Thabrany Nhip Politics Process

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Politics of National Health Insuranceof Indonesia: A New Era of 

Universal Coverage

 Hasbullah Thabrany

 Institute for Social Security,

University of Indonesia

hasbullah.thabrany@ui.edu

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Conditions of 2004

• Government financing mainly trhough supply sidesubsidy: inappropriate, lost and corrupt

• Access to Primary care is OK, but quality is poor 

• High and uncertain out of pocket: public hospital chargefee for service

• High burden of out of pocket: 100% - 240% of monthlyincome for a single hospitalization: 83% householdsneeded inpatient care experiences catastrophic health

expenditures• Corporatization and “privatization” of public hospitals:

increasing financial barriers

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The Driving Forces for Reforms

1. Amendment of the Constitution, 2002

2. Political Agenda?

3. Perceived Gaps

4. Academic Exercises and International Pressures

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Political Process

• The Indonesian Law process

 – Government submit a Bill-discuss by

Parliament and the Government – Parliament initiate a Bill-response by the

Government by sending ‘partner’ to be

discussed together 

• Both initiatives solicit ideas, concepts, etc

from the public

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Political Interventions during

Process• In each step, stakeholders may intervene.• Supports by donors: GTZ, EU, ILO, WHO, ADB, AUSAID

• During the process in the Parliament, demos of to support or to reject the Bill have been made by Employer andEmployee Associations

• Opinions also published through News and Articles innewspapers and magazines

• International Bussiness Chamber of Commerces, frequentlyvoiced their oppositions

• An analysis, threatening the Government, was sent by a

USAID consultant• Organized meetings by NGOs supported by USAID to voice

opposition with the concept

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The Askeskin, Government

Sponsored Insurance for the Poor • Starting January 2005, the new government,

 promising free health care before, paid the first

contribution for 36,7 million the poor.• Administration of the scheme undertook by Askes,

the administrator for National SHI for civil

servants. 40 years experienced with more than 280

 branch offices

• Criticisms and complaints were sent, especially by

HMOs (JPKM)

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Two Months After Government

Paid the First Contribution• The law was challenged to the Constitutional Court by

 provincial legislative, East Java Province, claiming the HI

is a provincial jurisdiction. It was rejected

• Two years after Askes administered, accusation of 

mismanaged fund by Askes voiced by some MoH officials

• In 2008, administration by Askes was truncated to only

membership administration. Claim by hospital paid directly

 by MoH

• Financial audit was undertaken. No misconduct was found.

But the official at MOH continue to administer the fund by

themselves

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After almost five years, the law has not been

implemented and objections are on:

• Mandatory system

• Monopolistic system/central government control

system. Although it is actually by a quasi-government autonomy body

• Shared contribution by employees

• Integration of the system into a single scheme• Demand for provincial control on fund

management

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Conclusion

• Indonesia has long implemented social health insurance, but it grows very slowly due to inconsistent

implementation of SHI principles

• Current SHI implementation needs improvement in

 benefits, premiums, management, and payment to

 providers. This improvement is being undertaken

• A National Health Insurance Program was passed, but

many resistances and trials (including political “lipsticks”

 promising “free health care” by candidates of governors)

are being voiced

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Thank You