Management of Health Insurance in Indonesia Based on Universal Health care in the Form of

BPJS (Badan Penyelenggara Jaminan Sosial Ketenagakerjaan) or JKN (Jaminan Kesehatan

Nasional)

Wenna Valentine Puspitasari, Friska Ardiani Putri, Tiara Andini Putri Nastiti, Wahyu Dwi
Purnomo

Pendidikan Dokter, Fakultas Kedokteran, Universitas Muhammadiyah Malang

Jl. Bendungan Sutami 188 A Malang, 65145

valentinewenna@yahoo.co.id

Abstract (max 300 word)

There is growing awareness of the fact that ill-health perpetuates poverty. In order to prevent the
negative downward spiral of poverty and illness, developing countries in recent years are increasingly
implementing various models of health insurance, but due to low public awareness and myths that
circulate in the community around insurance makes people reluctant to buy insurance products. In
Indonesia there is a legal entity that functions to organize a health insurance program for all
Indonesian people. BPJS (Badan Penyelenggara Jaminan Sosial Ketenagakerjaan) is the agency
state owned enterprises that are specifically assigned by the government to organize health care
insurance for all people of Indonesia.Nowadays a large and growing body of literature has
investigated the effect of health insurance on health care use. Scholars have realized that spending on
health care, and the utility that it generates, plays a central role in determining the value of health
insurance. This Research includes library research, which is an object that is supported is a book or
other source of literature, namely journals, notes as well research reported from experimental
research. Application BPJS health still has problems in many ways. First, talk BPJS health has
appeared since the card activation process. Second, referral to health service institutions appointed
by BPJS health as well limited and inflexible. Third, the complexity of the flow BPJS health services
because it applies a tiered service flow. The study carried out is to solve the problem, which is
basically relies on critical and in depth review of relevant library materials.
Background:
There is growing awareness of the fact that ill-health perpetuates poverty. In order to prevent the
negative downward spiral of poverty and illness, developing countries in recent years are
implementing various models of health insurance to increase access to health care for poor
households. In Indonesia, citizens have basic rights to their health in accordance with Pancasila, the
philosophy and principle of the country. The right to live healthy is also stated in the 1945
Constitution article 28H and article 34 and regulated in Law 36/2009. Law 36/2009 affirms that
everyone has equal rights to affordable and quality health services. Consequently, every citizen also
has the obligations. The National Health Insurance Program or Jaminan Kesehatan Nasional (JKN)
handbook on the socialization of National Social Security System 2014 or Sistem Jaminan Sosial
Nasional (SJSN) states that the governmens responsible for implementing public health insurance
through JKN (Nisa C & Intan Nina Sari,2019). National (JKN) developed in Indonesia is part of the
National Social Security System. Some principles adhered to JKN are the principles of mutual
cooperation, non-profit, openness, prudence, accountability, efficiency, effectiveness, portability,
mandatory participation, mandated funds and the results of the management of the Social Security
Fund (Listiyana I, 2017).
Methods:
This Research includes library research, which is an object that is supported is a book or other source
of literature, namely journals, notes as well research report from experimental research. Data searched
and found through a literature review that is relevant to the discussion. This research includes
qualitative research categories with activity procedures and presentation techniques with Denzin and
Lincoln which explains qualitative research using scientific phenomena, with the intention of
addressing the phenomena that occur and is done by involving various methods available
Result:
Discussion and Conclusion:.

Keywords: (5-8 word)

Management, Health insurance, BPJS

Introduction
There is growing awareness of the fact that ill-health perpetuates poverty. In order to prevent the
negative downward spiral of poverty and illness, developing countries in recent years are increasingly
implementing various models of health insurance to increase access to health care for poor
households. While there is consistent evidence that health insurance schemes have caused an increase
in access to health generally, the debate regarding the most appropriate health insurance scheme that
suits the poor continues unabated (Maximillian KD, 2014).
Insurance is one important element in financial planning, but due to low public awareness and
myths that circulate in the community around insurance makes people reluctant to buy insurance
products. Insurance is also known only for the upper middle class. On the other hand the realization
of a prosperous society, one of which is assessed from the level of good health of the community. For
this reason, the government issues mandatory social insurance where all people, under the mandate
of the law, are required to become participants of the program (Vandawati Z, et al, 2016).
In Indonesia, citizens have basic rights to their health in accordance with Pancasila, the
philosophy and principle of the country. The right to live healthy is also stated in the 1945
Constitution article 28H and article 34 and regulated in Law 36/2009. Law 36/2009 affirms that
everyone has equal rights to affordable and quality health services. Consequently, every citizen also
has the obligations. The National Health Insurance Program or Jaminan Kesehatan Nasional (JKN)
handbook on the socialization of National Social Security System 2014 or Sistem Jaminan Sosial
Nasional (SJSN) states that the governmens responsible for implementing public health insurance
through JKN (Nisa C & Intan Nina Sari,2019). National (JKN) developed in Indonesia is part of the
National Social Security System. Some principles adhered to JKN are the principles of mutual
cooperation, non-profit, openness, prudence, accountability, efficiency, effectiveness, portability,
mandatory participation, mandated funds and the results of the management of the Social Security
Fund (Listiyana I, 2017).
BPJS health (Organizing Agency Health Social Security) is the agency state owned enterprises
that are specifically assigned by the government to organize health care insurance for all people of
Indonesia. Health BPJS with BPJS employment (formerly known as Jamsostek) is a government
program in unity National Health Insurance (JKN) which inaugurated on December 31, 2013. BPJS
health began operating since January 1, 2013, while BPJS, employment began operating on July 1
2014. The total number of JKN participants counted 1 December 2017 reached 186,602,571
(Rianingsih AK, et al, 2019).
BPJS is a legal entity that functions to organize a health insurance program for all Indonesian
people including foreigners who work for a minimum of 6 months in Indonesia. This health insurance
is in the form of health protection so that participants obtain health care benefits and protection in
meeting the basic health needs provided to everyone who has paid contributions or the contributions
are paid by the government (Aktansu dan Pajak 2015).
The government has established several forms of social health insurance through PT Askes
(Persero) and PT Jamsostek (Persero), which serve civil servants, pensioners, veterans, and private
employees. For poor communities, the government has the so called free health care scheme
(Jamkesmas), social insurance for maternity care (Jampersal), and local government’s free health care
scheme (Jamkesda) (Nisa C&Intan Nina Sari, 2019).
A large and growing body of literature has investigated the effect of health insurance on health
care use. Scholars have realized that spending on health care, and the utility that it generates, plays a
central role in determining the value of health insurance. For an expected utility maximizing
consumer,the demand for health insurance and health care is interdependence. Individual who expects
to consume more health care will be more likely to buy health insurance or purchase more
comprehensive health insurance coverage (Arpah AB, et al,2016).
Americans still have serious health issues since many of them have no health coverage. As a
result of this fact, the health coverage issue is one of the significant issues in the USA, in terms of the
issue’s magnitude, prevalence and cost to the society. The statistics reveals that about 50 million of
the all American have to face every day with this condition meaning no medical exam and treatment.
Statistics indicate that the US Government allocates more funds onhealthcare by comparison with the
middle developed countries. But, the reality is that the USA cannot offer better care to the people.
Some analyses reveal that the highest number of the people having no health insurance coverage
cannot afford to get a health insurance owing to their economic condition (Yesilbas M 2015).

Material and Methods (min 30 journal)

This Research includes library research, which is an object that is supported is a book or other
source of literature, namely journals, notes as well research report from experimental research. Data
searched and found through a literature review that is relevant to the discussion. This research
includes qualitative research categories with activity procedures and presentation techniques with
Denzin and Lincoln which explains qualitative research using scientific phenomena, with the
intention of addressing the phenomena that occur and is done by involving various methods available
(Kadarisman M, 2015).
The study carried out is to solve the problem, which is basically relies on critical and in depth
review of relevant library materials. Because this research is a research library, data collection
methods used in the form of library materials continuous (coherent) with the object of study under
study. 10 source data obtained through library research that is by searching books or writings on the
effectiveness of the SJSN institution and other books that support the analysis and sharpnessof
analysis. In the method of data collection, researches identify discourses from various books or
articles, magazines, journals, web (internet) or other information related to the substance of research
to look for relationships with variables in the form of notes, transcripts, newspapers, and magazines
/ journals. For this reason, the following steps are carried out : a) editing, i.e. re-examination of the
data obtained, especially in terms of completeness, clarity of meaning and the coherence of meaning
between one and the other, b) organizing, namely compiling the data obtained within a predetermined
framework, c) research findings, i.e conducting further analysis of the results of data compilation
using rules, theories and methods thar have been determined so that certain conclusions (inferences)
are obtained which are the answer to the problem formulation (Kadarisman M, 2015).
 Data analylisis is the most important part of the method scientific, because it is through analysis
that the data can bemeaningful in solving research problem. Analysis of qualitative data used in this
study is in the form of words rather than numbers arranged in broad themes. So, this research uses
content analysis method. Content analysis is a research technique for making inferences that can be
replicated and with valid data, taking into account the context (Kadarisman M, 2015).

Findings
Indonesian people are not familiar with insurance. Every insurance agent approaches, most of
us will try to stay away and reject it. Yet when viewed with a broader perspective, insurance is a
necessity. Humans can not be sure that this body will always be healthy and ready to be used for
various activities. That is what makes insurance is a must to guarantee medical expenses when sick.
Every time you get sick, the costs involved can sometimes be unpredictable. Actually many
understand that insurance is an important thing (Vandawati Z, et al, 2016).
Fee for service for the health care system causes society is difficult to get proper health services.
However, agreement going into insurance, not many people can afford to pay fees premium. For
example, in 1995, the cost of hospitalizing patients during hospital five days spent 1.4 times on
average Jakarta. 1998 this cost jumped to 2.7 times. If the fee is not borne by the office or insurance,
means the household costs of that person. It is expected to be siphoned off to pay for treatment at the
hospital (Kadarisman M, 2015).
Based on the implementation of the law 44/2004 national health insurance program that he
implemented entrusted to the health BPJS is still far from the meaning of justice. Application BPJS
health still has problems in many ways. First, talk BPJS health has appeared since the card activation
process. BPJS apply the rule that BPJS user cards can only be active a week after registration be
accepted. While the ill occur unexpectedly and can’t be postponed. Second, referral to health service
institutions appointed by BPJS health as well limited and inflexible. BPJS participants can only
choose one facility health to receive referrals and not be able to other health facilities than cooperating
with BPJS. That limitation makes it difficult for people who are travel often and work far away. Thir,
the complexity of the flow BPJS health services because it applies a tiered service flow. Before going
to the hospital, participants must first go to the first level health facilities, namely the health center.
Fourth, many BPJS participants complained about payment of fees treatment that is not fully covered
by BPJS (Kadarisman M, 2015).
According to Pertiwi (2016) satisfaction is the result of consumer evaluation (assessment) of
various aspects of service quality. States the quality of service must start from the needs of consumers
and end on consumer perception. Patient or participant insurance satisfaction is one factor that can be
used as a reference in determining the success of a service program. Based on research conducted by
Pertiwi (2016) regarding the analysis of differences in service quality in BPJS patients and general
patients on patient satisfaction in outpatients in Surakarta City Hospital it is found that from 3
dimensions namely patient safety, effectiveness and efficiency, patient oriented, there are significant
differences between BPJS patients and general patients, this can be seen from the mean value of the
three dimensions of higher general patients than BPJS patients. This also affects the results of patient
satisfaction (Pertiwi, 2016).
Research conducted by Listiyana in Semarang on national health insurance satisfaction on BPJS
users shows that the majority of respondents are dissatisfied with national health insurance.
Respondents were not satisfied because when compared with the previous health insurance namely
Jamsostek, medicines and hospital services had decreased. According to respondents the price of
BPJS Health patient medicine is different from the price of drugs that the respondent got when he
was Social Security pesesta. This shows that respondents are only based on price, not benefits or drug
content in it, because of public perception that something expensive is more quality (Listiyana 2017).
satisfaction towards health insurance is considerably affected by their residency status,
socioeconomic status, the cost of their treatment, and the actual coverage that health insurances
provides them during medical care. a rise in insurance coverage will prompt and increase
inprobability of the patients’ satisfaction towards health insurance services. In the first place, this
might sound obvious, and Vietnamese policy-makers seemed to be thinking the same when setting
the idealistic 100% insurance rate (Vuong Q H 2017).
But reality shows that it is not possible for any citizen to exclusively rely on insurance to pay
for their entire treatment [21], this can be seen at first glance in Table 2, where the maximum
insurance coverage in real life cases only attains 90%, minimum coverage is null, and average
coverage stays merely 60%. Due to possible frictions in the administrative system and insurance
eligibility based on residency status, patients are often stuck with inadequate insurance coverage. In
the end, they do not receive what they are promised to be given, and remain frustrated with the system
(Vuong Q H 2017).
In accordance with the basic concepts stated by Government of Indonesia regarding objectives
National Health Insurance Program, comprehensive services include protective, preventive, curative
and rehabilitative services. This is similar to the concept National Health Insurance was implemented
in Turkey in 2008 where the Ministry of Health added their health promotion disease prevention
programs for the entire population, especially children and women. Universal Health Coverage can
be well funded when the government conducts fact-based health promotion programs and employ
health professionals. Effective health promotion and disease prevention reduce pressure on the health
system and thus economically and directly improve one's health and extend life expectancy.
 Consider the basic concepts of the community health centeras stipulated in the Minister of
Health Regulation, public health centers provide promotive and preventive actions as a primary health
facility. Provision of health promotion mandatory services for community health centers. At the
global level, the first international conference related to primary health care as a tool to improve
health status is the Alma-Ata declaration made in 1978 in Kazakhstan.11 In the declaration, basic
health services categorized as including solving health problems at the community level, and provides
promotion, prevention, curative and rehabilitation services (Nurmansyah 2017).
Efforts to increase satisfaction for both classes by increasing insurance coverage will not
produce results. The current health insurance system has no choice and becomes rigid given the
observed population heterogeneity. Therefore, it would be more beneficial if policymakers, rather
than promising universal coverage that is not affordable, target vulnerable people and develop more
diverse insurance schemes to accommodate their needs, such as micro health insurance. This can be
done by lowering general costs - which will be a long way to go - and modifying health insurance
policies - which is a more feasible step, in a shorter period of time (Vuong Q H 2017).
Some studies say that insurance ownership affects mortality rates. In some circumstances,
insurance can increase mortality by increasing access to dangerous drugs (oral opioid) or procedures
such as morcellation hysterectomy, on the other hand, can reduce mortality rates in some serious
conditions, although little can be detected. Except hypertension, which is not insured but is the highest
contributor to death (Woolhandler, 2017)
Society could be affected negative due to the absence of insurance. Some groups like
disadvantages groups, particularly, would be mainly affected such as handicapped people, children,
elderly people, pregnant women since they would not get any treatment if they are no health insurance
coverage. That could lead to many unfortunate consequences from high mortality rate, lower life
quality to excessive financial burdens. All these factors affect the general social welfare, as well as,
the financial vitality of the country. Consequently, the mandate system might provide several benefits
to the society according to this CBA results (Yesilbas M 2015).
Most countries around the world are commited to developing an effective health insurance
system for the purpose of achieving universal coverage. Yet, there is an on-going debate on the
relative advantages of different forms of health insurance. The purpose of health financing are to
mobilise resources for the health system, to set the right financial incentives for providers, and to
ensure that all individuals have access to effective health care. The united kingdom, for example has
developed a taxbased national health system that covers every resident social health insurance on
other hand relies on employess contributing a percentages of their salaries to a health insurance fund
that is used to refund affiliates’s health expenditures. Private health insurances is said to mainly serve
the affluent segments of a population, and it offers health plans covering a specified list of health
conditions in exchange for a renewable. Community-based health schemes on the other hand are
common in low and middle-income countries often targeted to benefit the poor and in many countries
it is used to mobilize supplementary revenues to support fragmented health systems or pluralistic
financing systems (Maximillian KD, 2014).
Health insurance is one of the basic rights of every citizen in the European Union, divided into
compulsory health insurance and additional health insurance, compulsory health insurance covers
costs arising from basic health care and medical care, additional health insurance covers the care
required under urgent procedures and on voluntary forms and into additional or voluntary forms of
health insurance which always takes over from the cost up to the total costs not covered by
compulsory insurance and provides a wider range of services. In Croatia, health insurance is divided
into compulsory health insurance and three different forms of voluntary insurance: additional,
additional and private health insurance. In the Federal Republic of Germany, the health insurance
system is divided into mandatory health insurance and private health insurance (Gerić K 2016)
The principles of social health insurance include membership which is mandatory and non
discriminatory for formal groups, fee based a percentage of income becomes a shared expense
between the employer and the recipient of work to the limit certain, so there is mutual cooperation
Among which is rich, low risk of illness, old young with the same medical service benefits (equity
principle), and services can be accessed nationally (portability). Are comprehensive, with service
benefits promotive, preventive, curative and health rehabilitative, including medicine and medical
materials are used up use. Management is done with principles prudence, non-profit, transparency
and high accountability, and program funding is a mandate fund that is used in the maximum amount
for the benefit of the participants (Yohanes budi 2009).
In contrast to Japan, referring to historical experience, Japan provides advice to countries that
want to move towards universal health coverage. The recent editorial, Naoki Ikegama, argues that the
Japanese government made three strategic decisions during the early stages of modernizing their
country's health system which facilitated the development of primary health services. 1) integrate
existing primary health care providers into organized health systems. 2) Limiting the government in
hospital financial services, 3) empowering primary health care providers as livelihoods that reflect
the importance of health services (Gerald B, 2017).
Social insurance is a mechanism for collecting contributions that are compulsory from
participants, in order to provide protection to participants from the socio-economic risks that befall
them and or their family members (SJSN Law No.40 of 2004). The National Social Security System
(SJSN) is a procedure for administering Social Security programs by the Health Insurance
Administering Agency (BPJS) and the Employment BPJS. Social Security is a form of social
protection to ensure that all people can fulfill their basic needs for a decent life (Syiah Kuala 2015).
 Ikegama said the lesson to be learned from Japan is that short-term initiatives to achieve
universal coverage needs must be complemented by a long-term health management system change,
which involves coalitions for primary health care, managing and controlling unnecessary increases
in hospital services. This is an important message to health sector leaders and the research community
(Gerald B, 2017).
The recent IJHPR article by Green and colleagues-examining, understanding of supplementary
health insurance (SHI) among Israeli consumers-provides an important and timely answer to the
above question. Indeed, their study addresses similar problems to the ones identified in the US health
care market, with two notable finding. First, they show that overall – regardless of demographic
variables-there are low levels of knowledge about SHI, which the literature has come to refer to more
broadly as “health insurance literacy”. Second they find a significant disparity in health insurance
literacy between different SES groups, where Jews were significantly more knowledgeable about SHI
compared to their Arab counterparts. The authors’ findings are consistent with a growing body of
literature from the U.S. and elsewhere, including our own, presenting evidence that consumers
struggle with understanding and using health insurance. Studies in the U.S have also found that
difficulties are generally more acute for populations considered the most vunerable and consequently
most in need of adequate and affordable health insurance coverage. The authors’ findings call
attention to the need to tailor communication strategies aimed at mitigating health insurance literacy
and, ultimately, access and outcomes disparities among vulenarable populations in Israel and
elsewhere. It also raises the importance of creating insurance choice environtments in health systems
relying on consumers to make coverage decisions that facilitate the decision process by using “choice
architecture” to, among other things, simplify plan information and highlight meaningful differences
between coverage option (Andrew JB, 2017)
The rate of reporting of insurance-based discrimination in the United States is higher among
uninsured and publicly insured adults than among privately insured adults. These findings highlight
the need for academic and policy attention to address insurance-based discrimination in health care
settings. One intervention is to foster positive relationships between providers and patients at the
organizational and country level. The health care sector can establish, monitor and enforce policies
that prohibit discriminatory practices and provide ongoing cultural competency training for health
care providers (at all levels in the organization) that targets their perceptions and behavior towards
patients with public and non-insurance insurance. Education to improve the ability of doctors to
understand, communicate and interact effectively with Medicaid applicants can increase their
tendency to maintain a consistent, respectful and fair relationship with patients (Han X 2015).
Health insurance coverage, although signi ficant, may not be sufficiently affirmative and
equitable health care. Insurance-based discrimination contributes to disparities in health care and may
reduce people's ability to access health care when needed. Given its negative effects on health care
utilization and potential threats to longer term health outcomes, state and local governments should
adopt policies targeting the reduction of insurance-based discrimination in health care. .Because more
Americans have gained coverage, the success of health care reform should not be judged simply by
how many people are covered by insurance, but by how well coverage ensures access to needed health
care. One important step forward in that direction includes measuring and monitoring the presence
and impact of insurance-based discrimination in health care settings (Han X 2015).
According to Grubber (2011) Universal Health Insurance in principle can be implemented both
through government and private expansion. The national health insurance program is implemented
by the Health BPJS as a body mandated by the Law. This body is given the authority to collect
contributions and manage health insurance contributions or premiums. Therefore this program can
be called social health insurance.
If you look at the design of JKN membership, then the path to becoming universal health
insurance has found an appropriate path. If the "three-legged stool" criteria is used as a measure, the
first criterion that prohibits the implementation of the health insurance program to reject participants
with pre-existing conditions has been fulfilled with the appointment of a body to implement the JKN
program. That way everyone will be guaranteed more participation in the JKN program. (Ferry afi
andi 2015)

Conclusion
Most countries around the world are commited to developing an effective health insurance system
for the purpose of achieving universal coverage. Yet, there is an on-going debate on the relative
advantages of different forms of health insurance. The purpose of health financing are to mobilise
resources for the health system, to set the right financial incentives for providers, and to ensure that
all individuals have access to effective health care. Universal Health Insurance in principle can be
implemented both through government and private expansion.
Education to improve the ability of doctors to understand, communicate and interact effectively with
Medicaid applicants can increase their tendency to maintain a consistent, respectful and fair
relationship with patients

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