Moving Toward Universal Health Coverage

I N D O N E S I A1
I. II. III. IV. V. VI. VII. VIII. IX. X. TheEvolutionofInsuranceReforminIndonesia AnOverviewofInsuranceSchemesinIndonesiaToday Funding PopulationCoverage,Enrollment,andCommunication BenefitsPackages ServiceDeliverySystem ProviderPaymentSystems InstitutionalStructures MonitoringandEvaluation TheWayForward

BasicDemographicandHealthStatistics ThefollowingtablepresentsabriefoverviewofsomekeyhealthanddemographicstatisticsinIndonesia i : Table1:SelectedDemographicandHealthStatistics,Indonesia,2006: Indonesia(2006) Grossnationalincomepercapita(PPPinternational$) 3,310 Population(inthousands)total 228,864 Percapitatotalexpenditureonhealth(PPPint.$) 87 Privateexpenditureonhealthaspercentageoftotalexpenditureonhealth 49.6 Infantmortalityrate(per1000livebirths)bothsexes 26 Lifeexpectancyatbirth(years)female 69 Lifeexpectancyatbirth(years)male 66 Maternalmortalityratio(per100000livebirths) 420 TheEvolutionofInsuranceReforminIndonesia IndonesiasfirsthealthfinancingsystembeganinthecolonialperiodwhentheDutchestablishedamandatoryhealth insuranceschemeforcivilservants.Sinceitsinceptioninthelate1930s,thatcivilservantsschemewentthroughmany evolutions.Thevariousiterationsoftheschemefacedallthesameproblemsthatmoderninsuranceschemescontinue tosuffer,includingmoralhazard,highcoststothepublicbudget,highadministrativecosts,andnoncoverageofretired officers. In1968,AskesPerserowasestablishedtofinanceanddeliverhealthinsuranceservicestobothactiveandpensioned civilservants,includingtheirdirectfamilymembers.Inaddition,P.T.Askes(astateownedinsurancecompany)was grantedexclusiverightstomanageitsowninsurancefundtosupportadministrativeandfunctionaloperations.Starting in1991,P.T.Askesbroadeneditsmarketandproductcoveragetotheprovisionofcommercialhealthinsurance programstothepublic. In1992,theJamsostek,asocialsecurityprogramforprivateemployeesandemployers,wasintroduced.The noteworthyattributeoftheJamsostekprogramwasthatmediumandlargeprivatefirmsweregrantedtheoptionto operatetheirowninsuranceordirectmedicalcareprovisionprogramfortheirworkers.Asaconsequence,over90%of formalsectorworkersanddependentsarenotcurrentlyenrolledintheJamsostekprogram,butrathercoveredthrough theiremployersownprograms.DuetothefactthatformalsectorJamsostekenrollmenthasstalled,Jamsostekhas

ThiscasestudywascompiledbytheResultsforDevelopmentInstitutewithinputsfromDr.DavidDunlop(GTZIndonesia),Dr.AscobatGani(Dean,SchoolofPublic Health,UniversityofIndonesia),andDr.GhufronMukti(Dean,FacultyofMedicine,GadjahMadaUniversity).

beenpilotingprogramstoenrollinformalsectorworkers.Asyetthereislittleinformationwhethertheseeffortsare meetingwithanysubstantialsuccess. Inresponsetothefinancialandeconomiccrisisof199798,newemphasiswasplacedonpropoorfinancinganda numberofeffortswereundertakentodealwiththesevereeconomiccircumstances.Donorfundingincreasedsharplyin 199899sothattheoveralllevelofpublicfundingremainedclosetothelevelsoftheearlytomid1990s.The governmentofIndonesiadevelopedseveraltargetedprogramstocushiontheeconomicshocksofthecrisisonthepoor andothervulnerablegroups.TheseprogramsarecollectivelyreferredtoastheJaringPengamanSosialorJPSprograms. JPSschemesincludedworkersalaries,subsidizedricesales,targetedscholarships,healthsubsidies,andvillageblock grants.Overthisperiod,theMinistryofHealth(MoH)wasinvolvedinencouragingvariouscommunitybasedand voluntaryinitiatives,includingthepromotionofvillagecommunitydevelopmentandcommunitymanagedhealthcare. Whilethesechangesledtomanyimportantmodificationsinthehealthcaredeliverysystemanditsfinancing,theMoH wasunabletoformallymandateafundamentalchangeinthedeliverysystemwhichwouldhaveledtothecreationof anHMOmodelofservicedeliveryandfinancing. Intheearly2000s,twomajorreformsbegantoemerge:(i)thedecentralizationreformof2001,and(ii)the governmentsdedicationtouniversalhealthcoveragereform.Sincethen,thecountryspoliticalsystemunderwenta profoundtransformation:fromacentralizedauthoritarianregimetoadecentralizeddemocraticpolity.Despiteinitial turbulence,asenseofpoliticalstabilityhasgrownasdemocraticprocesseshavematuredandachievedwider acceptance. Decentralization,whilestillfarfromcomplete,hasdevolvedsubstantialfundsandauthoritytolocalgovernments,and newformsofdecentralizedparticipationinpolicymakinghavebeencreated.Indonesiasgrowingeconomy,political stability,anddecentralizationprospectshaveallowedthecountrytothinkaboutexpandinghealthcarecoveragetothe entirepopulation,includingthoseintheinformalurbanandruraleconomicsectors. ThetablebelowprovidesasummarytimelineoftheevolutionofhealthinsuranceprogramsinIndonesiaupto2001. Table2:HistoricalEvolutionofIndonesiasHealthInsuranceProgramsupto2004: Year Initiative 1968 HealthinsuranceforcivilservantsAskes 19741990 1992 1997 1998 1999 2000 2001 2004 PromotionandexperimentsinCBHIDanaSehat SocialsecurityforprivatesectoremployeesJamsostek,JPKM(HMOs),and CBHI Financialcrisis MinistryofHealthattempttomandateHMOsfails JPS(SocialSafetyNet):financialassistanceforthepoorviaADBloan Comprehensivereviewofhealthinsuranceandamendmentofconstitutionto prescribetherightstohealthcare Decentralizationlawimplemented NationalSocialSecurity(SJSN)LawmandatedSocialHealthinsuranceforthe entirepopulation

AnOverviewofInsuranceSchemesinIndonesiaToday Leveragingthenewlyadopteddecentralizationpolicyandcommitmenttouniversalcoverage,Indonesiaintroducedthe firstphaseofitsplantoachieveuniversalhealthcoveragethroughamandatorypublichealthinsuranceschemein2004. AsuransiKesehatanMasyarakatMiskin,orAskeskin,wastargetedtothepoorandhasincreasedaccesstocareand financialprotectionforthepoorest.Itinitiallytargetedthepoorest40millionpeople.Theprogramreimbursed providersintwoways:(i)acapitationpaymentprovidedtoPuskesmas(healthcenters)basedonthenumberof registeredpoor;and(ii)afeeforservicepaymentscoveringthirdclasshospitalbedsreimbursedthroughP.T.Askes(a stateownedinsurer).Allpublichospitalswereautomaticallyqualifiedasproviders,whileAskescontractedwithprivate (mostlynonprofit)hospitalsindividually.

Askeskinimplementedin2005,differedfromthepreviousprogramsforthepoorintwomajorways:First,ratherthan beingapurelygovernmentrunprogram,itprovidedablockgranttoP.T.Askes,whichthentargetedthepoorwith Askeskincardsandreimbursedhospitalclaims;second,thebeneficiarycardsinAskeskinwereindividuallytargeted ratherthanhouseholdcardsusedinpreviousprograms. By2008Askeskinhadexpandedenrollmenttocoverover70millionpeople.Thenin2008,Askeskinevolvedinto JaminanKesehatanMasyarakat,orJamkesmas,whichisaMoHruninsuranceprogramwhichnowcoversover76.4 millionpoorandnearpoorIndonesians. ManydistrictgovernmentshavefollowedtheleadofJamkesmasandestablisheddistrictbasedinsuranceschemes (typicallycalledJamkesda)thatcoverthenearpoororthosenotcoveredunderJamkesmas.Theseschemestake differentforms.SomeJamkesdaaredesignedasextensionsofJamkesmas,withthegoalofcoveringanadditional populationofnearpoor,ontopofthosecoveredbyJamkesmas;otherschemesfocusonspecificservices,suchasin Yogyakarta,wherematernalandchildhealthservicesfor104,500childrenandpregnantwomenarecoveredundera districtledscheme. ThereareseveralimportantdifferencesbetweenthepriorAskeskinprogramandtheJamkesmasprogram.Jamkesmas ismanagedbyDepkes(MinistryofHealth)andPTAskesisnolongerinvolved,exceptinmanagingtheenrollmentof membersandthedistributionofJamkesmascards.Inaddition,districthealthofficesnowdirectlymanagecontracting andclaimsprocessing.AndJamkesmasnowcontractswithmanyprivatehospitalswhereasAskeskinutilizedmainly publicproviders. AsofJanuary2010,theJamkesmasprogramisbeingimplementedthroughoutthecountryandwillserveasoneofthe keybuildingblocksofthegovernmentsproposeduniversalcoverageagenda,hopefullyby2014. To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 millionpoorandnearpoorenrollees.Inaddition,totalutilizationhasincreasedby50%forambulatorycareandabout 106%forinpatientcare2andtheratesofserviceusebetweenthemostaffluentandthepooresthavenearlyequalized. Funding FinancingsourcesforIndonesianinsuranceschemesdifferacrossprograms.Thetablebelowoutlinesfundingsources andpricingforthevariousprograms: Table3:FundingandTargetPopulationsofVariousHealthInsuranceSchemesinIndonesia,2010: Target Scheme FundingSource(s) EffectivePremium Population Activecivilservantsand Membercontributionof2%of Askes dependents,civilservice& salaryplusgovernmentmatchof DependsonSalary militaryretirees 2% Militaryworkersandpolice Taspen andtheiruncovered Outofpocket Varies dependents Membercontributionof3%of Privateformalsector salaryforsingles,6%forfamilies employees(anddependents) Jamsostek (LimitRp1million(USD110)if Dependsonsalary offirmswithtenormore minimumwageisgreaterthan1 employees million) PrivateHealth Privateformalsector Outofpocket Varies Insurance employeesanddependents Communitybased Informalsectorworkersand Outofpocket Varies HealthInsurance studentsinselected
2

SeeAppendix1ofClaudiaRokxetal.,HealthFinancinginIndonesia:AReformRoadmap.WashingtonD.C.:WorldBank,2009.

Jamkesmas (Askeskin)

Jamkesda

universities,andcertain otherschools Poorandnearpoor,based onindividualandhousehold targeting Poorandnearpoor, homeless,orphans,and noncivilserviceteachers Someschemestarget differentpopulations

Generalrevenues(100%funded bycentralgovernment.)

Rp5,000(USD0.50) percapitapermonth

Districtgovernmentsforthose whocannotpay Variesbylocality Outofpocketforthosethat canpay,basedonasliding scaledefinedlocally

AparamountquestionofimportanceinIndonesiaisthesolvencyoftheJamkesmasprogram.Increasingutilizationof healthcareisgoingtoincreasethecostofhealthinsurance,particularlyforthepoorestpopulationscoveredby Jamkesmasascurrentlythereisnocopaymentprovisionwithintheprogram.WhileutilizationofPuskesmasservices hasincreased,thecapacityoflocalservicedeliverymaynotbeabletokeeppacewithincreasingdemandswithout furthercollaborationwithprivateprimaryhealthcareproviders. Currently,itistheresponsibilityofthelocalgovernmenttofinancethegapbetweentheactualcostofinsuringits populationandwhatthecentralgovernmentprovidesviaJamkesmasreimbursements.Withoutfurthersupportforthe poorestlocalities,thisgrowingresponsibilitywillbecomemoreproblematic.Thecentralgovernmentrecognizesthis problem,andinordertocontinuetostrivetowardsuniversalcoverage,itisconsideringhowitmightintroduce strategiestodevelopfurtherapproachestocofinanceservicedeliveryatthelocallevel. Theproposedfundingrequirementsfortheoperationalcostsofpreventiveandpromotiveservicedeliveryisunder activeconsiderationwithintheparliamentatthistimeandknownastheBOKfund. PopulationCoverage,Enrollment,andCommunication Table4showscurrentcoveragebytypeofinsuranceschemeasofJanuary2010.Totalpopulationcoverageis approximately46%ofthepopulation,upfromabout10%15%in2004.ThetablealsoshowsthattheJamkesmas programhasmoreenrolleesthananyotherprogrambyfar.ThedataalsoshowthattheJamsostekprogramhas relativelyfewenrolleesgiventheoptoutprovision.Finally,notethatthedataontheenrollmentofJamkesda(sub nationalschemes)underrepresentsactualcoverageasitisbasedona2008studywhentherewerereportedlyabout35 Jamkesdaprograms.AsofJanuary2010,therearenearlyfivetimesmoreJamkesdathanin2008,butthenumberof coveredpersonsisunknown. Table4:TotalInsuranceCoverageJanuary2010: Scheme No.Enrollees,inMillions Askes(currentandretiredgovernmentemployees) Taspen(Militaryandpolice) Jamsostek(Privateformalsectorworkers) PrivateSchemes Jamkesmas(poor) Jamkesda (poor,rural) TotalCovered PopulationNotCoveredattheendof2009
3

15.2 1.1 4.2 7.0 76.4 2.3 106.2 123.8

3 TheseestimatesarebasedonastudyofsubnationalschemesconductedbyAscobatGani,etalin2008.Asoftheendof2009,therewereabout
80to90additionalschemeswhichmayhaveenrolledanother2to3millionmemberswhicharenotincludedinthesefigures.

TheJamkesmastargetpopulationisdefinedwiththeuseofanannuallyadministerednationalsurveyknownasthe SUSENAS.ItisasocialandeconomichouseholdsurveyusedtodefinetotalhouseholdconsumptionforGDPestimation purposes.Basedonstandarddefinitionsofthepoorintermsofdailyhouseholdconsumption,thetotalnumberofpoor hasbeendefined.Thesubnationaldistributionofthistotalhasalsobeendefinedinasimilarmanner. PTAskesremainstheadministratorofmembershipintheJamkesmasprogramsinceithasoperatedtheprogramsince 2005.PTAskeshasacontractwiththeMoHtoadministerthemembershippartoftheprogramseparatefromother programs.PTAskesobtainsalistofthenumberofpersonseligibleeachyearfromtheCentralBureauofStatisticswhich isapartofBappenas(thenationalplanningagency).PTAskesthendistributesthecardsandregistersenrolleesintothe program. TheMinistryofHomeAffairs(MoHA)isresponsibleforthedevelopmentofanationalidentitycardtobedistributed throughouttheentirepopulation.Whenthiscardhasbeendistributed,itwillbecomethebasisforenrollmentintothe nationalhealthinsuranceprogram. Jamkesmasisnotbeingformallymarketed,asithasbeenoversubscribedsinceitsinceptionin2008. BenefitPackage ThebenefitsprovidedbyvariouspubliclyimplementedinsuranceschemesinIndonesiavary.Table4belowoutlinesthe benefitsprovidedbyeachscheme. Table5:BenefitPackagesofPublicInsuranceSchemesinIndonesia,2010: Scheme Benefits Exclusions Cosmeticsurgery,alternativemedicine,dental Comprehensive(inandoutpatient),including prostheses,fertilitytreatment,nonbasic Askes maternity,annualphysicals,andpreventive immunizations,hemodialysis,andsecondary healthcare cancertherapy Healthconditionsdirectlycausedbynatural disaster,selfinflictedproblems,extreme Comprehensive(inpatientandoutpatient), sports,generalcheckups,cancertreatments, Jamsostek includingmaternity,annualphysicals,and heartsurgery,renaldialysis,andlifelong preventivehealthcare treatmentforcongenitaldiseases,prostheses, nonbasicimmunizations,transplantation,and fertilitytreatment Comprehensive(inpatientandoutpatient), Varybyplantherearemorethan50private PrivateHealth includingmaternity,annualphysicals,and carriers,thoughPTAskeshasthelargest Insurance preventivehealthcare marketshare Cosmeticsurgery,annualphysicalcheckups, Comprehensive(inpatientandoutpatient), alternativemedicine,dentalprosthesis, Jamkesmas includingmaternityandpreventivehealthcare fertilitytreatment.Cancertreatmentislimited, asareheartrelatedproblems Communitybased Primarilyoutpatientservices,including DependsonSchememanyexcludespecialist HIandJamkesda maternityandpreventivehealthcare.Some andinpatientservices,annualphysicalcheck schemes schemescoverinpatientcare ups Therearesomedifferencesindrugbenefitsacrossprograms.Forexample,Jamkesmasenrolleesareonlyentitledto drugsfromspecificformulariesandmustoptforgenericdrugsforcoverageofprescriptionmedications.Askesisalso verystrictondruguse,dispensingonlygenericsandinsomehospitalsmaintainingtheirownpharmacyforAskes patients. 4
4

Askescollectsdataondrugdispensingandcostsandareabletoshowthattheyhavereduceddrugcostsfromapproximately45%ofexpenditureto25%of expenditureoverthelast5yearsorso.

Overall,freeaccesstomanyprovidersbothprivateandpublicandacomprehensivebenefitspackagemake JamkesmasmoreattractivetothemajorityofthepopulationeventhosecoveredunderAskesandJamsostek.A recentsurveyinearly2008entitledStudyonBenefitPackageBasedonCommunitysPreferenceconductedbyCenter forHealthFinancingPolicyandHealthInsuranceManagementattheUniversityofGadjahMadahasshownthat79.8% ofpeoplewhowerealreadyenrolledwithhealthinsuranceschemes,suchasAskesandJamsostek,preferredtobe entitledwithJamkesmasbenefitsastheyfeltthecoverageprovidedunderJamkesmaswassuperiortothatprovided undertheirexistingplan. ServiceDeliverySystem Healthservicesacrosseachschemearedeliveredbyamixofproviders,withmostschemesrelyingheavilyonthepublic sectorfordeliveryofcare.Table6outlinesthetypesofservicedeliveryoutletscoveredeachscheme. Table6:HealthCareDeliveryOutlets,IndonesianHealthInsuranceSchemes,2010: Scheme Ambulatoryservices Inpatientservices Publicandsomeprivateprovidersare Askes Publiconly included Jamsostek Publicandprivate Publicandprivateinnetwork PrivateHealth Privatepublicwhereprivatecareis Privateandpublicwhereprivatecareis Insurance notavailable notavailable Publicandsomeprivateprovidersare Jamkesmas(Askeskin) Public included CommunitybasedHI Publiconly Dependsonscheme andJamkesda Onebigdifferencebetweentheschemesiswherebeneficiariesobtaincare.Someschemesallowbeneficiariesaccessto bothpublicandprivateproviders(e.g.,Jamsostek),whereasothersrequirebeneficiariestoobtainservicesfromthe largelypublicnetworkofproviders(e.g.,AskesandJamkesmas)formostservices,withaccesstoprivateprovidersfora smallerrangeofcare. TherearesignificantoutofpocketcostsforJamsostekandAskesbeneficiaries(estimatedatupto40%)whoselect privatecare.Continuinglargeoutofpocketpaymentssuggestthatthelevelofcoverageand/orfinancialprotection providedbythoseinsuranceschemesmaybelimited. Jamkesmascontractswith926hospitalstoprovideservices,including220privatehospitalsforcertaintypesofcare. Askesalsocontractswithalargenumberofprivateprovidersforthecivilserviceprogram. ProviderPaymentMechanisms Aswithrevenueraising,targetpopulations,andbenefits,providerpaymentandcontractingmechanismsvarywitheach scheme.Table7providesasummaryoftheproviderpaymentmodelsusedbyeachgovernmentschemebasedonthe typeofcaredelivered: Table7:ProviderPaymentMechanismsEmployedinIndonesia,2010: Scheme InpatientCare PrimaryCare Askes Feeschedules Capitation Jamsostek Capitationandfeeforservice Capitation Historicallyfeeforserviceto CapitationtoPuskesmasbased publichospitals;transitioning Jamkesmas(Askeskin) onnumberofpoorinthe toaDRGsystembeginningin catchmentarea 2009 ForJamkesmas,whilethebenefitpackageisthesamenationally,districtssetthereimbursementratesforvarious servicesbasedonlocalconditions,aslocaldistrictgovernmentshavejurisdictiontoestablishhospitalfees.Until2009, reimbursementwasbasedonservicesprovided(feeforservice),althoughtherearemaximumreimbursementratesby

typeofservices.Beginning2009,Jamkesmaswasintheprocessoftransitioningitsreimbursementsystemfromfeefor servicetoonebasedondiagnosisrelatedgroups(DRGs).AllhospitalsarebeingincorporatedintotheDRGpayment processin2010. Jamkesmashasverificatorsineverynetworkhospital.Theseverificatorshavebeenputinplacetoassure reimbursementsaremadeonlyfordocumentableclaimswithafullmedicalrecord.Verificatorsprocessclaimsandsend themelectronicallytotheMoH.Verificatorshavestandardreviewprocedureswhichtheyfollowtodocumentevery case.ThesestandardsweredevelopedbytheMoH.OncetheMoHreceivestheclaim,itbeginsthereimbursement processtoproviders. Whiletherehasbeenbroadexperiencewithcontractingpublicandprivateprovidersthroughthepublicallyfunded schemes,thecontractmechanismshavenotusedreimbursementorpaymentpoliciesstrategicallytodrive improvementsinqualityofefficiency.Thereareexamplesinmaternalhealthwherethecurrentreimbursementsystem byJamkesmashascreatedthewrongincentivesforproviders,suchasnotreimbursingmidwivesforpredeliverycareif thereispostpartumhemorrhage.Inaddition,onceapatientisreferredtothehospital,thehospitalreceivesafull reimbursementfordelivery,whilethemidwifereceivesnofee,therebydiscouragingmidwivesfromreferringpatientsto hospitalsforcomplicationsastheywouldloseincome. InstitutionalStructure ArevisedinstitutionalstructureofIndonesiasJamkesmasschemeiscurrentlybeingdeveloped. Currently,therearefivemainactorsinvolvedintheinsuranceadministrativeprocessesforthisprogram:(1)the NationalSocialSecurityCouncil(knownasDJSN);(2)nationalgovernmentagenciesincludingDepkes(MoH),the MinistryofFinance(MoF),theMinistryofHomeAffairs(MoHA)whichadministersthedecentralizationprocess,the coordinatingMinistryforSocialAffairs(Menkokesra),andtheplanningministry(Bappenas);(3)provincialanddistrict governments;(4)publicandprivateprovidersofcare;and(5)theinsurer/thirdpartyadministrator(PT Askes/Jamsostek).Thetablebelowsummarizestherolesandresponsibilitiesofalloftheorganizationsinvolvedin implementingnationalhealthinsurance,includingJamkesmas: Table8:CurrentInstitutionalStructureoftheIndonesianNationalHealthInsuranceSystem,2010 LR=longrun;SR=shortrun National government NationalSoc agencies Provincialand Insurer/TPA Providersof CharacteristicsoftheScheme SecCouncil (MoH,MoF, district (Askes/ Care (DJSN) MoHA, Governments Jamsostek) Menkokesra, Bappenas) Oversightofscheme X(LR) X(SR) Financingscheme X X Settingparameters(benefits package,definitionsofpoor, X(LR) X(SR) etc.) Accreditation/Empanelmentof X X providers Enrollment X X X Financial X(LR) X(SR) management/planning Actuarialanalysis X(LR) Settingrateschedulesfor X(LR) X(SR) services/reimbursementrates X(Under X(District Claimsprocessingandpayment X Review) level)

Outreach,Marketingto X beneficiaries Servicedelivery X Developingclinicalinformation X(LR) X(SR) systemformonitoring/eval Monitoringlocallevel utilizationandotherpatient X(LR) X(SR) information Monitoringnationalaggregate X(LR) information Customerservice X X NotethattheMinistryofFinancehasanofficeoverseeinginsuranceprogramsandcarriersofalltypes.Theyalsohave actuarialcapacityavailablewhenrequired. MonitoringandEvaluation WhiletherearenoformalevaluationsoftheJamkesmasscheme,theIndonesiangovernmentandmanyinternational organizations,includingtheWorldBankandGTZ,arecollaboratingtoimprovetheprogramtoaddressbothpolicyand implementationchallenges. DatafromthegovernmentsuggestthatJamkesmashasmadeasignificantimpact.Ahighlevelofcoveragehasbeen achievedwithinlessthan2years,reaching76millionpoorandnearpoorenrollees.Totalutilizationofserviceshasalso increasedby50%forambulatorycareandabout106%forinpatientcare 5andtheratesofserviceusebetweenthemost affluentandthepooresthavenearlyequalized. TheWayForward Atthepolicylevel,allaspectsofhealthfinancingreforminIndonesiaarecomplicatedbydecentralization.Althoughthe conceptatfirstappearssimplewithdistrictsresponsibleforimplementinghealthservices,thecomplexityoftheflowsof fundssometargetedtohealth,othersnotandsomepaymentsmadethroughinsuranceorganizations,andothers madedirectlytopublicproviders(hospitals,Puskesmas,andpersonnel)makeforanintricateandfragmentedsetof financingflows.Recentstudiesindicatethatmanypoordistrictsarereceivingmuchhigherlevelsoffundingthan previously,buthavebeenunabletospendthesefundsbecauseoflocalcapacityconstraints.Capacitybuildingis necessarytoensurethesystemcancontinuetobuildadministrativeexpertiseandcapacitytoexpandcoverage. Inaddition,thoroughactuarialanalysisofthetruecostofexpandingcoverageisnecessarytoensureappropriatefunds areallocatedtoachievinguniversalcoverage.Intheshortrun,itwillalsobenecessarytodevelopreliablecost informationondeliveringservicesinalltypesofhealthfacilities. ThereisalsoalackofenforcementofthemanyexistingstandardsinIndonesia(e.g.,clinicaltreatmentstandards, hospitalstandards,standarddrugformularies).Neithergovernmentofficialsnorprofessionalassociationshavereally addressedhowtoensuremorerigorousclinicalstandardsoftreatment.Jamkesmashasagreaterabilitytoenforce thesestandardsastheycanapplycontrolsoverthereleaseoffundsintheformofreimbursementsthanispossible byeithertheMoHorprofessionalassociations.Tohelpaddresstheissueofenforcingstandards,providerpaymentand monitoringstructuresarebeingreassessedbytheDJSNintheirprocessofdevelopingimplementableguidelines.This assessmentisreviewinghowdifferentproviderpaymentsystemsmightinfluenceproviderbehavior,howtoenforce thatprovidersadheretotreatmentprotocols,promotespecifichealthservices,andremoveexistingdisincentivesto adheretoprotocol.Therearealsocurrentlypilotsofvariouspaymentmethodsunderway. Finally,Jamkesmasmaybeaveryusefultoolforimprovinghealthoutcomesandpromotingtheutilizationofcertain healthservices.Unfortunately,theseleversarenotbeingwidelyutilizedbytheprogramasyet,noristherean operationalresearchprograminplacewithintheprogramtoengageinthistypeofexercise.Therearetwoissues.First,
5

SeeAppendix1ofClaudiaRokxetal.,HealthFinancinginIndonesia:AReformRoadmap,(WashingtonD.C.:WorldBank,2009).

Jamkesmascanencourageproviderstotargetcertainservicesbyadjustingthereimbursementratesforvariousservices. Familyplanningisoneexamplewhereprovidersprefertorelyonshorttermmethods,suchasoralcontraceptivesand injectables,astheprimarymethodsforpromotingfamilyplanning.IfJamkesmasincreaseditsreimbursementratefor longertermmethods,suchasIUDs,toalevelthatmotivatesproviderstoprovidetheservice,theymaymoreactively offeritasalternativestopatients.Second,fromthestandpointofpublichealthprogramming,Jamkesmasmaybe usefulfordrivingforwardpublichealthpriorities.IfJamkesmasmademinorchangesinitspayment/reimbursement policiesonimportanthealthproblemareas(e.g.,maternalhealth,TB),therecouldbesignificantpositiveimplicationson howthesediseasesaretreatedbyproviders.

i

WorldHealthOrganizationNationalHealthAccounts.Indonesia2006.