Nowadays, Indonesia has a mix system. There is social health insurance through PT. ASKES for civil servant and PT. JAMSOSTEK for employee. Tax based system for the poor through JAMKESMAS –National level- and JAMKESDA –Province/ District level- like Medicaid in United States. And there is small share of private health insurance in Indonesia. Even though, Indonesia has prepared a major reform of the health insurance system. Health insurance will be centralized into and called BPJS 1 as an insurance carrier in 2014. It is a big challenge because they have to merge all health insurance exist –except private health insurance-.
Here the figure of population shared of health insurance coverage from 60% total population Indonesia:
Source: SJSN Road map presentation
The advantages of social health insurance which already run by PT. ASKES is a certainty premium by civil servants. And with centralized management, it is more efficient in terms of administration process and not much problems in terms of portability.
There are weaknesses of Social health insurance through PT. ASKES. Most of the problems are in premium issue. Employee’s basic salary is considered quite low. This leads to lace the premium received. Since the calculation of premiums based on basic salary, instead of take home pay. Another problem is, the increasing of basic salaries of civil servants are not always follow the changes in health care costs or services user fee for health and medicine. And there is no regular or determined period of salary increase which led to uncertainty predictions of premium income.
PT JAMSOSTEK as a company to protect the health workforce has been started since 1992. This program is mandatory for all employers who have 10 employees or more, or pay more than 1 million per month (take home pay). The premium regulations are 3% for single and 6% for workers who have been married.
Weakness of this system is the opt out option. These opportunities made company tend to not apply health insurance through JAMSOSTEK or else. In addition, since the companies have an obligation to pay premiums, while not the labor thus led to lack of sense belonging. And more importantly, the complexity of management due to high labor mutations, either because of changing jobs, changing status, addition or subtraction of a family member which requires adequate information system.
JAMEKSMAS and JAMKESDA is a huge breakthrough health insurance program in Indonesia. Within a relatively short time, the government can protect the all poor and near poor people. And some of the provinces already cover all its population. And with budget constraints, Central government is able to provide a comprehensive benefit without any cost sharing from the participants. JAMKESMAS has used the DRG system for hospital payment rates and service levels first capitation payment (PHC).
On the other hand, JAMKESMAS and JAMKESDA have not set the insurance premium rate on actuarial basis. The premium is only based on rough calculation by a team tasked to manage the scheme. They use average of utilization rate of visit to Puskesmas and Hospital. In other words, everything based on the judgment of the team. Since it is really hard to collect the premium although in terms of amount is relatively small, most of JAMKESDA prefer to simply provide a subsidy. Thus makes the insurance financing depends on capacity and commitment of government. The budget allocation in the central and local budget for the health sector. 1
There are key factors of a success health insurance by all kind various systems, they are:
- The support of employers and labor organizations who can understand that the health insurance program will eventually be beneficial to increase their productivity.
- Benefits provided are adequate and sufficient quantity and quality. Therefore it is costly medical services must be guaranteed, while the cheaper services benefit may be reduced or cost sharing applied.
- Amount of premium shall be sufficient to fund benefits are provided (adequate).
- The implementation is done by a professional, transparent, clean and responsible. Participants are entitled to accurate information about the organization, the amount of premium collected and the amount of funds spent on service and management costs…
- Political and economic stability.
- The existence of strong government support which ensures all stakeholders fulfill their obligations. So that participants and employers do not worry if health care costs increase and BPJS bankrupt. 2
1. Gani A, Thabrany H, Pujianto, Yanuar F, Tachman T, Siregar A, et al. Report on Assesment of Health Financing System in Selected Districts and Municipalities. Jakarta: Australia Indonesia Partnership2008.