Health Care Statistics
World Health Statistics
Country Profile
Several national health insurance schemes had already been operational prior to the rollout of the Jamkesmas scheme in 2004, including schemes for civil servants and, later, all formal sector workers. Indonesia’s first health financing system began in the colonial period when the Dutch established a mandatory health insurance scheme for civil servants. Since its inception in the late 1930s, that civil servant scheme went through many evolutions.
Several national health insurance schemes had already been operational prior to the rollout of the Jamkesmas scheme in 2004, including schemes for civil servants and, later, all formal sector workers. Indonesia’s first health financing system began in the colonial period when the Dutch established a mandatory health insurance scheme for civil servants. Since its inception in the late 1930s, that civil servant scheme went through many evolutions. The various iterations of the scheme faced the same problems that modern insurance schemes continue to suffer, including moral hazard, high costs to the public budget, high administrative costs, and non-coverage of retired officers.
In 1968, Askes Persero was established to finance and deliver health insurance services to both active and pensioned civil servants, including their direct family members. In addition, P.T. Askes (a state-owned insurance company) was granted exclusive rights to manage its own insurance fund to support administrative and functional operations. Starting in 1991, P.T. Askes broadened its market and product coverage to the provision of commercial health insurance programs to the public.
In 1992, the Jamsostek, a social security program for private employees and employers, was introduced. The noteworthy attribute of the Jamsostek program was that medium and large private firms were granted the option to operate their own insurance or direct medical care provision program for their workers. As a consequence, over 90% of formal sector workers and dependents are not currently enrolled in the Jamsostek program, but rather covered through their employers’ own programs. Due to the fact that formal sector Jamsostek enrollment has stalled, Jamsostek has been piloting programs to enroll informal sector workers. As yet there is little information whether these efforts are meeting any substantial success.
In response to the financial and economic crisis of 1997–98, new emphasis was placed on pro-poor financing and a number of efforts were undertaken to deal with the severe economic circumstances. Donor funding increased sharply in 1998–99 so that the overall level of public funding remained close to the levels of the early to mid-1990s. The government of Indonesia developed several targeted programs to cushion the economic shocks of the crisis on the poor and other vulnerable groups. These programs are collectively referred to as the Jaring Pengaman Sosial or JPS programs. JPS schemes included worker salaries, subsidized rice sales, targeted scholarships, health subsidies, and village block grants. Over this period, the Ministry of Health (MoH) was involved in encouraging various community-based and voluntary initiatives, including the promotion of village community development and community-managed health care. While these changes led to many important modifications in the health care delivery system and its financing, the MoH was unable to formally mandate a fundamental change in the delivery system which would have led to the creation of an HMO model of service delivery and financing.
In the early 2000s, two major reforms began to emerge: (i) the decentralization reform of 2001, and (ii) the government’s dedication to universal health coverage reform. Since then, the country’s political system underwent a profound transformation from a centralized authoritarian regime to a decentralized democratic polity. Despite initial turbulence, a sense of political stability has grown as democratic processes have matured and achieved wider acceptance.
Decentralization, while still far from complete, has devolved substantial funding and authority to local governments, and new forms of decentralized participation in policy making have been created. Indonesia’s growing economy, political stability, and decentralization prospects have allowed the country to think about expanding health care coverage to the entire population, including those in the informal urban and rural economic sectors.
The table below provides a summary timeline of the evolution of health insurance programs in Indonesia up to 2001.
| Year | Initiative |
|---|---|
| 1968 | Health insurance for civil servants – Askes |
| 1974-1990 | Promotion and experiments in CBHI – Dana Sehat |
| 1992 | Social security for private sector employees – Jamsostek, JPKM (HMOs), and CBHI |
| 1997 | Financial crisis |
| 1998 | Ministry of Health attempt to mandate HMOs fails |
| 1999 | JPS (Social Safety Net): financial assistance for the poor via ADB loan |
| 2000 | Comprehensive review of health insurance and amendment of constitution to prescribe the rights to health care |
| 2001 | Decentralization law implemented |
| 2004 | National Social Security (SJSN) Law mandated Social Health insurance for the entire population |
Indonesia
Historical Context
Several national health insurance schemes had already been operational prior to the rollout of the Jamkesmas scheme in 2004, including schemes for civil servants and, later, all formal sector workers. Indonesia’s first health financing system began in the colonial period when the Dutch established a mandatory health insurance scheme for civil servants. Since its inception in the late 1930s, that civil servant scheme went through many evolutions. The various iterations of the scheme faced the same problems that modern insurance schemes continue to suffer, including moral hazard, high costs to the public budget, high administrative costs, and non-coverage of retired officers.
In 1968, Askes Persero was established to finance and deliver health insurance services to both active and pensioned civil servants, including their direct family members. In addition, P.T. Askes (a state-owned insurance company) was granted exclusive rights to manage its own insurance fund to support administrative and functional operations. Starting in 1991, P.T. Askes broadened its market and product coverage to the provision of commercial health insurance programs to the public.
In 1992, the Jamsostek, a social security program for private employees and employers, was introduced. The noteworthy attribute of the Jamsostek program was that medium and large private firms were granted the option to operate their own insurance or direct medical care provision program for their workers. As a consequence, over 90% of formal sector workers and dependents are not currently enrolled in the Jamsostek program, but rather covered through their employers’ own programs. Due to the fact that formal sector Jamsostek enrollment has stalled, Jamsostek has been piloting programs to enroll informal sector workers. As yet there is little information whether these efforts are meeting any substantial success.
In response to the financial and economic crisis of 1997–98, new emphasis was placed on pro-poor financing and a number of efforts were undertaken to deal with the severe economic circumstances. Donor funding increased sharply in 1998–99 so that the overall level of public funding remained close to the levels of the early to mid-1990s. The government of Indonesia developed several targeted programs to cushion the economic shocks of the crisis on the poor and other vulnerable groups. These programs are collectively referred to as the Jaring Pengaman Sosial or JPS programs. JPS schemes included worker salaries, subsidized rice sales, targeted scholarships, health subsidies, and village block grants. Over this period, the Ministry of Health (MoH) was involved in encouraging various community-based and voluntary initiatives, including the promotion of village community development and community-managed health care. While these changes led to many important modifications in the health care delivery system and its financing, the MoH was unable to formally mandate a fundamental change in the delivery system which would have led to the creation of an HMO model of service delivery and financing.
In the early 2000s, two major reforms began to emerge: (i) the decentralization reform of 2001, and (ii) the government’s dedication to universal health coverage reform. Since then, the country’s political system underwent a profound transformation from a centralized authoritarian regime to a decentralized democratic polity. Despite initial turbulence, a sense of political stability has grown as democratic processes have matured and achieved wider acceptance.
Decentralization, while still far from complete, has devolved substantial funding and authority to local governments, and new forms of decentralized participation in policy making have been created. Indonesia’s growing economy, political stability, and decentralization prospects have allowed the country to think about expanding health care coverage to the entire population, including those in the informal urban and rural economic sectors.
The table below provides a summary timeline of the evolution of health insurance programs in Indonesia up to 2001.
| Year | Initiative |
|---|---|
| 1968 | Health insurance for civil servants – Askes |
| 1974-1990 | Promotion and experiments in CBHI – Dana Sehat |
| 1992 | Social security for private sector employees – Jamsostek, JPKM (HMOs), and CBHI |
| 1997 | Financial crisis |
| 1998 | Ministry of Health attempt to mandate HMOs fails |
| 1999 | JPS (Social Safety Net): financial assistance for the poor via ADB loan |
| 2000 | Comprehensive review of health insurance and amendment of constitution to prescribe the rights to health care |
| 2001 | Decentralization law implemented |
| 2004 | National Social Security (SJSN) Law mandated Social Health insurance for the entire population |
Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme, Asuransi Kesehatan Masyarakat Miskin, or Askeskin, in 2004. Askeskin was targeted to the poor and increased access to care and financial protection for the poorest. It initially targeted the poorest 40 million people. In 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, an MoH-run insurance program. 106.2 million Indonesians, or roughly 46% of the population, are now covered, either through Jamkesmas or a number of other existing programs targeting civil servants, the formal sector, and other population segments.
Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme, Asuransi Kesehatan Masyarakat Miskin, or Askeskin, in 2004. Askeskin was targeted to the poor and increased access to care and financial protection for the poorest. It initially targeted the poorest 40 million people. In 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, an MoH-run insurance program. 106.2 million Indonesians, or roughly 46% of the population, are now covered, either through Jamkesmas or a number of other existing programs targeting civil servants, the formal sector, and other population segments.
The table below shows current coverage by type of insurance scheme as of January2010. Total population coverage is approximately 46% of the population, up from about 10%- 15% in 2004. The table also shows that the Jamkesmas program has more enrollees than any other program by far. The data also show that the Jamsostek program has relatively few enrollees given the opt out provision. Finally, note that the data on the enrollment of Jamkesda (sub-national schemes) under-represents actual coverage as it is based on a 2008 study when there were reportedly about 35 Jamkesda programs. As of January 2010, there are nearly five times more Jamkesda than in 2008, but the number of covered persons is unknown.
| Enrollees (millions) | Scheme |
|---|---|
| 15.2 | Askes (current and retired government employees) |
| 1.1 | Taspen (Military and police) |
| 4.2 | Jamsostek (Private formal sector workers) |
| 7.0 | Private Schemes |
| 76.4 | Jamkesmas (poor) |
| 2.3 | Jamkesda (poor, rural) |
| 106.2 | Total Covered |
| 123.8 | Population Not Covered at the end of 2009 |
There are several important differences between the prior Askeskin program and the Jamkesmas program. Jamkesmas is managed by Depkes (Ministry of Health), whereas Askeskin was managed by a state-owned insurer, PT Askes, which received a block grant for the program. In addition, district health offices now directly manage contracting and claims processing. Finally, Jamkesmas now contracts with many private hospitals whereas Askeskin utilized mainly public providers.
Jamkesmas is financed entirely through general government revenues, with contributions made from both central and local governments. There are no required contributions by beneficiaries and care is free at the point-of-service. Jamkesmas offers a comprehensive package of care, including inpatient and outpatient care as well as maternal and preventive health services. Jamkesmas is administered in a largely decentralized fashion. While the central government plays an oversight role and partially finances the program, operations responsibilities fall largely with provincial and district governments.
Many district governments have followed the lead of Jamkesmas and established complementary district-based insurance schemes (typically called Jamkesda) that cover the near poor or those not covered under Jamkesmas. These schemes take different forms. Some Jamkesda are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas; other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme.
To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 million poor and near poor enrollees. In addition, total utilization has increased by 50% for ambulatory care and about 106% for inpatient care and the rates of service use between the most affluent and the poorest have nearly equalized. As of January 2010, the Jamkesmas program is being implemented throughout the country and will serve as one of the key building blocks of the government’s proposed universal coverage agenda, hopefully by 2014.
Indonesia
Summary of Reforms
Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme, Asuransi Kesehatan Masyarakat Miskin, or Askeskin, in 2004. Askeskin was targeted to the poor and increased access to care and financial protection for the poorest. It initially targeted the poorest 40 million people. In 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, an MoH-run insurance program. 106.2 million Indonesians, or roughly 46% of the population, are now covered, either through Jamkesmas or a number of other existing programs targeting civil servants, the formal sector, and other population segments.
The table below shows current coverage by type of insurance scheme as of January2010. Total population coverage is approximately 46% of the population, up from about 10%- 15% in 2004. The table also shows that the Jamkesmas program has more enrollees than any other program by far. The data also show that the Jamsostek program has relatively few enrollees given the opt out provision. Finally, note that the data on the enrollment of Jamkesda (sub-national schemes) under-represents actual coverage as it is based on a 2008 study when there were reportedly about 35 Jamkesda programs. As of January 2010, there are nearly five times more Jamkesda than in 2008, but the number of covered persons is unknown.
| Enrollees (millions) | Scheme |
|---|---|
| 15.2 | Askes (current and retired government employees) |
| 1.1 | Taspen (Military and police) |
| 4.2 | Jamsostek (Private formal sector workers) |
| 7.0 | Private Schemes |
| 76.4 | Jamkesmas (poor) |
| 2.3 | Jamkesda (poor, rural) |
| 106.2 | Total Covered |
| 123.8 | Population Not Covered at the end of 2009 |
There are several important differences between the prior Askeskin program and the Jamkesmas program. Jamkesmas is managed by Depkes (Ministry of Health), whereas Askeskin was managed by a state-owned insurer, PT Askes, which received a block grant for the program. In addition, district health offices now directly manage contracting and claims processing. Finally, Jamkesmas now contracts with many private hospitals whereas Askeskin utilized mainly public providers.
Jamkesmas is financed entirely through general government revenues, with contributions made from both central and local governments. There are no required contributions by beneficiaries and care is free at the point-of-service. Jamkesmas offers a comprehensive package of care, including inpatient and outpatient care as well as maternal and preventive health services. Jamkesmas is administered in a largely decentralized fashion. While the central government plays an oversight role and partially finances the program, operations responsibilities fall largely with provincial and district governments.
Many district governments have followed the lead of Jamkesmas and established complementary district-based insurance schemes (typically called Jamkesda) that cover the near poor or those not covered under Jamkesmas. These schemes take different forms. Some Jamkesda are designed as extensions of Jamkesmas, with the goal of covering an additional population of near-poor, on top of those covered by Jamkesmas; other schemes focus on specific services, such as in Yogyakarta, where maternal and child health services for 104,500 children and pregnant women are covered under a district-led scheme.
To date, data from the government suggest that the scheme for the poor has made a significant impact, reaching 76 million poor and near poor enrollees. In addition, total utilization has increased by 50% for ambulatory care and about 106% for inpatient care and the rates of service use between the most affluent and the poorest have nearly equalized. As of January 2010, the Jamkesmas program is being implemented throughout the country and will serve as one of the key building blocks of the government’s proposed universal coverage agenda, hopefully by 2014.
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
At the policy level, all aspects of health financing reform in Indonesia are complicated by decentralization. Although the concept at first appears simple with districts responsible for implementing health services, the complexity of the flows of funds—some targeted to health and others not, and some payments made through insurance organizations and others made directly to public providers (hospitals, Puskesmas, and personnel)—make for an intricate and fragmented set of financing flows. Recent studies indicate that many poor districts are receiving much higher levels of funding than previously, but have been unable to spend these funds because of local capacity constraints. Capacity building is necessary to ensure the system can continue to build administrative expertise and capacity to expand coverage.
There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formularies). Neither government officials nor professional associations have really addressed how to ensure more rigorous clinical standards of treatment. Jamkesmas has a greater ability to enforce these standards—as they can apply controls over the release of funds in the form of reimbursements—than is possible by either the MoH or professional associations. To help address the issue of enforcing standards, provider payment and monitoring structures are being reassessed by the DJSN in their process of developing implementable guidelines. This assessment is reviewing how different provider payment systems might influence provider behavior, and how to enforce that providers adhere to treatment protocols, promote specific health services, and remove existing disincentives to adhere to protocol. Pilots of various payment methods are currently underway.
In addition, thorough actuarial analysis of the true cost of expanding coverage is necessary to ensure appropriate funds are allocated to achieving universal coverage. In the short run, it will also be necessary to develop reliable cost information on delivering services in all types of health facilities.
Finally, Jamkesmas may be a very useful tool for improving health outcomes and promoting the utilization of certain health services. Unfortunately, these levers are not being widely utilized by the program as yet, nor is there an operational research program in place within the program to engage in this type of exercise. There are two potential opportunities in this regard. First, Jamkesmas can encourage providers to target certain services by adjusting the reimbursement rates for various services. Family planning is one example where providers prefer to rely on short term methods, such as oral contraceptives and injectables, as the primary methods for promoting family planning. If Jamkesmas increased its reimbursement rate for longer-term methods, such as IUDs, to a level that motivates providers to provide the service, they may more actively offer it as alternatives to patients. Second, from the standpoint of public health programming, Jamkesmas may be useful for driving forward public health priorities. If Jamkesmas made minor changes in its payment/reimbursement policies on important health areas (e.g., maternal health, TB), there could be significant positive implications on how these diseases are treated by providers.
Indonesia
The Way Forward
While Indonesia has made significant strides toward universal health coverage over the past decade, significant challenges lie in the road ahead. Though necessitated by Indonesia’s geography and other intrinsic characteristics, decentralization will continue to create challenges in managing the scheme and its funding flows, and in enforcing existing clinical and quality standards. A better understanding of the true actuarial cost of reforms will also be necessary in the months and years ahead.
At the policy level, all aspects of health financing reform in Indonesia are complicated by decentralization. Although the concept at first appears simple with districts responsible for implementing health services, the complexity of the flows of funds—some targeted to health and others not, and some payments made through insurance organizations and others made directly to public providers (hospitals, Puskesmas, and personnel)—make for an intricate and fragmented set of financing flows. Recent studies indicate that many poor districts are receiving much higher levels of funding than previously, but have been unable to spend these funds because of local capacity constraints. Capacity building is necessary to ensure the system can continue to build administrative expertise and capacity to expand coverage.
There is also a lack of enforcement of the many existing standards in Indonesia (e.g., clinical treatment standards, hospital standards, standard drug formularies). Neither government officials nor professional associations have really addressed how to ensure more rigorous clinical standards of treatment. Jamkesmas has a greater ability to enforce these standards—as they can apply controls over the release of funds in the form of reimbursements—than is possible by either the MoH or professional associations. To help address the issue of enforcing standards, provider payment and monitoring structures are being reassessed by the DJSN in their process of developing implementable guidelines. This assessment is reviewing how different provider payment systems might influence provider behavior, and how to enforce that providers adhere to treatment protocols, promote specific health services, and remove existing disincentives to adhere to protocol. Pilots of various payment methods are currently underway.
In addition, thorough actuarial analysis of the true cost of expanding coverage is necessary to ensure appropriate funds are allocated to achieving universal coverage. In the short run, it will also be necessary to develop reliable cost information on delivering services in all types of health facilities.
Finally, Jamkesmas may be a very useful tool for improving health outcomes and promoting the utilization of certain health services. Unfortunately, these levers are not being widely utilized by the program as yet, nor is there an operational research program in place within the program to engage in this type of exercise. There are two potential opportunities in this regard. First, Jamkesmas can encourage providers to target certain services by adjusting the reimbursement rates for various services. Family planning is one example where providers prefer to rely on short term methods, such as oral contraceptives and injectables, as the primary methods for promoting family planning. If Jamkesmas increased its reimbursement rate for longer-term methods, such as IUDs, to a level that motivates providers to provide the service, they may more actively offer it as alternatives to patients. Second, from the standpoint of public health programming, Jamkesmas may be useful for driving forward public health priorities. If Jamkesmas made minor changes in its payment/reimbursement policies on important health areas (e.g., maternal health, TB), there could be significant positive implications on how these diseases are treated by providers.