1. Laksono Trisnantoro Universitas Gadjah Mada
Supply side challenges for JKN, Benefit Package, and their implications for equity
Laksono Trisnantoro
Universitas Gadjah Mada

2. Contents: Health Financing Situation: Who gets the most from BPJS?
Supply side growth and its impact on equity
Political-economy analysis
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
In 2015 and 2016: Also projected deficits
Pardede, 2015

5. PMA 2020: Is it a proper thing?
Captures data on insurance coverage for family planning services.
Poorer women are likely to be covered by Jamkesda
Wealthier women by BPJS
Overall:
26% covered by Jamkesda
21% by BPJS

6. Analysis Using Health Financing Concepts: Revenue Collection Pooling
Purchasing
and
Political Economy

7. Health Financing Concepts applied in Indonesia (simplified)
Non-tax Income
Tax Income
Non-PBI, former
PT Askes
APBN
Very low premium relative to benefit received
Non-PBI self-employed
BKKBN
PBI
BPJS
MoH
Private Insurance
Other Ministries
Primary Care
Referral Care
489 (72.9 T)
Pemda
Out of pocket
Local Gov

8. Revenue Collection (2014 data)
Non-tax Income
Tax Income
Non-PBI, former
PT Askes
(67.5 T)
APBN
~20 T
Non-PBI self-employed
BKKBN
PBI
BPJS
Nonpoor members
(19.93 T)
MoH
Private Insurance
4 T
Other Ministries
Primary Care
Referral Care
489 (72.9 T)
Pemda
Out of pocket
NHA 2009 : (18 T)
Local Gov revenues

9. Pooling MoH, big pool. BKKBN (Family Planning body), small pool.
BPJS Kesehatan, big pool.
The Pools

10. Purchasing APBN BPJS MoH Primary Care Referral Care Tax Income
Non-tax Income
Tax Income
Non-PBI, former
PT Askes
APBN
Non-PBI self-employed
BKKBN
PBI
BPJS
MoH
Private Insurance
Other Ministries
Primary Care
Referral Care
Pemda
Out of pocket
Local Gov

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
Who gets the most from BPJS?

12. Who gets the most from BPJS?
Non-tax Income
Tax Income
Claim Ratio
Less than 90% (Nov 2014)
Non-PBI, former
PT Askes
APBN
Non-PBI self-employed
Not so poor
BKKBN
PBI
BPJS
MoH
Private Insurance
In Nov 2014:
Claims Ratio was around 1300%
In 2015: around 400 – 600%
Other Ministries
Primary Care
Referral Care
Pemda
Out of pocket
Local Gov

13. Possibility: Subsidy for the poor (PBI) is used by the middle and upper class of society
Non-tax Income
Tax Income
Non-PBI, former
PT Askes
BPJS
APBN Rp
Non-PBI self-employed
BKKBN Rp
PBI Rp
MoH
Private Insurance
Other Ministries
Primary Care
Referral Care
Pemda
Out of pocket
Local Gov’t income

14. There is widening inequity in who benefits from BPJS.
Overall:
There is widening inequity in who benefits from BPJS.

15. 2. Supply side growth and its impact on equity a
2. Supply side growth and its impact on equity a. The Growth of Hospitals b. Medical specialists situation and education
MoH data from December 2015

16. a. Growth in the Number of Hospitals National Data

17. a. Growth in the Number of Hospitals National Data

18. Hospital growth by ownership

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
Region 5: Kep. Babel, NTT, Kaltim, Maluku, Malut, Papua Barat, Papua

20. 2015: Number of Hospitals by Region and ClassNo
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 78
213 86
189 4
Region 4 6 25 11 5
Region 5 16 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
Region 5: Kep. Babel, NTT, Kaltim, Maluku, Malut, Papua Barat, Papua

21. b. Medical Specialists

22. 2015: Numbers of 4 Major Specialists
Per Dec 2015
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.

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
The impact:

26. Claim system (INA-CBG)
Essentially fee-for-service hospital payment system
Favors more-developed provinces
There is no cap on hospital claims and regional expenditure
Fraud control is not yet in place
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?
Benefit Package
Benefit Package BPJS almost unlimited
Standard minimum package
In less developed provinces
In developed provinces
Number of People in Regions:

29. Gap for achieving UHC is widening
DIY
NTT
Zero
2014
2015
2016
2017
2018
2019
The problems of supply side:
Gap for achieving UHC is widening

30. 3. Political-economy analysis

31. The political economy debate
Welfare State
Market Orientation vs
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.
Government should pay less. Social expenditure is expensive and sometimes beyond the capacity of government to finance Let the market work

32. The welfare state requires:
large fiscal capacity: strong tax revenue
Well-distributed health facilities and human resources

33. Trends in Government Revenue and GDP 2007 – 2016
Tax Revenue
Non-Tax Revenue

34. What is happening in the current Indonesian situation?
The economy is weak: Tax revenue collected is significantly under targets
Non-tax Income
What is happening in the current Indonesian situation?
Tax Income
Non-PBI, former
PT Askes
APBN
Non-PBI Self-employed
BKKBN
PBI
BPJS
MoH
Private Insurance
Some of subsidy for the poor is used by the rich
Other Ministries
Primary Care
Referral Care
Pemda
Out of pocket
Local Gov

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 A
For better
social justice B
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

37. Financial Flow Recommendations
Non-tax Income
Tax Income B A
Non-PBI ex
PT Askes
APBN
Non-PBI Mandiri
Very low premium relative to benefit
BKKBN
PBI
BPJS
Private Insurance
MoH
Other Ministries
Primary Care
Referral Care
489 ( 72.9 T)
Pemda
Out of pocket
Local Gov

38. Note: Hard challenge to address
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 78
213 86
189 4
Region 4 6 25 11 5
Region 5 16 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
Region 5: Kep. Babel, NTT, Kaltim, Maluku, Malut, Papua Barat, Papua

39. Financing Structure Change
Private financing
BPJS
Jamkesda
100 %
Financing Structure Change
50 %
Is it possible?
Is it better?
Is it more equitable?
0 %
Poorest
Poor
Middle
Rich
Richest

40. Expected policy: Source: Trisnantoro, 2016 Benefit Package
Catastrophic Insurance
Standard minimum package
Compensation policy for Human Resources
In less developed provinces
In developed provinces
Number of People in Regions:

41. Let’s discuss
Thank you