2016 Jamsos Askes Sesi 7 LT Benefit Package

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Laksono Trisnantoro

Universitas Gadjah Mada

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Supply side challenges for JKN,

Benefit Package, and their

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Contents:

1. Health Financing Situation: Who

gets the most from BPJS?

2. Supply side growth and its

impact on equity

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1. Health Financing under JKN

• _{Health Social Security system for achieving}

UHC started in January 2014.

• _{Service Providers (Supply side) include}

Primary and Referral Care.

• _{Supply side is extremely not well distributed}

across Indonesia

- Human resources - Health facilities

- In 2015, some reports show that BPJS faces a deficit of Rp. 2-4 trillion

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BPJS Funding Deficits in 2014

• _{Pardede, 2015}

In 2015 and 2016:

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PMA

2020:

5

• _{Poorer women are likely to be covered by Jamkesda} • _{Wealthier women by BPJS}

• _Overall:

26% covered by Jamkesda 21% by BPJS

Captures data on

insurance coverage for family planning services.

Is it a proper

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Analysis

Using Health Financing Concepts:

•_{Revenue Collection} •_Pooling

•_Purchasing

and

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Health Financing Concepts applied in Indonesia

(simplified) APBN BPJS Tax Income Non-tax Income Non-PBI self-employed Primary

Care Referral Care

Non-PBI, former PT Askes

MoH

Out of pocket

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Revenue Collection

(2014 data) APBN BPJS Tax Income Non-tax Income Non-PBI self-employed Primary

Care Referral Care

MoH

Out of pocket

Other Ministries PBI Pemda 8 Local Gov revenues Private Insurance (67.5 T)

NHA 2009 : (18 T)

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Pooling

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a. MoH, big pool.

b. BKKBN (Family

Planning body),

small pool.

c. BPJS Kesehatan, big

pool.

(10)

Purchasing

APBN BPJS Tax Income Non-tax Income Non-PBI self-employed Primary

Care Referral Care

MoH

Out of pocket

(11)

Facts on JKN implementation in 2014:

• _{Capitation is not linked with}

performance indicators

• _{There is no upper limit for hospitals}

on claims for services

• _{Fraud prevention, detection,}

deterrence, and prosecution system is not yet established

• _{Regions which have many doctors,}

health services, and high technology equipment get more funding

11

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Who gets the most

from BPJS?

Care Referral Care

MoH

Out of pocket

Other Ministries PBI Pemda Local Gov Private

Insurance In Nov 2014:_{Claims Ratio was}

around 1300% In 2015: around 400 – 600%

(13)

MoH

Out of pocket

Other Ministries PBI Pemda 13 Local Gov’t income Private Insurance BKKBN

Possibility:

Subsidy for the poor (PBI)

is used by the middle and

upper class of society

Rp

(14)

Overall:

There is widening

inequity in who

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2. Supply side growth and its

impact on equity

a. The Growth of Hospitals

b. Medical specialists situation and education

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a. Growth in the Number of Hospitals

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a. Growth in the Number of Hospitals

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Hospital growth by BPJS region

Keterangan:

Region 1: DKI, Jabar, Jateng, DIY, Jatim, Banten Region 2: Sumbar, Riau, Sumsel, Lampung, Bali, NTB

Region 3: NAD, Sumut, Jambi, Bengkulu, Kepri, Kalbar, Sulut, Sulteng, Sulsel, Sultra, Gorontalo, Sulbar

Region 4: Kalteng, Kalsel

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2015: Number of Hospitals by Region

and Class

No Keterangan A B C D Non Kelas Per Dec 2015

1 Region 1 39 208 442 240 355

2 Region 2 8 32 140 70 81

3 Region 3 8 78 213 86 189

4 Region 4 2 6 25 11 11

5 Region 5 2 16 67 67 65

Region 3: NAD, Sumut, Jambi, Bengkulu, Kepri, Kalbar, Sulut, Sulteng, Sulsel, Sultra, Gorontalo, Sulbar Region 4: Kalteng, Kalsel

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b. Medical Specialists

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2015: Numbers of 4 Major Specialists

Ketersediaan spesialis di DKI Jakarta, Jawa Barat, Jawa Tengah, Sumatera Utara, Banten lebih banyak dibanding di provinsi lain, di NTT hanya 0.2% dari total jumlah spesialis 4 dasar tersebut.

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Number of Specialists per Province

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Residents and fellows

•

No data

•

They are not classified yet as medical workers

•

They are classified as students

•

No significant increase of medical education

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Supply side growth in 2015

•

Not much change

•

Region 1 grew fast

•

More private for profit hospitals

•

Number of specialists did not change much

•

There was no significant policy to balance

supply side in 2014 and 2015

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The

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Claim system

(INA-CBG)

• _Favors

more-developed provinces

• _{There is no cap}

on hospital claims and regional

expenditure

• _{Fraud control is}

not yet in place

Essentially fee-for-service hospital payment system

• _{Claims Payments in}

Region 1 exceeded the budget

• _{In some remote}

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Benefit Package and Equity

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Who enjoys BPJS benefits?

28 Standard minimum package

Benefit Package

Number of People in Regions: Benefit Package BPJS almost unlimited

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Gap for achieving UHC is widening

2014 2015 2016 2017 2018 2019

DIY

NTT

Zero

(30)

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The political economy debate

Welfare State

Argues that the government has a key role to play in promoting the welfare of all

society.

Rely on government revenue (mainly tax-based) for

financing health and family planning programs.

Market Orientation

Government should pay less.

Social expenditure is expensive and sometimes beyond the

capacity of government to finance

Let the market work

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The welfare state requires:

•

large fiscal capacity: strong tax

revenue

•

Well-distributed health

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Trends in Government Revenue and GDP 2007 – 2016

GDP

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The economy is weak: Tax revenue collected is significantly under targets

APBN BPJS Tax Income Non-tax Income Non-PBI Self-employed Primary

MoH

Out of pocket

Other Ministries PBI Pemda Local Gov Private

Insurance Some of

subsidy for the poor is used by the rich

What is

happening in the current

Indonesian situation?

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The Power of Private Financing through increasing Premium, Private Insurance and Out of Pocket

mechanism is big

GDP

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4. Policy Recommendations:

• _{Balancing the supply side.}

• _{More investment in health facilities}

and human resources.

• _{Residents and fellows should be}

classified as medical workers

• _{Compensation policy should be in}

place For better

social justice

•_{No hidden subsidy for the rich;}

•_{Premium increases from the middle}

and upper segments of society should be imposed;

•_{Private financing from the better off}

should be encouraged

•_{Introduce catastrophic insurance for}

the middle and upper classes

A

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Financial Flow Recommendations APBN BPJS Tax Income Non-tax Income Non-PBI Mandiri Primary

Care Referral Care

Non-PBI ex PT Askes

MoH

Out of pocket

Other Ministries PBI Pemda 37 Local Gov Private Insuran ce 489 ( 72.9 T)

BKKBN Very low

premium relative to

benefit

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Note:

Hard challenge to address

No Keterangan A B C D Non Kelas Per Dec 2015

1 Region 1 39 208 442 240 355

2 Region 2 8 32 140 70 81

3 Region 3 8 78 213 86 189

4 Region 4 2 6 25 11 11

5 Region 5 2 16 67 67 65

Region 3: NAD, Sumut, Jambi, Bengkulu, Kepri, Kalbar, Sulut, Sulteng, Sulsel, Sultra, Gorontalo, Sulbar Region 4: Kalteng, Kalsel

(39)

39 100

%

50 %

0 %

Poorest Poor Middle Rich Richest

1. Is it possible? 2. Is it better? 3. Is it more

equitable?

Private financing BPJS

Jamkesda

Financing

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Expected policy:

40 Standard minimum package

Benefit Package

Number of People in Regions: Catastrophic Insurance

In developed provinces In less developed provinces

Compensation policy for Human Resources

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Let’s discuss

Thank you