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JLN PRIMARY HEALTH CARE INITIATIVE HEALTH BENEFITS POLICY COLLABORATIVE

DESIGNING HEALTH BENEFITS POLICIES IN INDONESIA (JKN) A COUNTRY ASSESSMENT REPORT

JAKARTA | 2018

Atikah Adyas

Yusuf Kristanto

Ede Surya Darmawan

Ali Ghufron Mukti

Authors Atikah Adyas, Ministry of Health Yusuf Kristanto, Forum Dentist Association Ede Surya Darmawan, University of Indonesia Ali Ghufron Mukti, University of Gajah Mada, Center for Financing Policies and Health Insurance Management Acknowledgments The authors gratefully acknowledge the generous funding from the Bill & Melinda Gates Foundation that made possible the production of this assessment report.

Other partners contributed valuable technical expertise and created opportunities for exchange that supported the development of this assessment. In particular, the authors would like to thank the Joint Learning Fund, the Ministry of Health and Badan Penyelenggara Jaminan Sosial of the Government of Indonesia, and the National Health Insurance Service and Health Insurance Review and Assessment of the Government of South Korea, all of whom helped support joint learning exchanges that informed the information presented here.

This assessment report is part of a series of country regulatory assessment reports that are contributing to the body of evidence and practical knowledge synthesized in Designing Health Benefits Policies: Lessons from JLN Country Experiences.

This report was produced by the Joint Learning Network for Universal Health Coverage (JLN), a community of policymakers and practitioners from around the world who jointly create practical guidance to accelerate country progress toward universal health coverage.

This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0). To view a copy of this license, visit https://creativecommons.org/ licenses/by-sa/4.0/legalcode. The content in this document may be freely used and adapted in accordance with this license, provided it is accompanied by the following attribution:

Designing Health Benefits Policies in Indonesia (Jkn): A Country Assessment Report, Copyright © 2018, Joint Learning Network for Universal Health Coverage, Bill & Melinda Gates Foundation, Results for Development.

For questions or inquiries about this report or other JLN activities, please contact the JLN Coordinator Team at [email protected].

Contents

Preface .................................................................................................................................. 1

Introduction .......................................................................................................................... 3

Country Overview ........................................................................................................................ 3

The Health Sector ......................................................................................................................... 3

Health Benefits Policy Objectives .......................................................................................... 9

Health Benefits Policy Priorities ................................................................................................. 16

Formulation of the PHC Benefits Package ........................................................................... 19

Analysis of the JKN’s PHC Benefits Package ................................................................................ 19

Engagement with the Six Implementation Domains .......................................................... 25

Financing: Mobilizing and Pooling Resources ............................................................................. 25

Financing: Payment Mechanisms ............................................................................................... 26

Supply-side Strengthening .......................................................................................................... 27

Accountability Mechanisms........................................................................................................ 28

Protocols and Pathways ............................................................................................................. 29

Generating Demand ................................................................................................................... 30

Summary .................................................................................................................................... 30

Conclusions ......................................................................................................................... 32

References ........................................................................................................................... 33

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PREFACE

Many low- and middle-income countries are strengthening access to high-quality primary

health care (PHC) services as part of a move toward universal health coverage (UHC). A key

step in this process is defining a PHC benefits package. A health benefits package is the set

of health or medical services that beneficiaries are entitled to. Health planners must think

about more than just the package itself, however. They must find ways to orient the entire

health system to improve beneficiary access to PHC services. The policies that facilitate the

development or reform of the benefits package are known as health benefits policies.

In 2016, a group of committed country practitioners in the JLN PHC Initiative joined together

to share knowledge on how to create effective health benefits policies as well as to address

the lack of international guidance in this area. These practitioners formed the JLN Health

Benefits Policy (HBP) Collaborative and began sharing experiences and compiling practical

advice for use by other low- and middle-income countries. As part of this effort, six

countries—Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam—conducted

assessments to evaluate their own efforts to implement a new or revised benefits package

within a comprehensive health benefits policy.

The countries each conducted a document review using secondary data sources and

collected primary data through in-depth interviews and focus groups involving national and

subnational government entities (ministries of health, health financing agencies, regional

health directors, and government-owned providers), professional associations, and private-

sector providers.

The countries used the PHC Benefits Policy Framework developed by the collaborative to

assess their PHC benefits package and overall health benefits policies. (See Figure 1.) At the

center of the framework is the benefits package. The choice of services to include in the

package is the common starting point for countries that want to improve access to PHC

services. The outermost circle shows the objectives commonly stated by policymakers for

PHC-oriented reforms. The inner circle lays out the complementary policy domains that

enable implementation of the benefits package to advance PHC objectives.

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Figure 1: PHC Benefits Pol icy Framework

This report documents Indonesia’s experience in implementing the PHC health benefits

package within the Jaminan Kesehatan Nasional (JKN) scheme.

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INTRODUCTION

Indonesia has been reforming its health sector since 1992 and has implemented a universal

health coverage (UHC) scheme called Jaminan Kesehatan Nasional (JKN). This report looks at

JKN’s health benefits policy design for primary health care (PHC) at primary-level health

facilities from 2014 to 2017.

Country Overview

Indonesia is the largest archipelago in the world, with an estimated 17,504 islands; it is the

14th largest country by area, at 1,990,250 square kilometers. Its population is highly diverse,

with hundreds of ethnic groups, cultures, and languages spoken. Indonesia’s national motto

is “Unity in Diversity,” which is reflected in its efforts to achieve UHC through the JKN

scheme.

The Indonesian health system has a mix of public and private providers and public and

private financing. The health care delivery system has three interconnected tiers: primary,

secondary, and tertiary. When a patient needs care beyond the primary level, the primary-

level health facility refers the patient to a secondary or tertiary provider (such as a specialist

or a hospital).

The Health Sector

Indonesia’s health care reforms began with Health Act #23 in 1992, which integrated

financing and services into a managed care system called Jaminan Pemeliharaan Kesehatan

Masyarakat (JPKM). This system mandated a comprehensive health benefits package

spanning primary care through hospitalization. Two government institutions implemented

the health insurance program that year: PT Askes for civil servants, their families, and civil

service retirees (covering about 13 million people) and PT Jamsostek for the formal-sector

workforce (covering about 2 million people). Other private-sector insurance covered about

1 million people. Jamsostek provided a coverage floor; formal-sector companies could

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purchase private plans with a more expansive benefits package.1 All health plans were

encouraged to incorporate JPKM’s managed care system in their operations.

JPKM grew to cover almost 27 districts/cities and five provinces. But it was criticized—

particularly by experts, academics, and some community organizations—for not adequately

regulating private-sector providers and ensuring the quality of their services. Other critics

noted that JPKM did not significantly increase health coverage because membership was

voluntary. By 1997, health coverage eligibility was about 25 million, or about 10% of the

population, while enrollment was at about 17 million.

In 1998, Indonesia experienced an economic crisis that led to a decline in the use of health

facilities, particularly primary care facilities. In response, the government implemented a

health safety net for the poor—Jaring Pengaman Sosial Bidang Kesehatan (JPS-BK)—with

support from the Asian Development Bank, the World Bank, and, in some pilot areas (24

districts/cities), Jaminan Pemeliharaan Kesehatan Keluarga Miskin, JPK-Gakin, a district-level

financed coverage scheme. After the crisis ended, the program continued to be supported

by the national government and local governments. The national funding came from the Oil

Subsidy Reduction Program, which decreased subsidies for fuel and shifted them to health.

Districts and provinces developed their own locally funded health insurance plan, called

Jaminan Pemeliharaan Kesehatan Daerah (Jamkesda), which typically covered lower-income

groups that lacked adequate access to health care.

The next health care reform occurred in 2004, with a constitutional amendment and

National Social Security System (SJSN) Act #40, which unified the health system, extended

coverage, and implemented compulsory membership2 through social insurance. This

extended health coverage to up to 60 million people through the Asuransi Kesehatan

Keluarga Miskin (Askeskin) program. In 2008, the government increased funding for the

program, allowing for enrollment of up to 76.4 million people, and renamed it Jaminan

Pemeliharaan Kesehatan Masyarakat (Jamkesmas). In January 2011, the government

launched Jaminan Persalinan (Jampersal), which guaranteed maternity care—including

delivery, prenatal care, and postpartum care at public facilities for lower-income families.

1 Jamsostek Act #3 of 1992 2 While insurance coverage is compulsory, no penalties are imposed on the uninsured.

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Meanwhile, the health coverage of other plans also increased, bringing total coverage to

132.6 million, or 55% of the population, by 2010.

Indonesia’s health care system remained fragmented, however, with different agencies

offering different benefits packages. In 2014, all of the plans were consolidated under a

single payer, BPJS Kesehatan (BPJS-K).

This reform was implemented under the newly elected president, Joko Widodo, after the

launch of JKN. The JKN law stipulated that all government-sponsored insurance plans—

Jamkesmas, Jamkesda, Jampersal, Askes, and Jamsostek—be administered by BPJS-K, which

would be directly answerable to the president. For an overview of the Indonesian health

system and demographic make up please refer to Table 1. The law guaranteed basic health

protection to everyone who paid their contributions or had their fees paid by the

government. The government defined the JKN benefits package to be comprehensive and

includes primary, secondary, and tertiary levels of services. (See Figure 2.)

Figure 2. JKN Design

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Table 1. Demographic and Health Indicators

Indicator Measure Source(s)

Per capita income

GDP per capita US$3,605

Local currency: 47,096,000 IDR

databoks.katadata.co.id/datapublish/2017/02/06/2016-pendapatan-perkapita-indonesia-tumbuh-625-persen

Total population 261,890,900 Indonesia Centre Statistics Body (www.bps.go.id/)

Dependency ratio 48.6 Indonesia Centre Statistics Body (www.bps.go.id/)

Urban population 53.3%

National Planning, Central Statistics, and UNFPA. Indonesia Population Projection, 2013.

www.bappenas.go.id/files/5413/9148/4109/Proyeksi_Penduduk_Indonesia_2010-2035.pdf

Poverty rate 10.22% www.bps.go.id/LinkTableDinamis/view/id/1119 (accessed January 18, 2018)

Infant mortality rate 22.23 per 1,000 births Directorate of Family Health Annual Report, 20153

Maternal mortality ratio 305 per 100,000 births Directorate of Family Health Annual Report, 2015

3 kesga.kemkes.go.id/images/pedoman/Laptah%20TA%202016%20Dit%20Kesga.pdf

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Top three illnesses that create demand for health services

Heart disease

Stroke

Diabetes mellitus

ylki.or.id/2017/12/pola-konsumsi-dan-biaya-kesehatan/ (cited by the MOH and BPJS-K)

GDP growth rate (past 5 years for which data are available)

6.0% (2012)

5.6% (2013)

5.0% (2014)

4.9% (2015)

5.0% (2016)

World Bank Data: data.worldbank.org/indicator/NY.GDP.MKTP.KD.ZG?locations=ID

Total health expenditure (THE) per capita

US$380 (2014)

Local currency: 1,498.10 IDR (2014)

Centre for Health Financing and Insurance, MOH. The Report of Indonesia—National Health Account 2005–2014.

THE as a share of GDP 3.6% of GDP (2014)


General government health expenditure as a share of THE

41.2%

Centre for Health Financing and Insurance, MOH. The Report of Indonesia—National Health Account 2005–2014

Private expenditure on health as a share of THE

58.6%


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Out-of-pocket expenditure as a share of THE

45.3% (2014)


Percentage of the population with coverage for essential health services

71.78%

(187,982,949 people)

BPJS-K website, December 2017

bpjs-kesehatan.go.id/bpjs/ index.php/jumlahPeserta

Household expenditures on health as a share of total household expenditures

6% to 15% of nonfood expenses go toward outpatient care; 20% to 71% go towad inpatient care.

Almost 77% of people in urban and rural areas use more than 50% of their nonfood expenditures for inpatient care each month.

Mardiati Nadjib dan Pujiyanto. December 2002. “Household Expenditure Pattern for Health on Marginal Groups.” Makara Journal of Health Research 6, no. 2.

Degree of government decentralization

Indonesia has 34 provinces, which are further divided into 416 districts and 98 cities. Districts and cities are further subdivided into subdistricts, where health clinics (puskesmas) are located.

The public system is administered in line with the decentralized government system (with central, provincial, and district/city responsibilities).

Law No. 22/1999 on the autonomy of regional governments (districts and municipalities)

www.kompasiana.com/rizwanhamdi/otonomi-daerah-dan-pembangunan-kesehatan-di-indonesia_55002700a333112f7550fb54

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HEALTH BENEFITS POLICY OBJECTIVES

Table 2 describes the foundational documents and laws behind the JKN program, while

Table 3 describes how the law defined different functions within JKN.

Table 2. Foundational Documents of the Health Benef its Policy Reform

Document or Law Methodology Main Findings Source(s)

Constitution

SJSN Act

BPJS Act

Presidential regulations

MOH regulations

Each agency drafts additional regulations through consultation with external stakeholders (academics, experts, Parliament, government)

Everyone has the right to live physically and mentally prosperous, residence and got a good environment and healthy and receive medical care.

Amendment of Constitution Article 28H Paragraph 1

Competency standards for doctors

The standards were designed by a working group of the association of medical education institutions and the medical council

All general practitioners must be trained to manage 144 diagnoses.

Konsil Kedokteran Indonesia Regulation No. 11/2012)

Clinical Practice Guidelines for Doctors at Primary Health Facilities

Discussion with providers

Created the legal framework for the 144 diagnoses that all general practitioners must be trained to address.

MOH Regulation No. 5/2014

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Document or Law Methodology Main Findings Source(s)

List of benefits packages

Discussion and brainstorming

Benefits packages for capitation and noncapitation payment

MOH Regulation 71/2013

bpjs-kesehatan.go.id/bpjs/ index.php/post/read/2014/77/Dana-Kapitasi-BPJS-Kesehatan-

Management and use of capitation funds

Discussion and brainstorming

At least 60% of the capitation funds must be used for staff salaries; the rest can be used for operational costs

Presidential Regulation No. 32/2014

Table 3. JKN Functions and Associated Regulations

JKN Function MOH Regulation

Preparation of JKN activities MOH Decree 36/2013

Standard fees for primary-level health facilities and specialty care


JKN health services MOH Regulation 71/2013

Use of JKN capitation for services and operations in primary care facilities operated by local governments


Guidelines for Indonesian Case Based Groups (INA-CBGs)4


JKN implementation guidelines MOH Regulation 28/2014

4 A bundled payment for all hospital inpatient stays and outpatient visits for certain medical diagnoses.

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JKN Function MOH Regulation

Capacity management of primary-level health facilities owned by local governments


National tariff or payment rates for hospital services

MOH regulation 59/2014

Outlines the physician associations that advocate for primary care providers that deliverJKN5 services


Fraud prevention MOH Regulation 99/2015

Table 4 describes studies that have evaluated JKN implementation.

Table 4. Monitor ing and Evaluation Studies

Research Study Methodology Main Findings Source(s)

Study analyzing referral pathways for JKN enrollees in Bogor City in 2014

Quantitative study with cross-sectional design using secondary data from BPJS-K

Facilities with low staffing are likely to refer patients who are diagnosed with one of the 144 diagnoses that general practioners are required to treat.

Related factors to referral cases of BPJS Kesehatan participants at primary health care of Bogor City in 2014 lib.ui.ac.id/detail?id=20412030&lokasi=lokal

5 Appointed associations are medical associations that have been put in charge of negotiating rates and contracts with BPJS-K, disseminating contractual agreements to medical association members, and determining credentialing standards.

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Study of asymmetric supply and demand for doctors at puskesmas in Bandung City 2015

Descriptive

Asymmetric supply and demand for PHC doctors is due to reasons such as dissatisfaction with the capitation payment system and heavy workloads.

Setiawati, E, et al. 2017. “Asymmetric Supply and Demand for Distribution of Medical Doctors in Primary Health Care in West Java. Global Medical and Health Communication Journal 5, No 1, 39–46.

Analysis of the misalignment between national health referral standards and realities on the ground

Observational research and cross-sectional design using qualitative evaluation methods\

JKN implementation aligns with the Guidelines on National Health Referrals, but informed consent is poorly implemented and communication between patients and the referral provider is poor.

Ratnasari, D. 2017. “Analysis of the Implementation of Tiered Referral System for Participants of National Health Security at Primary Health Centre X of Surabaya” Indonesian Journal of Health Administration 5, 145–54.

e-journal.unair.ac.id /JAKI/article/view/4642

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Monitoring and evaluation of JKN; study of capitation fund management and utilization (2015)

Quantitative and qualitative study of 384 randomly selected PHC facilities in seven regions and 20 districts.

Most private PHC facilities have experienced budget deficits. Although an increase in overall income from capitation funds was observed in the majority of PHC facilities, patient utilization increased at a higher rate, leading to lower actual capitation income.

Kurniawan, F. and E.K. Budi. 2016. “Capitation Fund Management and Utilization.” Jurnal Kebijakan Kesehatan Indonesia 5, No. 3, 122–31.

Analysis of PHC access issues

Formative analysis

The number of primary-level health facilities is insufficient to ensure effective JKN coverage. Access to health care is subject to geographical constraints, with beneficiaries increasingly living far away from health centers. Travel time averages 90 to 120 minutes, and transportation costs an average of IDR 200,000.

Yandrizal, Desri Suryani. 2015. “Case study of the government role in JKN primary health care in Bengkulu Province” Andalas Journal of Health 4, No. 1, 107–14. jurnal.fk.unand.ac.id/index.php/jka/article/view/208

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Contraceptive use and JKN

Secondary data analysis from the Intercensal Population Survey (2015)

A year after the introduction of JKN, the rate of contraceptive use (including long-term contraception) fell significantly compared to before JKN. Utilization of the BPJS-K health card for family planning services is still low.

Oesman, Hadriah. 2017. “The pattern of contraceptive use and utilization of BPJS-K card on family planning” Jurnal Kesehatan Reproduksi 8, No. 1, 15–29.

ejournal.litbang.depkes.go.id/index.php/kespro/issue/current

Study of patient experiences of using primary care services under UHC reforms

Examination of patient views on JKN implementation and factors that influence the decision to enroll

Participants acknowledged that while primary care clinics were conveniently located, access was often complicated by long wait times and short service hours. Participants expressed lower trust in primary care doctors than in hospital and specialist care.

Ekawati et al. 2017. “Patients’ Experience of Using Primary Care Services in the Context of Indonesian Universal Health Coverage Reforms.” Asia Pacific Family Medicine 16, No. 4.

doi.org/10.1186/s12930-017-0034-6

Implementation study on JKN policy in Makasar City, 2016

Qualitative study (observation, documentation, and interviews)

JKN targets are appropriate, but implementation through BPJS-K has not been completely successful.

journal.unhas.ac.id/index.php/jakpp/article/view/1023

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Meeting report N/A Capitation payment should be linked to provider quality measures.

kanalpengetahuan.fk.ugm.ac.id/the-2nd-indonesia-health-economic

DJSN (National Social Security Council nt) evaluation

Monitoring and evaluation

JKN policy faces eight challenges: identifying participants, referral services, human resources and facilities, emergency care criteria, admission categorization, perception of drug formularies, quality standards, and provider payment rates.

www.hukumonline.com/berita/baca/lt57bd0ba444be5/8-masalah-penghambat-jaminan-kesehatan-nasional

Service readiness at the primary care level

In-depth interviews, analysis

Staffing is still inadequate because of heavy workloads, incomplete infrastructure, and lack of access among general practitioners to medicines necessary to address the 144 diagnostic competencies.

Nur Maimun, Josua Tobing. 2016. “Case study evaluating the 144 General Practitioner Diagnostic Competencies at primary-level health facilities and the government-owned police clinic in Riau Province. 2016” Jurnal Maternity dan Neonatal 2, No. 2.

e-journal.upp.ac.id/index.php/akbd/article/view/1082

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Case study in two provinces in Jakarta and East Nusa Tenggara

Data from 309,301 BPJS-K claims

Patients diagnosed with end-stage renal disease, cardiovascular disease, cancer, thalassemia, and hemophilia are at risk for high out-of-pocket payments if they are not enrolled in JKN.

jurnalkesmas.ui.ac.id/jurnal-eki/article/download/1771/592

University of Gadjah Mada. JKN Evaluation conducted in 2016

Descriptive (cross-sectional)

Puskesmas and clinics need more staff and facilities to serve the minimum number of 5,000 to 10,000 JKN participants.

www.slideshare.net/InsanAdiwibowo1/monitoring-dan-evaluasi-program-jkn

Health Benefits Policy Priorities

Table 5 shows the priority levels assigned to the objectives of the HBP framework within the

JKN program.

Table 5. Health Benefits Pol icy Prior it ies

Health Objective Objective of the Reform? (Yes/No)

Priority Level (1 = lowest priority,

10 = highest priority)

Health outcomes Yes 8

Financial protection Yes 10

Quality Yes 8

Efficiency Yes 7

Equity Yes 7

Sustainability Yes 10

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Health Outcomes

JKN aims to guarantee health care to all Indonesian people so they can live healthy,

productive, and prosperous lives. JKN was officially launched by President Joko Widodo in

November 2014. The government intended to measure the impact of JKN after a decade of

implementation.

To support this vision, BPJS-K established its mission statement for 2016–2021 to improve

the quality of services, expand JKN membership to cover all Indonesian citizens, maintain

the sustainability of the JKN program, strengthen policy and implementation of JKN, and

strengthen organizational capacity and governance.

BPJS Health is strongly committed to improving health services for JKN participants,

especially at primary-level health facilities.

Financial Protection

The government is committed to paying JKN premiums for the poor so they do not face

financial barriers to accessing health services.

Quality

To improve quality, the Indonesian Medical Council issued Regulation No. 11/2012 to

require doctors to have 144 diagnostic competencies (a revision of Decree No. 21A/2006).

These are the services that the government wants delivered at the primary care level.

Within JKN, these 144 competencies represent the primary care component of the benefits

package. All medical students must be proficient in these competencies when they

graduate. To further improve quality, the Ministry of Health is overseeing the development

of clinical guidelines for primary care physicians and, jointly determining accreditation

standards in collaboration with BPJS-K for primary care facilities. By 2019, the government

expects that all puskesmas will have been accredited by BPJS-K.

Efficiency

To improve efficiency, JKN has worked to limit unnecessary referrals by improving the

capacity of primary care physicians to deliver the 144 services that are part of the PHC

benefits package. BPJS-K also encourages all parties to improve quality and efficiency and

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prevent fraud. The Corruption Eradication Commission, the Ministry of Health, and BPJS-K

collaborate on a Fraud Task Force Team.

Equity

Equity is a JKN objective. To improve access for poor families, the government created a

monitoring system to identify lower-income beneficiaries who are eligible for government

support and to ensure there is adequate access to primary care level services considering

the number of JKN beneficaries in each area. To improve access to PHC in remote areas, the

government developed a program called Nusantara Sehat that sends medical teams into

those areas.

Sustainability

Sustainability is ensured within JKN because JKN coverage is mandatory (through the

government or through formal-sector insurance). Parliament and the government are

committed to paying premiums for the poor. Formal-sector and government workers fund

JKN coverage through a payroll tax.

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FORMULATION OF THE PHC BENEFITS PACKAGE

JKN’s PHC benefits package includes 144 compentencies, which can include the following:

• Service administration

• Promotive and preventive services

• Medical examination, treatment, and consultation

• Non-specialist medical acts, both operative and non-operative

• Medical supplies and medical supplies

• Laboratory diagnostics

Noncapitation payment is paid based on the type and amount of health services provided,

including:

• Ambulance services

• Pharmaceutical prescriptions

• Investigation of referral services

• Certain health screening services, including cryotherapy services for cervical cancer

• First-line midwifery care and prenatal services performed by midwives or doctors,

according to their competence and authority

• Some family planning services

• Services provided in areas with no eligible health facilities

• Blood transfusions

• Emergency services at health facilities that do not contract with BPJS-K

Analysis of the JKN’s PHC Benefits Package

Primary-level health facilities can reduce referrals to advanced facilities and can develop

referral programs for BPJS-K participants who have chronic conditions but are otherwise

healthy. Table 6 outlines the beneficiaries who are entitled to the JKN benefits package.

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Table 6. Target Benef iciaries

Target Group or Population Rationale Source(s)

JKN targets the entire population, especially the poor (with a goal of achieving UHC by 2019).

According to the CEO of BPJS-K, at the end of 2017 about 73% of the population was covered by JKN, with about 92.4 million people eligible for government premium support. Meanwhile, 71 million Indonesians were not covered.

DJSN, the Road Map to Universal Health Coverage

The Jamkesda program in 416 districts and 98 cities should be integrated into JKN.

As of August 2015, 13 provinces and 270 districts/cities that used Jamkesda (local insurance) were integrated into the national insurance managed by BPJS-K. A total of 10,657,038 people (7.2% of JKN participants) were Jamkesda enrollees.

DJSN report

Presidential Decree 8/2017 and Presidential Instruction 8/2017 regarding optimization of JKN

Individuals with chronic diseases, specifically diabetes and hypertension.

Chronic diseases represent a large proportion of total health spending.

BPJS-K

Table 7 lists the documents used to inform the benefits package, based on priority

conditions and Table 8 outlines the criteria for what services were included in the benefits

package.

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Table 7. Documents Used to Inform the PHC Benefits Package

Research Study Purpose of the Study

How the Study Results Were Used

in Designing the Benefits Package

Source(s)

Basic Health Research (Riskesdas)

2013

Mapping disease patterns.

Diabetes is the third most prevalent noncommunicable disease in Indonesia. About 12,191,564 people have Type 2 diabetes.

Diabetes is included in the PROLANIS program and the JKN PHC benefits package

Research and development body, MOH; 2013.

Wellness program participation and impact on health outcomes

Measuring the relationship between adherence to PROLANIS procedures and blood sugar stability in diabetic patients.

Compliance with PROLANIS is correlated with blood sugar stability.

Primahuda, Aditya, and Untung Sujianto. 2016. “Relationship between compliance with the BPJS-K PROLANIS program and stability of blood sugar for diabetes patients in puskesmas in the Lamongan District” Jurnal Jurusan Keperawatan, 1–8.

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Research Study Purpose of the Study

How the Study Results Were Used

in Designing the Benefits Package

Source(s)

Relationship between PROLANIS activities and HbA1c levels.

The correlation between the level of compliance with PROLANIS measures for Type 2 diabetes and HbA1C levels is significant.

HbA1c will be used as an indicator within the PROLANIS program.

Syuadzah, R. 2015. “Hubungan antara Tingkat Kepatuhan Mengikuti Kegiatan Prolanis pada Pasien Diabetes Mellitus Tipe 2 dengan Kadar HbA1C.” digilib.uns.ac.id/dokumen/detail/50282/

Strengthening PHC services

N/A N/A

bpjs-kesehatan.go.id/bpjs/index.php/post/read/2014/278/

Table 8. Criter ia for Determining Included Services

Criterion Used? (Yes/No)

Ranking 1 = top criterion (use for

only one) 2 = secondary

(can use multiple times) 3 = also considered

(can use multiple times)

Cost effectiveness Yes 2

Total cost Yes 1

Burden of disease Yes 1

Fiscal/budget impact Yes 1

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Consumer preferences No 3

Financial protection Yes 3

Reduce out-of-pocket spending Yes 2

Focus on prevention Yes 1

Political or legal mandate to include specific services

Yes 1

The participants in the process of outlining the PHC benefits package are listed in Table 9.

Table 9. PHC Benefits Package Design Participants

Participant Major Activities Role

Ministry of Health

The MOH regulates JKN. It takes initiative for the JKN PHC benefits package and consults with relevant institutions on: • Developing practice guidelines for medical doctors

and clinical practices • Reviewing benefits packages and premiums • Performing health technologies assessments

Workshop

BPJS-K (SJSN 40/2004,BPJS 24/2011)

For JKN:

• Conducting and/or receiving registration of

participants

• Collecting contributions from participants and

employers

• Receiving donations from the government

• Managing social security funds for the benefit of

participants

• Collecting and managing data on social security

participants

• Paying benefits and/or financing health services in

accordance with the provisions of the social security

programs

• Providing information on the implementation of

social security programs to participants and

communities

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Participant Major Activities Role

DJSN (SJSN law 40/2004)

The DJSN (social security committee) formulates general policies and synchronizes the SJSN (national social security system), including: • Conducting research related to the implementation

of social security • Proposing investment policies for the National Social

Security Fund • Proposing the social security budget for beneficiaries

and the availability of operational budget to the government

Workshop, study

Professional medical associations

Medical associations that provide input on the benefits package: Indonesia Medical Association Family Doctors Association, Association of Clinical Practice Indonesia, Indonesia Midwives Association, Indonesia Nurses Association, Indonesia Hospital Association.

Workshop and drafting

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ENGAGEMENT WITH THE SIX IMPLEMENTATION DOMAINS

This section describes how the health policy environment facilitates implementation of the

JKN package. It is organized according to the six policy domains identified in the Health

Benefits Policy Framework:

• Financing: Mobilizing and Pooling Resources

• Financing: Payment Mechanisms

• Supply-side Strengthening

• Generating Demand

• Protocols and Pathways

• Accountability Mechanisms

Financing: Mobilizing and Pooling Resources

To achieve UHC, BPJS-K has worked closely with local governments. Law No. 22/1999 gave

local governments a greater role in administering health care. Law No. 36/2009 requires

local governments to allocate 10% of their budget for the health sector to cover community

public health programs and maintenance of public health facilities. (Allocation from the

central budget is 5%.) The Minister of Home Affairs has instructed local governments to

implement the JKN program, including integrating the Jamkesda program into JKN. Article

67 of Law 23/2014 on Regional Government calls for regional heads and deputy regional

heads to comply with the national standards on for JKN services. Not all districts and

provinces track their health spending. Many districts and municipalities have developed

local health financing systems in order to lpromote community level access for health

services.

Studies have shown that 15 provinces (45%) self-regulate benefits through local regulations;

only 18 provinces (54%) use the JKN benefits package. There are two reasons why some

local governments implement their own health benefits package: 1) they have uninsured

populations that cannot afford to pay JKN premiums but are not eligible for central

government support, and 2) they are more capable than the central government of

providing a benefits package. A total of 37.5% of districts offer a benefits package that is

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smaller than the JKN package for individuals who are not eligible for central government

support but are unable to afford JKN. Seven districts/cities (2.9%) provide additional

services on top of JKN; these regions are able to mobilize additional funding for the added

benefits.

Other research shows that districts with greater financial resources are 1.92 times more

likely to provide Jamkesda benefits, as appropriate, and they offer more Jamkesmas

benefits compared to districts with fewer resources.

As of January 2017, BPJS-K recorded that 433 districts or local governments had integrated

the Jamkesda program into the JKN program. Their support includes financing, membership,

, and development of health service infrastructure.

To further increase the amount of revenue available for JKN, the Ministry of Health has

revised MOH Decree 40/2016 as MOH Decree 53/2017. It includes technical guidance on

using cigarette taxes for health; 75% of the fund is to be used for JKN, including the PHC

benefits package.

Financing: Payment Mechanisms

The JKN PHC benefits package is implemented by primary-level health facilities—local

government-owned puskesmas, central government–owned health facilities (including

some public clinics and all primary class D hospitals), and private practices (individual

physician practices, individual dentist practices, and clinics). Puskesmas are required to

provide JKN benefits, while private providers can voluntarily contract with BPJS-K to provide

JKN benefits. JKN’s prospective payment systems use capitation for primary care at primary-

level facilities and INA-CBGs for advanced-level services (clinic specialists and hospitals). The

INA-CBG system makes a bundled payment that covers an entire inpatient stay or

outpatient visit. The package rates are calculated based on cost data from departments

within various hospitals in Indonesia (government and private).

Capitation is a monthly payment based on the number of enrollees in primary-level

facilities, without regard for the type or amount of health services provided. Standard

capitation rates are 300,000 to 600,000 IDR (about US$.22 to US$.43) per participant per

month. The rate for private providers is 800,000 to 1,000,000 IDR (about US$.58 to US$.72)

(for remote areas and islands) and 2,000 IDR (about US$.14) for individual practice dentists.

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Performance-Based Capitation

BPJS-K implements commitment-based service contracts with primary-level providers (such

as puskesmas, pratama clinics6 and individual-practice physicians) and aims to improve

service performance at that level. The performance-based capitated payment for PHC is

linked to three facility-level indicators. If a facility fails to meet a benchmark for an indicator,

the capitated payment is lowered by a set amount. The total capitated payment and the

performance penalty are reviewed every two years. A total of 33 provinces have

implemented performance-based capitation in 960 puskesmas.

The indicators include:

• Contact rate—the number of times a physician has contact with enrollees in the facility’s catchment area. The number of contacts must exceed 135 to 150 contacts per 1,000 JKN enrollees.

• Nonspecialist referral rate—the proportion of referrals to specialists that are for a primary care diagnosis.7 A facility’s referral rate must be lower than 5% of total primary care patients.

• PROLANIS measures—the proportion of individuals with hypertension or diabetes who participate in a facility’s fitness and wellness club and have regular home or office visits. A facility must have more than 50% participation among patients with these chronic conditions.

The capitated payment structure has some issues. Even though BPJS-K pays capitation

directly to the puskesmas, the puskesmas are not allowed to use the funds without

authorization from district health offices. This lack of budgetary autonomy makes it difficult

for providers to properly invest in their facilities and their workforce, leading to high rates of

patient referrals to hospitals.

Supply-side Strengthening

Health facilities must be credentialed in order to work with BPJS-K. This ensures their ability

to provide effective and efficient health services based on objective standards. The Ministry

6 Pratama clinics are facilities that offer basic health services. 7 One of the 144 general practitioner competencies.

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of Health and BPJS-K have enlisted professional organizations and local governments to

conduct the credentialing process, which can take four to five months.

Indonesia’s population was projected to reach 252,286,647 by 2016. To reach have one

clinic per 10,000 people, it would need about 25,228 PHC providers. By September 8, 2017,

the number of JKN participants reached 181,210,694, and BPJS-K was working with 21,095

primary-level health facilities (9,841 puskesmas, 4,586 individual practice physicians, 5,495

pratama clinics, 13 Type D hospitals,8 and 1,160 individual practice dentists). BPJS Health

also partnered with 5,566 Advanced Health Referral Facilities (2,227 type A, B, and C

hospitals and clinics, 2,332 pharmacies, and 1,007 opticians). But the total number of clinics

did not meet the predicted need.

Since Indonesia is an archipelago, most Indonesians lack access to health facilities because

of geographic limitations. Many families live on remote islands and are unable to receive

basic primary care. To solve this problem, the Ministry of Health implemented the Health

Nusantara (Nusantara Sehat) program, which sends teams of health professionals to

isolated areas.

Accountability Mechanisms

In the era of JKN, a tiered system of referrals has been implemented. BPJS Health creates

some accountability through performance-based capitation payment—specifically, tying

capitation payments to referral rates. JKN beneficiaries are not allowed to go directly to the

hospital or to an advanced health facility except for a medical emergency.

All primary-level facilities are required to report to BJPS-K each month using Indonesia’s PHC

electronic health record system, P-care.

The Corruption Eradication Commission, the Ministry of Health, and BPJS-K formed a joint

fraud management team within the JKN program to help detect fraud and creating a

mechanism for routine audits.

8 Type D hospitals offer only the most basic inpatient services.

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Protocols and Pathways

Protocols and pathways consist of the medical guidelines for primary-level health facility

services, including guidelines for physicians, facility accreditation, public health services,

PROLANIS measures, and referrals.

These protocols listed below are intended to improve the quality of the JKN PHC benefits

package.

Accreditation of puskesmas, physician private practices, dentist private practices, and clinics


Clinical practices of physicians in primary-level health facilities

MOH Decree 514/2015

Management of puskesmas MOH Decree 44/2016

National and regional referrals Reinforcement of regional and national response of MOH Decree 390/2014 and MOH Decree 391/2014

PROLANIS measures BPJS-K:

www.bpjs-kesehatan.go.id/bpjs/dmdocuments/06-PROLANIS.pdf

Indonesia has improved its health IT system through P-care. BPJS-K has a special reporting

system for primary-level health facilities so they can access data on BPJS-K servers to

improve patient care management. P-care has been continuously improved since its

introduction in 2014. BPJS-K has created additional functionality to improve data access for

puskesmas. P-care enables better coordination of care and tracking of patient records.

PROLANIS Measures

One of Indonesia’s innovations in the realm of improving protocols and pathways is the

PROLANIS program. Through the capitation system, primary-level health facilities must

provide promotive and preventive services as well as treatment to JKN participants. BPJS-K

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developed a program for chronic diseases called PROLANIS, which is administered by

providers to diabetic and hypertensive beneficiaries in the community.

PROLANIS encourages people with chronic illnesses to improve their quality of life. Among

registered BJPS Health participants visiting first-level facilities, 75% had a “good” outcome in

managing Type 2 diabetes and hypertension.

Each primary-level health facility manages its own PROLANIS program. The Ministry of

Health is promoting a related community-based effort to promote healthy living (GERMAS)

and a Healthy Indonesia program.

Generating Demand

JKN uses many kinds of media to expand its reach. Local governments are indispensable in

this effort. A good example of local government involvement is the Annual Jamboree—

which is a large meet-up group with PROLANIS beneficiaries, which began in August 2014 in

Batam District. This event is an effort to improve primary-level health facility competence

and understanding of JKN. By April 2017, the PROLANIS program had 302,325 diabetes

patients and 334,979 hypertension patients enrolled. Studies have shown that enrollment

and use of JKN has continued to increase. Between 2014 and 2016, JKN visits increased from

92 million visits to 192 million visits.9

Summary

Table 10 summarizes the domains of JKN implementation and the findings in those areas.

Table 10. F indings by Subdomain

Domain Findings

Financing: Mobilizing and Pooling Resources

Funding for JKN comes from central government budget for former Jamkesmas enrolees, payroll taxes, local government, community-based resources, and contributiosn from voluntary enrolees. .

9 bpjs-kesehatan.go.id/bpjs/index.php/post/read/2017/535/Manfaat-Program-JKN-KIS-Makin-Luas

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Domain Findings

Financing: Payment Mechanisms

Performance-based capitation is used for some PHC services; noncapitation payment is used for specific services such as vaginal delivery and government procurement of pharmaceuticals through the national formulary.

Supply-side Strengthening

Professional organizations offer training, internships, site visits, credentialing (with local government), and private-sector engagement.

Accountability Mechanisms

Mechanisms include 144 general practitioner competencies for PHC services. Measurement and evaluation are the responsibility of the MOH and BPJS-K, with the involvement of professional associations and local governments.

Protocols and Pathways

Medical guidelines increase quality of care with the involvement of private providers, professional associations, and local governments. The Pcare system helps improve protocols and pathways of service delivery.

Generating Demand

All kinds of media (electronic media, mass media) are used to expand the reach of JKN. Local governments are indispensable in promoting JKN; one example of such promotion is the Annual Jamboree for PROLANIS.

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CONCLUSIONS

Indonesia has taken a long route to an integrated benefits package for its population. All

Indonesians have access to the same benefits packages; the poor have government

subsidized premiums, while the non-poor pay the full premium.

The central and local governments are working together to achieve UHC with JKN. Indonesia

began piloting the concept of UHC for the poor in some districts in 1998, with the

involvement of local governments. It provided guidelines and training to equip local

governments to define local benefits packages that are compatible with their own

resources.

Promotive and preventive efforts such as PROLANIS are the most important ways to make

benefits package use more efficient and effective. To reach populations living in remote

areas, the central government developed a program called Nusantara Sehat, which sends

medical teams to care for local populations.

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REFERENCES

Alfiana, Fuzna. “Related Factors to Referral Cases of BPJS Kesehatan Participants at Primary Health Care of Bogor City in 2014.” 2015. lib.ui.ac.id/detail?id=20412030&lokasi=lokal Ekawati et al. 2017. Asia Pacific Family Medicine 16, No. 4. ISSN: 1447-056X doi.org/10.1186/s12930-017-0034-6 Lagomarsino G., A. Garabrant, A. Adyas, et al. ”Moving Towards Universal Health Coverage: Health Insurance Reforms in Nine Developing Countries in Africa and Asia.” 2012. Lancet 380, 933–43. Nur Maimun, Josua Tobing. 2016. Jurnal Maternity dan Neonatal 2, No. 2 e-journal.upp.ac.id/index.php/akbd/article/view/1082 Oesman, Hadriah. 2017. Jurnal Kesehatan Reproduksi 8 No. 1, 15–29. ejournal.litbang.depkes.go.id/index.php/kespro/issue/current Yandrizal, Desri Suryani. Andalas Journal of Health 4, No. 1, 107–14. ISSN:2301-7406. jurnal.fk.unand.ac.id/index.php/jka/article/view/208