2014年-世界发展银行全球_Universal_Health_Coverage_for_Inclusive_and_Sustainable_Development___Country_Summary_Report_for_Indonesia_22页_379kb

Summary of the Japan-World Bank Partnership Program for Universal Health Coverage: Indonesia Country Report

Core Content

This report is part of the Japan-World Bank Partnership Program for Universal Health Coverage, which aimed to analyze the experiences of countries implementing UHC. The focus is on Indonesia, a low-middle income country with a population of about 242 million. The report outlines the current status of UHC in Indonesia, including legal frameworks, coverage, service delivery, and financial sustainability.

Main Points

1. Legal and Statutory Basis

• The 2004 National Social Security Law laid the foundation for JKN (Jaminan Kesehatan Nasional), a national health insurance program.
• Jamkesmas, Jamsostek, and Askes were the main pre-existing social health insurance programs.
• The 2011 BPJS Law established the transformation of PT Askes into a national health insurance agency.

2. Current Status of Coverage

• Jamkesmas is the largest program, targeting 76.4 million poor and near-poor individuals.
• Askes covers 16.6 million civil servants, while Jamsostek covers 5 million formal sector workers.
• In 2011, 40% of households were covered by insurance.
• Jamkesmas coverage was only 33% of the target population, with 53% leakage to non-eligible beneficiaries.
• Informal workers remain largely uncovered, with over 60 million not included in any insurance program.

3. Service Delivery

• Indonesia has a mix of public and private health service providers.
• Puskesmas (primary health centers) are the main public health delivery points, covering 25,000–30,000 individuals per center.
• Jamkesmas beneficiaries can access primary care services at all puskesmas and inpatient services at secondary and tertiary public hospitals and empanelled private hospitals.
• Primary care is also provided by private doctors, with 70% of puskesmas doctors offering private services.
• Referral systems are weak, and self-referral to higher-level facilities is common.

4. Financial Protection

• Public health spending accounted for 38% of total health expenditure in 2011.
• Out-of-pocket (OOP) spending was 47%, with the top three deciles bearing the majority of the burden.
• Jamkesmas has no cost-sharing, no copayment, no coinsurance, and no extra billing, which makes it more financially protective than other schemes.
• Catastrophic health expenditure is lower among Jamkesmas users than other groups.

5. Governance Structure

• Jamkesmas involves multiple actors: TNP2K, MOH, Bappenas, provincial/district governments, health providers, and the insurer/third-party administrator.
• The MOH is responsible for policy guidance, benefits package, and claims processing.
• Provincial and district governments handle service delivery and outreach.
• Public and private providers are involved in service delivery, with public hospitals playing a dominant role in inpatient care.

6. Health Financing

• Jamkesmas is fully funded by the central government, with a premium rate of Rp 6,500 per person per month (about $8 per person per year).
• Fiscal sustainability is a concern, as the true cost is estimated to be three to four times the current premium rate.
• Fiscal space has been sufficient due to positive economic growth and stable government finances.
• Health expenditure in Indonesia is low compared to other sectors, with 1.6% of the central government budget in 2011, versus 18.2% for fuel subsidies and 10.8% for education.

7. Cost Management and Value for Money

• Supply-side constraints and government subsidies help keep the program costs low.
• DRG-based reimbursement is used for hospitals, but no evidence is provided on whether it has improved efficiency.
• Puskesmas were initially reimbursed based on capitation, but since 2011, fee for service has been adopted.
• Subsidies account for two-thirds of the total cost of care under Jamkesmas, primarily for salaries and infrastructure.

Key Information

• Indonesia's goal: Achieve UHC by 2019 under the JKN Road Map.
• Coverage challenges: Limited service availability in remote and rural areas, high OOP spending, and undercoverage of informal workers.
• Financial challenges: Fiscal sustainability is uncertain due to rising utilization and low premium rates.
• Economic context: Indonesia has experienced robust economic growth (average of 6% between 2005–2011) and stable fiscal conditions, with government deficit at 1–2% of GDP and inflation and unemployment low.
• Key lessons: UHC requires inclusive coverage, financial protection, and sustainable financing. Indonesia's experience shows the importance of targeted subsidies, comprehensive benefits packages, and reform of reimbursement systems.

Conclusion

Indonesia has made significant progress in expanding health coverage, particularly through Jamkesmas, but faces ongoing challenges in service availability, fiscal sustainability, and financial protection. The country's mixed public-private system and government subsidies have helped maintain affordability, but further reforms are needed to ensure long-term sustainability and equity in health service delivery.