KebijakanStrategis untuk

mengurangiketidak adilan

dalam mencapaiUniversal Health

Coverage

Laksono Trisnantoro Universitas Gadjah Mada

InaHEA 2nd National Meeting, Jakarta, 9th April 2015

1

Strategic Policy for narrowing

inequity in Universal Health

Coverage programs

What Happened in 2014• JKN dimulai 1 Januari

2014• Situasi supply-side dalam

keadaan tidak seimbang.- SDM dokter dan kesehatan

tidak merata- Pelayanan kesehatan tidak

merata• Di awal tahun 2015,

berbagai sumbermenyatakan bahwa BPJS kekurangan 2 – 5 Triliun

• JKN started in January 2014

• Supply side is extremely not well distributed across Indonesia- Human resources- Health facilities

- In 2015 some report shows that BPJS is shortage of 2-4 Triliun

2

The Shortage of BPJS

• Pardede, 2015 3

Sumber: Data klaim Bulan Pelayanan Jan s/d Des 2014 (Bulan Pembebanan s/d Jan 2015) dari BPJS, Maret 2015.

Who Gets What in 2014?

• Siapa yang mendapatkan danaBPJS?

• Apakah masyarakatyang membutuhkan?Ataukahjustru masyarakatmenengah ke atas di kota-kota besar?

• Who get what from BPJS expenditure?

• Whether the poor or the better of community?

• Whether people in the remote area or in the big cities

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In more specific, which member group?

• Kelompok masyarakatmiskin yang dibayarmelalui PBI?

• Kelompok Non-PBI eks PT Askes Indonesia dan PT Jamsostek?

• Kelompok Non-PBI Mandiri (Pekerja BukanPenerima Upah)?

Bagaimana isu Ketidakadilan?

• Poor community paid by central government budget (PBI)?

• The ex PT Askes and PT Jamsostek members and formal sector?

• The Non-PBI Mandiri?

How is equity issue is managed?

5

The Analysis

• Revenue Collection• Pooling• Purchasing

6

Health Financing (simplified)

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

7Local Gov

Private Insurance

(19.93 T)

NHA 2009 : (18 T)

489 ( 72.9 T)

l.K20 T

4 T

(67,5 T)

Revenue Colelection

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

8Local Gov

Private Insurance

(67,5 T)

NHA 2009 : (18 T)

489 ( 72.9 T)

4 T(19.93 T)

+-20 T

Pooling

9

1. APBN1. MoH (47,5 T)—incl. PBI• Other Ministries (13,5 T)• Local Government (6.5 T of

APBN)

2. BPJS Kesehatan• PBI (19,8 T) plus• Non PBI-ex PT Askes• Non PBI-Mandiri

Two Big Pools1. Ministry

of Health

1. BPJS

What happened in the two Big Pools?

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

10Local Gov

Private Insurance

Ministry of Health

In 2014:• Small Budget for

Hospital Investment • Human Resources

budget stagnant

Pada tahun 2014• Dana investasi kecil

untuk penambahanpelayanan kesehatandan sumber dayakesehatan

11

Kemkes Pemprov Pemkab Pemko Kementerian lain TNI POLRI Swasta

non profit Swasta BUMN

2012 32 85 411 86 3 105 29 654 237 77 2013 32 89 447 88 3 115 39 727 468 75 2014 33 96 455 92 3 118 41 724 599 67 Updated 34 97 459 92 5 127 43 733 694 66

-

100

200

300

400

500

600

700

800

RSThe new Hospital financed by private

sector

Specialists Distribution

BPJS:

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

14Local Gov

Private Insurance

More Sick Members in the Voluntary Group

Kelompoksakit

Kelompoksehat

Adverse Selection problems in Non-PBI

Mandiri

APBN

BPJS

PajakPendapatanNegara bukan Pajak

Non-PBI Mandiri

PelayananPrimer:

PelayananRujukan

Non-PBiPNS, Jamsostekdll dll

Kemenkes

Dana dari Masyarakat langsung

Kementerianlain

PBI

Pemda

15PendapatanAsli Daerah

Kelompoksakit

Kelompoksehat

AskesSwasta

The health risk in BPJS pool

• Non-PBI-Mandiri(Voluntary Group)Not poor, some rich .

• PBI members (poor member)

• Non-PBI (ex PT Askes )More Healthy members

Kelompoksakit

Kelompoksehat

Kelompoksakit

Kelompoksehat

Kelompoksakit

Kelompoksehat

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What Happened in Purchasing?

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

17Local Gov

Private Insurance

489 ( 72.9 T)

BPJS, Purchasing and Payment Mechanism

• Kapitasi untuk pelayanan kesehatan primer, dan

• Klaim untuk pelayanan kesehatan rujukan berbasis INA-CBG.

• Capitation for Primary Care

• Claim, based on INA-CBG (DRG) type of payment

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The facts in 2014• Kapitasi tidak terkait kinerja

FKTP• Tidak ada batas atas

(plafond) di RS dalam melakukan klaim.

• Sistem Pencegahan danPenindakan Fraud belumberjalan

• Daerah dengan SDM lengkap, RS banyak, teknologi tinggiakan menyerap dana BPJS banyak

• Capitation is not linked with performance indicators

• There is no upper limit for hospital in claiming the services

• Fraud Prevention, Detection, deterrence, and prosecution system is not yet established

• Regions which have many doctors, health services, and high technology equipment get the fund more

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The Risk of this current condition of financing

• Health facilities in remote areas become more lagged behind

• The distribution of human resources for health will suffer

• Not efficient primary care• Fraud will be uncontrollable

and make the use of resources become less efficient

• Adverse selection problems • PBI budget is used by the

middle and higher income group

• Pembangunan RS dan faskes di daerah terpencil tidak dapatmengejar ketinggalan

• SDM kesehatan semakin tidakmerata

• FKTP tidak efisien• Klaim INA-CBGs tidak dijamin

efisiensinya karena fraud tidakterkendali

• Problem Adverse Selection semakin meningkat

• PBI (APBN) disinyalirmenanggung biaya pelayanankesehatan Non PBI (mandiri)

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Who get the most from BPJS

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

21Local Gov

Private Insurance

In Nov 2014:Claim Ratio is around 1300%

Claim RatioLess than 90% (Nov 2014)

The possibility:PBI Budget is used by Non-PBI

Mandiri (Pekerja BukanPenerima Upah)

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

22Local Gov

Private Insurance

In Nov 2014:Claim Ratio is around 1300%

Claim RatioLess than 90%

• Wheter UHC can be achieved in 2019?

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Scenario 1: OptimisticScenario 2: Pessimistic.

UHC pessimistic scenario

2014 2015 2016 2017 2018 2019

DIY

NTT

Zero

JKN increases geographical inequity,and also socio-economic inequity

Proposed Strategic Policy to reduce inequity

1. Using more reform approach in JKN; Not only Financing;

2. Short term recommendation in Financing Policy (Revenue Collection, Pooling and Purchasing).

26

More Strategic Policy using Health Sector Reform Concept

AccessQualityEfficiency

• Pembiayaan/Financing

• Pembayaran/Payment

• Pengorganisasian/Organizing

• Regulasi/Regulation• Promosi/Promotion

Status Kesehatan/Health Status

Kepuasan Publik/Public

Satisfaction

PerlindunganResiko/

Risk Protection

Cost

GoalControl Knobs

27

Equity?

(Harvard University-WB)

Proposed Strategic Policies in Financing to reduce in-equity

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Short-term Policy recommendation in

Financing

APBN

BPJS

PajakPendapatanNegara bukan Pajak

Non-PBI Mandiri

PelayananPrimer:

PelayananRujukan

Non-PBiPNS, Jamsostekdll dll

Kemenkes

Dana dari Masyarakat langsung

Kementerianlain

PBI

Pemda

29

AskesSwasta

More Budget for MoHto improve the supply

side

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

30Local Gov

Private Insurance

Kemkes Pemprov Pemkab Pemko Kementerian lain TNI POLRI Swasta

non profit Swasta BUMN

2012 32 85 411 86 3 105 29 654 237 77 2013 32 89 447 88 3 115 39 727 468 75 2014 33 96 455 92 3 118 41 724 599 67 Updated 34 97 459 92 5 127 43 733 694 66

-

100

200

300

400

500

600

700

800

RSMore MoH and local government budget to finance

new health services and hospitals

More MoH budget for redistribution of Specialist

Do not increase the premium for PBI

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

33Local Gov

Private Insurance

Increase the premium for the middle and rich

members

APBN

BPJS

Tax Income

Non-tax Income

Non-PBI Mandiri

Primary Care

Referral Care

Non-PBI exPT Askes

MoH

Out pof pocket

Other Ministries

PBI

Pemda

34Local Gov

Private Insurance

Aim:To reduce Claim Ratio

To reduce in-equity: there should be fundamental

change in BPJS

35

Needs compartment in BPJS

• In BPJS there should be compartment based on source of income and expenditure

Aim:• To prevent the budget

from PBI to be used by Non-PBI-mandiri members

(State budget for the poor should be used by the poor)

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Compartment in BPJS

APBNBPJS

PajakPendapatanNegara bukan Pajak

Non-PBI Mandiri

PelayananPrimer:

PelayananRujukan

Non-PBiPNS, Jamsostekdll dll

Kemenkes

Dana dari Masyarakat langsung

Kementerianlain

PBI

Pemda

37

RpRp

Rp

PendapatanAsli Daerah

AskesSwasta

Thank-you

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