Universal Health Coverage in Indonesia - Sep 2013

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September 2013!

Universal Health Coverage in Indonesia!A Primer!

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List of Abbreviations, Terms and Data Sources !

MoH is Ministry of Health DJSN is National Social Security Council BPJS is National Health Insurance Agency (or Badan Penyelenggara Jaminan Sosial) SJSN is National Social Protection System (or Sistem Jaminan Sosial Nasional) UHC is Universal Health Coverage

World Bank, Various Reports (2012, 2013) Ministry of Health, Republic of Indonesia www.jamsosindonesia.com (SJSN) Susenas (Statistics Indonesia), 2011 Press & News Reports The Jakarta Post Various Online Sources see pages for specific sources The Nossal Institute for Global Health, University of Melbourne, Working Paper (July 2013) DJSN, Roadmap towards National Health Insurance 2012-2019 (2012) and www.djsn.go.id AMCHAM (American Chamber) in Indonesia their website (http://amcham.or.id/)

Data Sources

List of Abbreviations

PT Askes is Private Health Insurance Company managing current insurance schemes of civil servants that would be converted to BPJS I on Jan 1, 2014 BPJS I is the entity established for health insurance service in the country (BPJS II is for pension, social security & retirement)

List of Terms

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Executive Summary 04

Universal Health Coverage 05

Contents !

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Executive Summary !

! Jamkesmas (the one scheme that will merge all), operational since 2005, already has ~76 Mn. people enrolled that will expand to ~122 Mn. by Jan 2014 when UHC starts under BPJS I

! Universal Health Coverage targeted to go to ~257.5 Mn. (the entire population) by 2019

UHC Roadmap

! Large supply-side shortfall anticipated, since not a large number of private hospitals & clinics are (currently) enrolled onto the UHC program

! Specific guidelines on enrollment of population is yet to be detailed ! Fiscal sustainability study on the program expected to be one of the worlds

largest health insurance programs by 2019 is yet to be carried out

UHC Implementation

* Refer following pages for more Notes: - UHC is Universal Health Coverage - Not only is there a general shortfall of facilities & infrastructure, Indonesia has ~50% hospital beds in the private sector

Universal Health Coverage!

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Evolution of Indonesias Health Insurance Programs up to 2012!

Year Initiative

1968 Health Insurance for civil servants

1992 Social Security for Private Sector employees Jamsostek, JPKM (HMOs) and CBHI

1999 JPS (Social Safety Net); financial assistance for the poor via ADB loan

2000 Comprehensive review of health insurance and amendment of constitution to prescribe the rights to health care

2004 National Social Security (SJSN) Law (No. 40/2004) mandated social health insurance for the entire population

2004 Introduction of Asuransi Kesehatan Masyarakat Miskin (health insurance for the poor)

2008 Askeskin is renamed Jamkesmas and extended to the near poor

2010 Law No. 17: The National Development Middle Plan (RPJMN) reconfirmed Indonesias commitment to provide universal health coverage by 2014

2011 Constitution No. 24/2011: Social Security Providers Bill is passed, which mandates that the Social Security Agency (BPJS) would be operational by January 1, 2014

Sources: http://www.uhcforward.org/content/indonesia; jamsosindonesia.com/english; 6

The employed (~131 Mn.)

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Health Insurance Coverage an overview!

Current Population (~240 Mn.)

Police and Military

Military Health Services 2.2 Mn.

Civil Servants ASKES (Civil

Servants insurance)

17.3 Mn.

Private Sector

JAMSOSTEK (Workers Social

Security) 5.6 Mn.

Private (self-insured) &

Commercial Insurance

18.3 Mn.

No Insurance / Reimbursement

System 88.4 Mn.

Self Employed /

Unemployed (~108 Mn.)

JAMKESMAS (health insurance

for the poor) 76.4 Mn.*

JAMKESDA (regional govt.

health insurance) 31.9 Mn.

* Expected to increase to 86.4 Mn. people by end-2013 as part of transition to universal coverage Notes: Figures may not fully add-up due to rounding-off error; data as of 2012

~25 Mn. insured under

different govt.

schemes

~18.3 Mn. insured in the private

sector

~108.3 Mn. insured by

under 2 schemes

2012

Targeted to go to 257.5 Mn. (the

entire population) by 2019

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Roadmap to Universal Health Coverage present-day to 2019!

Note: All statements are projections and estimates as set out in the roadmap (2012-2019) document

Universal Health Coverage under BPJS I

As of Jan 2014 2015 2016 2017 2018 2019

~122 Mn. under mgmt. of BPJS I

257.5 Mn. people covered by UHC

Private sector coverage (according to company size): - 20% large - 20% medium - 10% small - 10% micro companies

Private sector coverage(according to company size): - 50% large - 50% medium - 30% small - 25% micro Companies

All JAMKESDA members will be covered by BPJS Private sector target coverage (according to company size): - 75% of large - 75% medium - 50% small - 40% micro companies

Private sector coverage (according to company size): - 100% large - 100% medium - 70% small - 60% micro companies

Private sector coverage (according to company size): - 100% large - 100% medium - 100% small - 80% micro companies

Target 100% of Indonesia population

~15 Mn. people still covered by JAMKESDA

Jamkesmas, operational since 2005, already has ~76 Mn. enrolled that will expand to ~122 Mn. by Jan 14 when UHC starts under BPJS I

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Key Elements of Universal Health Coverage funding and resource contributions!

* Original calculations were for a subsidy of between Rp 22,000 Rp 27,000 per person per month for those categorized as poor; premium contributions also differ by type of hospital accessed for services ** 3% paid by employer & 2% by employee (in certain cases share of contribution is 4% employer & 1% employee); though under Jamsostek it is mandatory to register employees, compliance (estimates suggest only about 25% of formal sector employees are currently covered) Note: DRG is Diagnosis Related Group; INA-CBG is Indonesia Definitions; exchange rate may not up to date; $ are US$

Resource Contributions Extent of Pooling Purchasing / Provision

Govt.

Rp 15,500 (~ $ 1.5) payout* (revised

subsidy in 2013) / person / mth. by the govt. as contribution

for the poor

Existing funds to be pooled by 2014: ! Jamkesmas ! TNI/Polri (military & police) ! Askes PNS (civil servants) ! JPK Jamsostek ! Some of Jamkesda TOTAL: 121.6 million

Hospital

! DRG payments based on INA-CBG. Amounts to be negotiated with hospital associations & to vary according to region

Formal Sector

5% of wages** shared between

employer & employee

By 2019: total population, incl. remainder of Jamkesda schemes TOTAL: 257.5 million

Primary Health Centre

! Monthly capitation contribution based on registered users for public & private clinics

Informal Sector

Self-funded contribution of ~5-6%

of monthly income (+some govt. contribution)

BPJS as single institution managing pooled funds to be formed by conversion of PT Askes

Benefit Package

! Comprehensive ! Initially public ward for

govt. contributor & 2nd class ward for self-funded; shift to 2nd class for all by 2019

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Roll-Out of Universal Health Coverage steps taken and challenges ahead!

What Need Steps Taken / Challenges

Funding

Public Facilities

Cost structure of facilities & funding

! Rp 4 Trillion (US$ 400 Mn.) budget ear-marked for BPJS I, though fiscal study has not been undertaken

Private Facilities

How will facilities be funded?

! MoUs signed with 3 national banks for deposit of premiums ! Private sector funding not finalized

Overall ! No need for co-payment envisaged though how will longer-term funding needs be met still not clear

Service Provider(s)

All govt. owned health facilities to be included, though only select doctors & private facilities specifically contracted under the scheme would be. These would be selected by BPJS I

! Only 3,500 physicians & 15,000 primary clinics registered under the program stated massive supply-side shortfall

! Though private clinics can participate, no rules have been set on selection criteria & eligibility for (what) services

! Pilots started in Aceh, Jakarta & West Java provinces to try out coverage & service provision under UHC

Integration, Payment &

Arrangement

BPJS I will pay for health facilities prospectively through capitation (for primary health facilities) & service output payments using Indonesian definitions

! How the integration with other schemes will take place has not been finalized

! No rules are written / set yet to set the formula for capitation & service output payments

Note: MoU is Memorandum of Understanding; exchange rate as of July 1, 2013

The biggest challenges are supply-side readiness and financial sustainability of the program

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