Kebijakan

Strategis untuk
mengurangi
ketidak adilan
dalam mencapai
Universal Health
Coverage

Strategic Policy
for narrowing
inequity in
Universal Health
Coverage
programs

Laksono Trisnantoro
Universitas Gadjah Mada
InaHEA 2nd National Meeting,
Jakarta, 9th April 2015
1

Tujuan mempelajari kasus JKN di

tahun 2014
Memahami makna:
Revenue Collection
Pooling
Purchasing

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 sumber
menyatakan 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

The Shortage of BPJS

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

Pardede, 2015

Who Gets What in 2014?

Siapa yang
mendapatkan dana
BPJS?
Apakah masyarakat
yang
membutuhkan?Ataukah
justru masyarakat
menengah 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

In more specific, which member

group?
Kelompok masyarakat
miskin yang dibayar
melalui PBI?
Kelompok Non-PBI eks PT
Askes Indonesia dan PT
Jamsostek?
Kelompok Non-PBI
Mandiri (Pekerja Bukan
Penerima Upah)?

Poor community paid by

central government
budget (PBI)?
The ex PT Askes and PT
Jamsostek members and
formal sector?
The Non-PBI Mandiri?

Bagaimana isu Ketidak

adilan?

How is equity issue is

managed?
6

The Analysis
Revenue Collection
Pooling
Purchasing

Tax
Income

Non-tax
Income

Health Financing
(simplified)
Non-PBI ex
PT Askes

(67,5 T)

l.K
20 T

APBN
(19.93 T)

PBI

BPJS

MoH
Other
Ministries
489 (
72.9 T)

Pemda

Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran 4 T
ce

Referral Care

Out of pocket

NHA 2009 : (18 T)

8

Tax
Income

Non-tax
Income

Revenue Colllection
Non-PBI ex
PT Askes

(67,5 T)

+20 T

APBN
PBI

MoH
Other
Ministries
489 (
72.9 T)

Pemda

Local Gov

(19.93 T)

Primary
Care

BPJS

Non-PBI Mandiri
Private
Insuran 4 T
ce

Referral Care

Out of pocket

NHA 2009 : (18 T)

9

Pooling
1. APBN

Two Big
Pools
1. Ministry
of Health
1. BPJS

1. 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
10

Tax
Income

Non-tax
Income

What happened in the

two Big Pools?
Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out of pocket
11

Ministry of Health
Pada tahun 2014
Dana investasi kecil
untuk penambahan
pelayanan kesehatan
dan sumber daya
kesehatan

In 2014:
Small Budget for
Hospital Investment
Human Resources
budget stagnant

12

The new Hospital financed by private

sector
800
700

600

RS

500
400
300
200
100
Kemkes

Pemprov

Pemkab

Pemko

Kementeri
an lain

TNI

POLRI

Swasta
non profit

Swasta

BUMN

2012

32

85

411

86

105

29

654

237

77

2013

32

89

447

88

115

39

727

468

75

2014

33
34

96
97

455
459

92
92

3
5

118
127

41
43

724
733

599
694

67
66

Updated

Specialists Distribution

Tax
Income

Non-tax
Income

BPJS:
Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

More Sick
Members
in the
Voluntary
Group

Referral Care

Out of pocket

Kelompok
sakit

Kelompok
sehat
15

Pajak

Adverse Selection
problems in Non-PBI
Mandiri

Pendapatan
Negara
bukan Pajak

Non-PBi PNS,
Jamsostek dll dll

APBN

Kelompok
sakit

PBI

BPJS

Non-PBI Mandiri

Kemenkes
Kementerian
lain

Pemda
Pendapatan
Asli Daerah

Pelayanan
Primer:

Kelompok
sehat

Askes
Swasta

Pelayanan
Rujukan

Dana dari Masyarakat langsung

16

The health risk in BPJS pool

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

Kelompok
sakit

PBI members (poor member)

Kelompok
sakit

Non-PBI (ex PT Askes )More Healthy

members

Kelompok
sakit

Kelompok
sehat

Kelompok
sehat

Kelompok
sehat
17

Tax
Income

Non-tax
Income

What Happened in
Purchasing?
Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries
489 (
72.9 T)

Pemda

Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out of pocket
18

BPJS, Purchasing and Payment

Mechanism
Kapitasi untuk
pelayanan kesehatan
primer, dan

Capitation for Primary

Care

Klaim untuk pelayanan

kesehatan rujukan
berbasis INA-CBG.

Claim, based on INACBG (DRG) type of

payment

19

The facts in 2014

Kapitasi tidak terkait kinerja
FKTP
Tidak ada batas atas
(plafond) di RS dalam
melakukan klaim.
Sistem Pencegahan dan
Penindakan Fraud belum
berjalan
Daerah dengan SDM
lengkap, RS banyak,
teknologi tinggi akan
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
20

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 dapat
mengejar ketinggalan
SDM kesehatan semakin tidak
merata
FKTP tidak efisien
Klaim INA-CBGs tidak dijamin
efisiensinya karena fraud tidak
terkendali
Problem Adverse Selection
semakin meningkat
PBI (APBN) disinyalir
menanggung biaya pelayanan
kesehatan Non PBI (mandiri)

21

Tax
Income

Non-tax
Income

Who get the most from

BPJS

APBN

Claim
Ratio
Less than
90% (Nov
2014)

PBI

Non-PBI ex
PT Askes

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out pof pocket

In Nov
2014:
Claim
Ratio is
around
1300%
22

Tax
Income

The possibility:
PBI Budget is used by Non-PBI
Mandiri (Pekerja Bukan
Penerima Upah)

Non-tax
Income

Claim
Ratio
Less than
90%

Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out of pocket

In Nov
2014:
Claim
Ratio is
around
1300%
23

 Wheter UHC can be

achieved in 2019?

24

Scenario 1:
Optimistic
Scenario 2:
Pessimistic.

JKN increases geographical

inequity,
and also socio-economic
inequity
DIY

NTT

Zero
2014

2015

2016

2017

UHC pessimistic scenario

2018

2019

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).
27

More Strategic Policy using

Health Sector Reform Concept
Control Knobs

Goal

Pembiayaan/Fin
ancing
Pembayaran/Payme
nt
Pengorganisasian/O
rganizing
Regulasi/Regulation
Promosi/Promotion

Status Kesehatan/
Health Status

Access
Quality
Efficiency

Kepuasan Publik/
Public
Satisfaction

Cost

Equity?

Perlindungan
Resiko/
Risk Protection

(Harvard University-WB)
28

Proposed Strategic Policies in

Financing to reduce in-equity

29

Pajak

Short-term Policy
recommendation in
Financing

Pendapatan
Negara
bukan Pajak

Non-PBi PNS,
Jamsostek dll dll

APBN
PBI

BPJS

Non-PBI Mandiri

Kemenkes
Kementerian
lain

Pemda

Pelayanan
Primer:

Askes
Swasta

Pelayanan
Rujukan

Dana dari Masyarakat langsung

30

Tax
Income

More Budget for MoH

to improve the supply
side

Non-tax
Income

Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out of pocket
31

More MoH and local government budget to finance

new health services and hospitals
800
700

600

RS

500
400
300
200
100
Kemkes

Pemprov

Pemkab

Pemko

Kementeri
an lain

TNI

POLRI

Swasta
non profit

Swasta

BUMN

2012

32

85

411

86

105

29

654

237

77

2013

32

89

447

88

115

39

727

468

75

2014

33
34

96
97

455
459

92
92

3
5

118
127

41
43

724
733

599
694

67
66

Updated

More MoH budget for redistribution of Specialist

Tax
Income

Non-tax
Income

Do not increase the

premium for PBI
Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Out of pocket
34

Tax
Income

Increase the premium

for the middle and rich
members

Non-tax
Income

Non-PBI ex
PT Askes

APBN
PBI

BPJS

MoH
Other
Ministries

Pemda
Local Gov

Primary
Care

Non-PBI Mandiri
Private
Insuran
ce

Referral Care

Aim:
To reduce
Claim
Ratio

Out pof pocket

35

To reduce in-equity: there

should be fundamental
change in BPJS

36

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)
37

Pajak

Pendapatan
Negara
bukan Pajak

Compartment in
BPJS
Non-PBi PNS,
Jamsostek dll dll

BPJS
APBN
Rp

PBI

Rp
Rp

Kemenkes
Kementerian
lain

Pemda
Pendapatan
Asli Daerah

Non-PBI Mandiri
Askes
Swasta

Pelayanan
Primer:

Pelayanan
Rujukan

Dana dari Masyarakat langsung

38

Thank-you

39