS

Non-PBi

Kemenkes

Kementerian lain PBI Pemda 37 Rp Rp Rp Pendapatan Asli Daerah Askes Swasta

(38)