An evaluation of the National Health Insurance (JKN) scheme by Gadjah Mada University’s Centre for Health Policy and Management (PKMK) has highlighted the achievement of eight policy targets in the 2014-2019 JKN Road Map. The study was undertaken as part of PKMK’s partnership with the Knowledge Sector Initiative.
"The JKN Road Map needs to be evaluated after five years to see whether the targets have been achieved or not," said the Head of the Study Team, Laksono Trisnantoro, during a discussion at the Ministry of National Development Planning/National Development Planning Agency (Kementerian PPN/Bappenas). The discussion was part of the KSIxChange series.
The eight main objectives in the JKN Road Map are: 1) BPJS Kesehatan (Indonesia’s public health insurance provider) is operating effectively; 2) All Indonesians are covered by health insurance through BPJS Kesehatan ; 3) The same package of medical and non-medical benefits is provided to ensure social justice for all citizens; 4) Equitable distribution of health service facilities in terms of number and quality; 5) Regular review and alignment of implementing regulations to guarantee the quality of services; 6) Satisfaction expressed by at least 85% of participants for services provided directly by BPJS facilities or BPJS-contracted facilities; 7) Satisfaction expressed by at least 80% of staff and health facilities regarding compensation and remuneration received from BPJS, as well as; 8) Open, efficient, and accountable management of BPJS. These objectives are expected to be achieved by 2019.
These eight targets were grouped into three topics, namely governance (targets 1, 5, and 8), equitable distribution (targets 2, 3, and 4), and service quality (targets 6 and 7). Progress against these targets was evaluated using a realist evaluation approach or theory-based evaluation. The study used quantitative data collected from secondary sources at the national, provincial and district/city level as well as qualitative data in the form of case studies of cardiac health provision in 7 provinces.
"Targets related to the quality of health services have not been achieved evenly in all research locations," said Laksono.
The public was not yet receiving the same standard of health services and the JKN fraud prevention system was not yet functioning optimally because not all regions were assisted by facilitators.
On the issue of governance, Laksono said that the process of formulating policies at the national level without cross-sector coordination had led to a lack of understanding among local governments and inadequate quality of health service delivery. Consequently, BPJS Kesehatan data was not used by the local government in the planning and budgeting of health programs.
Finally, on the topic of equitable distribution of health services, Laksono explained that the availability of quality primary health care services had been difficult to achieve in provinces with limited resources and health infrastructure. Health service delivery is variable and sophisticated medical technology is only available in major cities
"These problems arise from the shortcomings of the National Social Security System (SJSN) Law and the centralistic BPJS (Social Security Service Agency) Act," Laksono said.
In response to these findings, UGM PKMK put forward three policy options for the government. Under the first option, the SJSN Law and the BPJS Act should not be changed. Under the second option, the regulations should be amended to enable BPJS to be the sole social security agency, but managing different types of funds for different types of beneficiaries.
"Our study found that unused funds intended for participants whose contributions are covered by te state were used to address deficits in funds for other beneficiary groups.” This means that the state budget is not being used for the benefit of the poor, "Laksono said.
The unused funds, Laksono added, could be used to provide health infrastructure and medical personnel for remote areas so that health services would be more evenly distributed.
The third option is to revise the regulations with a focus on establishing an institution outside of BPJS Kesehatan. People with higher incomes are not required to be members of BPJS Kesehatan but they must have private health insurance. They can still become members of BPJS Kesehatan but the services provided are standard, with no option for first, second, third or VIP services .
Bappenas welcomed the recommendations from UGM as input for the development of the 2020-2024 JKN Road Map. Bappenas’ Director of Population and Social Protection Planning, Maliki, said the options did not have to mean changes to the National Social Security System Law and the BPJS Act as it would be very time consuming to further develop and align the implementing guidelines of those regulations.
“Instead, we can just go straight to the amendment and adjustment of the implementing regulations to save time" Maliki said.
A member of the Indonesian Hospital Association, Odang Muchtar, agreed that there should only be one class of service available for all beneficiaries of BPJS to ensure social justice for all Indonesians. However, he did not agree with the suggestion to include private health insurance into the JKN scheme.
A different view was shared by Dewi Aryani from BPJS Kesehatan, who said that all Indonesians must be covered by JKN. The government can choose to provide full subsidies to the poor while those who can afford it should pay the premium themselves. When there is a deficit in JKN budget, the government can help address it because JKN has been established on mutual cooperation.
"Mutual cooperation does not mean that the rich should subsidize for the poor: it means the sick should be supported by the healthy.” The role of the state in addressing budget deficits should not be based on segmentation," Dewi said.
Inputs from KSIxChange#9 discussion enriched the study conducted by PKMK UGM. Laksono said that the research findings are still interim and will be refined using input from TNP2K, the Ombudsman, Ministry of Health, DJSN, and other stakeholders received by the end of December 2019.
Laksono said the final results of the study would be available in early 2020 to support evidence-based improvement and refinement of the JKN Program.
See presentation materials here.