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THE NUTS & BOLTS OF JAMKESMAS

INDONESIAS GOVERNMENTFINANCED HEALTH COVERAGE PROGRAM FOR THE POOR AND NEARPOOR
IMPROVING PUBLIC PURCHASING AND DELIVERY OF SERVICES IN INDONESIA
INDONESIA TEAM UNICO PRESENTATION HD LEARNING WEEK 2013

INDONESIA : COUNTRY OVERVIEW


Indonesia, 240 million across 17,000 islands, highly dispersed; with income level GDP US$ 2,500 per cap similar to Georgia Average economic growth in average 5% and projected 6-7% in the next 3-5 years Poverty headcount < $1/day = 18.1%, <$ 2/day = 46.1%; level of informality 50-60% Health spending is low at 2.6% GDP for its income level; for total health spending per capita US $77;; Public vs Private 43.5% : 57.5%; Private spending is decreasing over the years

HEALTH INSURANCE COVERAGE


Health insurance coverage ; administrative data shows 63% population has some type of coverage but household data shows much less is covered
OOP share of total health expenditure and coverage, 1995-2010
60
OOP share of total health spending

40

50

Health insurance coverage

30

Health insurance coverage


60 35

Out-of-pocket (OOP) spending

20

50

2005 Askeskin introduced

Poor and near-poor

10

2008 Askeskin expanded (renamed Jamkesmas)


25

30

Percentage (%)

Source: WHO; SUSENAS

30

15

20

Year

Percentage (%)

1995

1998

2001

2004

2007

2010

40

Decile share of total OOP health spending

OOP health spending share of total consumption

20

10

Poorest

3rd

5th

7th

Highest

0
Poorest

10

Economic deciles
Source: SUSENAS (2010)

3rd 5th 7th Economic deciles

Highest

INDONESIA CONTEXT FOR UC: JAMKESMAS


Objective: increase access to, and the quality of, health services for the poor and near poor;
Target: 86.4m poor and near-poor;

Benefit package: Comprehensive, even more generous than that of other social security schemes, and has no cost-sharing or co-payments
Service delivery: outpatient and inpatient; public for primary and mix for secondary; network of Puskesmas (Health Center), public hospitals, and participating private hospitals ;

JAMKESMAS FINANCING
Program fully financed from central government revenues; about of Central Government health budget;
Annual operating budget based on estimated premium rate of IDR 6,500 per person per month = US$8 per year;

Not the true cost... Actuarial and costing estimates indicate that true cost to be 3 to 6 times higher; Other estimates suggest that Jamkesmas covers only about 1/3 of true cost of care; 2/3 supply side subsidies

JAMKESMAS PURCHASING
MOH
(25% of budget)

PUSKESMAS
GOVERNMENT: Salaries Capital Operating Costs District Health Office Envelope of Funds: IDR 1000 per month per poor (not tied to enrolment)

Fee-for-service
reimbursement

GOVERNMENT: Salaries Capital Operating Costs

Case-based Payments

JAMKESMAS DESIGNED WITH GOOD INTENTIONS...


1. Utilization among beneficiaries has increased although remain lower compare to other insurance programs
2. Catastrophic incidence has decreased 3. Leakage in covering targeted beneficiaries

4. Knowledge of eligibility and benefit is low


5. Poor supply-side incentives due to the nature of a largely input-oriented purchasing system; Premium and payment to private provider does not reflect actual cost

SUPPLY-SIDE CONSTRAINTS
Deficiencies in the availability and quality of services limit the availability of real benefit package; Supply-side constraints comprise all the factors that limit health care delivery at the point of service, and therefore affect availability of services. Critical shortages: In general the availability of primary care facilities is good esp. in urban, and less available in remote provinces; but only public in the network, The availability of inpatient facilities is low in comparison to other comparable countries;

CHALLENGES AHEAD
Sustainability issues: actual and projection of cost; fiscal implications; and decentralized setting including yet to be explored local contribution Expanding coverage: improving targeting mechanism; covering large informal sector Lack of results-focused provider payment mechanism : incentives to improve quality and provider performance and to attain population-level targets; Ensuring supply-side readiness
- Benefit package is not uniformly available - Supply-side constraints limit service availability