2016 Jamsos Askes Sesi 7 LT Benefit Package
Laksono Trisnantoro
Universitas Gadjah Mada
1
Supply side challenges for JKN,
Benefit Package, and their
(2)
Contents:
1. Health Financing Situation: Who
gets the most from BPJS?
2. Supply side growth and its
impact on equity
3. Political-economy analysis
4. Policy Recommendations
(3)
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
(4)
BPJS Funding Deficits in 2014
• Pardede, 2015
In 2015 and 2016:
(5)
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
(6)
Analysis
Using Health Financing Concepts:
•Revenue Collection •Pooling
•Purchasing
and
(7)
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
Other Ministries PBI Pemda 7 Local Gov Private Insurance 489 (72.9 T) BKKBN Very low premium relative to benefit received
(8)
Revenue Collection
(2014 data) APBN BPJS Tax Income Non-tax Income Non-PBI self-employed PrimaryCare Referral Care
Non-PBI, former PT Askes
MoH
Out of pocket
Other Ministries PBI Pemda 8 Local Gov revenues Private Insurance (67.5 T)
NHA 2009 : (18 T)
489 (72.9 T) 4 T (19.93 T) ~20 T Nonpoor members BKKBN
(9)
Pooling
9
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 PrimaryCare Referral Care
Non-PBI, former PT Askes
MoH
Out of pocket
Other Ministries PBI Pemda Local Gov Private Insurance BKKBN
(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
Who gets the most from BPJS?
(12)
Who gets the most
from BPJS?
APBN BPJS Tax Income Non-tax Income Non-PBI self-employed PrimaryCare Referral Care
Non-PBI, former PT Askes
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%
Claim Ratio Less than 90% (Nov 2014) Not so poor BKKBN
(13)
APBN BPJS Tax Income Non-tax Income Non-PBI self-employed Primary
Care Referral Care
Non-PBI, former PT Askes
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
Rp Rp
(14)
Overall:
There is widening
inequity in who
(15)
2. Supply side growth and its
impact on equity
a. The Growth of Hospitals
b. Medical specialists situation and education
(16)
a. Growth in the Number of Hospitals
(17)
a. Growth in the Number of Hospitals
(18)
(19)
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
(20)
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 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
(21)
b. Medical Specialists
(22)
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.
Per Dec 2015
(23)
Number of Specialists per Province
Ketersediaan spesialis di DKI Jakarta, Jawa Barat, Jawa Tengah, Sumatera Utara, Banten lebih banyak dibanding di provinsi lain, di NTT hanya 1 % dari total jumlah spesialis tersebut.
(24)
Residents and fellows
•
No data
•
They are not classified yet as medical workers
•
They are classified as students
•
No significant increase of medical education
which are capable to train residents and
fellows
(25)
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
25
The
(26)
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
provinces (NTT), there is unspent PBI funding
(27)
Benefit Package and Equity
(28)
Who enjoys BPJS benefits?
28 Standard minimum package
Benefit Package
Number of People in Regions: Benefit Package BPJS almost unlimited
(29)
Gap for achieving UHC is widening
2014 2015 2016 2017 2018 2019
DIY
NTT
Zero
(30)
(31)
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
31 vs
(32)
The welfare state requires:
•
large fiscal capacity: strong tax
revenue
•
Well-distributed health
(33)
Trends in Government Revenue and GDP 2007 – 2016
GDP
Tax Revenue Non-Tax Revenue
(34)
The economy is weak: Tax revenue collected is significantly under targets
APBN BPJS Tax Income Non-tax Income Non-PBI Self-employed Primary
Care Referral Care
Non-PBI, former PT Askes
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?
(35)
The Power of Private Financing through increasing Premium, Private Insurance and Out of Pocket
mechanism is big
GDP
Tax Revenue Non-Tax Revenue
(36)
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
B
(37)
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
(38)
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 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
(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
(40)
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
(41)
Let’s discuss
Thank you
(1)
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
36
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
B
(2)
Financial Flow
Recommendations
APBN
BPJS
Tax Income Non-tax Income Non-PBI MandiriPrimary
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
(3)
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 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
(4)
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
(5)
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
(6)