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Jampersal (Maternity Insurance) as a step towards universal coverage and
health equity: experience of Indonesia*
Soewarta KosenHealth Economics and Policy Analysis Unit,
Center for Community Empowerment, Health Policy and Humanities, National Institute of Health Research & Development
Ministry of Health Republic of Indonesia
*Presented at the 4th Technical Review and Planning Meeting for the Health Policy and Health Finance Knowledge Hub,
Melbourne 10 -11 October 2011
BACKGROUND
• Indonesian Constitution (1945) stated the right of every citizen to obtain health care
• Indonesian Health Law (2009): right to obtain safe, accessible and quality health care
• The government is responsible to provide quality health services
• Social Security Law enacted since 2004, however the implementation is still fragmented
COVERAGE OF HEALTH INSURANCE (2010)
Distribusi Penduduk yang memiliki Jaminan Kesehatan (asuransi kesehatan) menurut Jenis Jaminan
43.98
56.02
Tidak memiliki Jamkes Punya Jamkes
Local Health Insurance (JAMKESDA) exists in 250 districts/cities
4 Provinces with Universal Coverage:South Sumatra, South Sulawesi, Bali, Nanggroe Aceh Darussalam
Proportion of Population with health insurance
12.45 3.33
57.78
20.83
5.61
Askes PNS&TNI POLRI JamsostekJamkesmas JamkesdaAsuransi Swasta & Lain
HEALTH INITIATIVES
• Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) has been implemented since January 2005 for 76.4 million (the poor and the near poor) to cover free primary health care services including maternity care at community health center (Puskesmas) and in-patient services in hospital wards (third class). The Ministry of Health has managed the implementation since 2008, and directly distribute the fund to Puskesmas and hospitals
• A universal maternity Benefit (Jaminan Persalinan/ Jampersal) is implemented since January 2011 for all pregnant women who are not covered by any maternity scheme.
BACKGROUND
• Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) is delivered through 8.917 community health centers/ PUSKESMAS) and hospitals (public and private)
• Maternity Insurance is delivered through physician and midwife practitioners, community health center/PUSKESMAS, maternity clinic and hospital
• Fund is channelled from central to district/city through social assistance mechanism
• Total budget for both programs in 2011: 6.3 Trillion Rupiahs (800 Million Au $)
6
Wilayah Sumatera
Share PDRB thdp Nasional
21,55%
Pertumb. Ekonomi 4,65%
Pendaptn perkapita 9,80 jt
Penduduk miskin 7,3 jt (14,4%)
Wilayah Jawa Bali
Share PDRB thdp Nasional
62,00%
Pertumbh Ekonomi 5.89%
Pendapt perkapita 11,27 jt
Pendudk miskin 20,19 jt (12,5%)
Wilayah Nusa Tenggara
Share PDRB thdp Nasional
1,42%
Pertmbuh Ekonomi 3,50%
Pendapt perkapita
3,18 jt
Pendudk miskin 2,17 jt (24,8%)
Wilayah Kalimantan
Share PDRB thdp Nasional
8,83%
Pertumb. Ekonomi 5.26%
Pendaptn perkapita 13,99 jt
Pendudk miskin 1,21 jt (9%)
Wilayah Sulawesi
Share PDRB thdp Nasional
4,60%
Pertmbh Ekonomi 7.72%
Pendapt perkapita 4,98 jt
Pendudk miskin 2,61 jt (17,6%)
Wilayah Maluku
Share PDRB thdp Nasional
0,32%
Pertumbh Ekonomi 4,94%
Pendaptn perkapita 2,81 jt
Pendudk miskin 0,49 jt (20,5%)
Wilayah Papua
Share PDRB thdp Nasional
1,28%
Pertmbuh Ekonomi 0,60%
Pendaptn perkapita 8,96 jt
Pndudk miskin 0,98 jt (36,1%)
Source : Statistics Ind. 2008Note: based on constant prices
Seven Development Area of BAPPENAS, 2008
REASONS TO IMPLEMENT JAMPERSAL
• High maternal, neonatal and infant mortality rates• Coverage of deliveries in health care facilities: 55.4 %• Decrease Contraceptive Prevalence Rate• Problems of geographical and financial access• Need to focus on delivery period and immediate post-
delivery period (90 % of complications) that include:– Post delivery bleeding (28 %)– Toxaemia (24 %)– Infection (11 %)– Puerperal complication (11 %)
Neonatal mortality by Island group, Indonesia, 1990 - 2015
Neonatal Mortality by Wealth Group
10
Infant Mortality Rate decreases from 35 to 34 per 1000 live births, with disparity among provinces
Source: DHS 2007MDG target for IMR: 23 per 1,000 live births by 2015
Angka Kematian Bayi (Per 1.000 Kelahiran Hidup)
Per Provinsi Tahun 2007
25
46 47
37 3942
4643
3943
28
39
2619
35
46
34
72
57
46
30
58
26
35
60
41 41
52
74
59
51
4136 34
0
10
20
30
40
50
60
70
80
NA
D
Sum
ater
a U
tara
Sum
ater
a B
arat
Ria
u
Jam
bi
Sum
ater
a S
elat
an
Ben
gkul
u
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pung
Ban
gka
Bel
itung
Kep
ulau
an R
iau
DK
I Jak
arta
Jaw
a B
arat
Jaw
a T
enga
h
D.I.
Yog
yaka
rta
Jaw
a T
imur
Ban
ten
Bal
i
Nus
a T
engg
ara
Bar
at
Nus
a T
engg
ara
Tim
ur
Kal
iman
tan
Bar
at
Kal
iman
tan
Ten
gah
Kal
iman
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Sel
atan
Kal
iman
tan
Tim
ur
Sul
awes
i Uta
ra
Sul
awes
i Ten
gah
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awes
i Sel
atan
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awes
i Ten
ggar
a
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onta
lo
Sul
awes
i Bar
at
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uku
Mal
uku
Uta
ra
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ua
Iria
n Ja
ya B
arat
IND
ON
ES
IA
Per
1.0
00 K
elah
iran
Hid
up
Angka Nasional34
Maternal Mortality Rate, Indonesia 1994 - 2007
11Source: DHS
390
334
307
228 226
102
0
50
100
150
200
250
300
350
400
450
1994 1997 2002 2007 2009 2015
AK
I Pe
r 1
00
.00
0 K
H
Tahun
MDG Target
Sasaran RPJM
Angka Kematian Ibu
12
Disparity by quintile of income
Infant Mortality Rate by quintile of income 56
47
3329 26
0
10
20
30
40
50
60
Q1 Q2 Q3 Q4 Q5
Sumber data : SDKI 2007
22.1
19.518.1
16.5
13.7
0
5
10
15
20
25
Kuintil 1 Kuintil 2 Kuintil 3 Kuintil 4 Kuintil 5
Kekurangan Gizi
Malnutrition among children under fives by
quintile of income
Sumber data : Susenas, 2007
Proportion of Safe Delivery (attended by trained health personnel) by expenditure Quintile
(Susenas 2006)
57.9
94.8Equity Index1.67
Objectives of Maternity Insurance
• To increase coverage of prenatal care, delivery attendance and puerperal care by trained health personnel
• To increase coverage of neonatal care by trained personnel
• To increase coverage of post-delivery family planning services
• To increase coverage of complication management for mothers and babies
FACILITIES FOR MATERNITY INSURANCE Contracted facilities (public and private) in all over Indonesia
Facilities for normal pregnant women, delivery and puerperal period:
* Community Health Center (Puskesmas) with or without in-patient facilities
* Village Maternity Hut (Polindes* General Practitioner * Midwife Practitioner * Private Maternity Clinic
•Facilities for emergency obstetric & neonatal management or complications: * Puskesmas with basic obstetric-neonatal emergency facilities * Hospitals
15
Availability of referral facilities (public hospital and private hospital) for JamKesMas/Health Insurance for the poor, 2008 - 2010
2008 2009 20100
200
400
600
800
1000
1200
855954
1012
582650 665
273 304 337
Faskes Jamkesmas
RS Pemerintah
RS Swasta
DISCUSSIONS
• The Health Insurance for the poor is estimated utilized only 40 millions out of 76.4 millions of poor people
• Under utilization showed by areas outside Jawa, Bali and Sumatra
• Main obstacles: poor geographical access & transport facilities and limited availability of health facilities (qualified personnel, drugs, equipment , physical infrastructure)
• Need special efforts to fix the situation, to achieve objectives of Maternity Insurance
CONCLUSIONS
• Universal coverage of Maternity Insurance as well as future social health insurance will be less effective with identified obstacles
• The government should solve several “bottle-neck” that include:– hiring and placement of physicians in remote and poor area– Increase quality and distribution of midwives– Improve availability and distribution of quality health care
facilities at primary and referral level – Improve availability and distribution of blood banks– Improve availability and distribution of Ob-Gyn and
Paediatricians in referral facilities
TERIMA KASIH