Download Indonesia: Approaches to covering poor, vulnerable, and informal

Indonesia: Approaches to covering poor, vulnerable, and informal populations to achieve
universal health coverage
Background on Scheme and Reforms
History: Indonesia introduced the first phase of its mandatory public health
insurance scheme, Askeskin, in 2004. In 2008, Askeskin evolved into Jaminan
Kesehatan Masyarakat, or Jamkesmas, a Ministry of Health (MoH)-run
“insurance” program which now covers over 76.4 million poor Indonesians. In
2014, the Government of Indonesia (GOI) initiated a social security reform
process to consolidate its existing health insurance schemes into a single
scheme, called Jaminan Kesehatan Nasional program (JKN) which is managed
by Badan Penyelenggara Jaminan Sosial (BPJS Kesehatan). Indonesia faces an
ambitious target to implement and scale JKN to achieve universal health
coverage (UHC) by 2019. BPJS Kesehatan has a staged plan for enrollment
according to the National Health Security Road Map. They will begin enrolling
the formal sector first, followed by organized groups, the poor and near-poor,
and lastly the informal sector. The priority in the first year of JKN is to merge
existing health insurance programs run by the government: Jamkesmas,
Jamkesda, Jamsostek, Askes Sosial, ASABRI. These programs roughly represent
the bottom 36% and the top-to-middle 11% of the population.
Governance: Presently, four main actors are involved in the administration
and governance of the BPJS scheme (1) the National Social Security Council
(DJSN), (2) national government agencies, including Depkes (MoH), the
Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of
Social Affairs (Menkokesra), and the Ministry of National Development
Planning (Bappenas), (3) provincial and district governments, (4) BPJS
Kesehatan, the administrator of membership for JKN.
Background Country Data
Total Population
(millions)
Life Expectancy at birth
(years, both sexes)
Infant Mortality
(per 1,000 births)
Maternal Mortality
(per 100,000 births)
249.9
70.6
25
190
Hospital beds
0.9
(per 1,000 people)
Public health expenditure
39.0
(% of total health
expenditure)
Total health expenditure
3.1
(% GDP)
OOP health expenditure
45.8
(% of total expenditure)
Poverty headcount ratio
16.2
at $1.25 a day (% of
population)
GDP per capita
3,475.2
(current USD)
Source: World Development Indicators,
accessed March 2015
Financing: BPJS is funded by general tax revenue from the national and local governments, employee contributions for
formal sector workers, and premium contributions from self-employed populations.
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Program Overview :
Jaminan Kesehatan Nasional
Year launched
Stage
Place of Operation
2014
Scale-up
National
Eligible Members
Entire population
Financing
Government revenue; employer and employee-based contributions
Unit of Enrollment
Family
Implementing Partners
and Roles
BPJS Kesehatan: Administrator of membership.
The National Social Security Council (DJSN)
National government agencies, including Depkes (MoH), The Ministry of Finance (MoF); Ministry of Home Affairs
(MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas)
Provincial and district governments:
BPJS Kesehatan: Overview of Membership Categories
Membership
Category
Employee:
government /
private
sector*
(Mandatory)
Eligibility Criteria
Contribution
Benefits
Providers
Federal and
private sector
employees (e.g.
civil servants,
entrepreneurs,
military officials,
police)
Salary deduction.
Government: 3% paid by
the employer, 2% by the
employees; Private sector:
4% paid by the employer,
0,5% by the employee
Out/inpatient;
designed to
be
comprehen
sive
Self-employed
Members
(Mandatory)
Non-poor selfemployed, also
referred to as
non-salaried
workers
Monthly premium paid by
member:
Class I: Rp25,500/ 1.96USD
Class II: Rp42,500/ 3.70USD
Class III: Rp59,500/ 5.17USD
Out/inpatient;
designed
to be
comprehe
nsive
Subsidized
Members
(Mandatory)
Poor and nearpoor classified
by Ministry of
Social Affairs
Monthly contribution
amount of Rp 19,225 ($2)
paid by central government
Out/inpatient;
designed
to be
comprehe
nsive
Public /
select
private
facilities.
Health
facility
options
depend on
premium
level paid
Public /
select
private
facilities.
Health
facility
options
depend on
premium
level paid
Public /
select
private
facilities
Identification
Mechanism
Data
migration of
former
members of
JAMSOSTEK
(e.g. army,
police, civil
servant)
Enrollment
Mechanism
Online enrollment ;
data transfer for
government
employees
previously enrolled
in JAMSTOTEK
Selfidentification.
Processes to
identify the
informal
sector are
under
development
Online enrollment
and in-person
enrollment at
banks and offices
Leverages
lists of eligible
groups
identified
through
Ministry of
Social
Welfare
*Employee-based membership not described below because it does not serve poor or vulnerable populations
For the poor: local
government
identifies and
enrolls populations
and pays
contribution to
subsidize coverage.
BPJS Kesehatan: Eligibility, Identification, Enrollment, and Monitoring
Eligibility
 Self-employed members: The definitions of the self-employed can be found in Presidential Decree No. 12/2013 and
government regulation no. 111 year 2013 article 4 no 3a. According to these definitions, the self-employed are
referred to as “non-salary workers,” and are defined as “those who work at their own risk” or "the workers who do
not receive any payment (no wages received).”
 Subsidized members: BPJS adopts the definition of the poor and near-poor used by the Indonesian Ministry of Social
Affairs. The poor and near-poor are classified as PBI (Penerima Bantuan Iuran), under which individuals are eligible
to receive government subsidies for insurance premiums.
Identification
 Self-employed members: BPJS is currently developing its approaches to identify informal sector workers and their
families. The self-employed can self-identify and enroll online or in-person at scheme offices for membership. In the
longer term, BPJS aims to align its approach and processes for identification with a national ID system under
development by the Ministry of Home Affairs (MoHA).
 Subsidized members: BPJS Kesehatan uses data from an annual national-level survey, SUSENAS, carried out by the
Central Bureau of Statistics to determine the number of poor and near-poor families eligible for coverage.
SUSENAS is a social and economic household survey used to define total household consumption for GDP
estimation purposes. BPJS obtains a list of eligible members each year from the Ministry of Health, which receives
the data from the Ministry of Social Welfare. Local government units are responsible for identifying and enrolling
populations; BPJS helps local government units define local PBI criteria.
Enrollment
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
BPJS has a roadmap to guide its progress in coverage and offers enrollment mechanisms tailored to each of its
target population groups:
 Self-employed members: in-person enrollment at a scheme office, participating banks, and online (see website
here – click here for English version via Google Translate);
 Organized groups/businesses/cooperatives: BPJS works with organized groups to identify and enroll hard-toreach populations and groups of informal sector workers;
 PBI: local government units are responsible for identifying and enrolling the poor and near-poor.
Monitoring & Evaluation

BPJS reports its membership coverage on a monthly basis to a Board of Supervisors.
National Health Insurance Scheme: Successes, Challenges, and Strategies
Successes
 Strong political support for UHC.
 Communications campaigns aimed at informing populations about JKN benefits and processes to enroll.
 Leveraging organized groups within communities (e.g. famers and fisherman cooperation’s) and with institutions
(universities, banks) for both outreach and enrollment of populations.
Challenges
 The scheme is facing substantial challenges with the roll-out and implementation of JKN, particularly due to
challenges with coordinating the integration of previous health insurance schemes under BPJS Kesehatan and the
ambitious timeline to achieve UHC by 2019.
 Difficulties in reaching uncovered populations, particularly hard-to-reach populations in rural and border areas and
informal sectors, and educating them about health insurance.
 Lack of ability and willingness to pay the premium among the self-employed populations.
 BPJS Kesehatan lacks insufficient personnel to manage applications from new beneficiaries.
 Ensuring alignment and harmonization between BPJS Kesehatan and social protection groups.
 Insufficient number of health facilities in rural areas to meet demand.
Strategies
 Indonesia has a National Identification System that uses biometric and retina sensor technology. BPJS plans to use
biometric enrollment linked to the national ID system.
 Developing sanctions to require BPJS for passport and license renewal.
 Leveraging community groups and community leaders for outreach.
 Use of credentialing / accreditation to ensure health facilities meet standards.
Sources

Presentation by Ichwansyah Gani, Head of Marketing and Membership ,BPJS Kesekatan. Joint Learning Network for
Universal Health Coverage Population Coverage Initiative. December 2014.
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