Joint Learning Network for Universal Health Coverage

Indonesia: Jamkesmas

76.4 million

Funding

None
All populations
Premiums, Co-payments

Population Covered

Below Poverty Line

Service delivery system

Both Public & Non-state
926
220

Institutional structure

Decentralized to district/local level
Central Government, District/Local Government, Commercial insurers
Central Government
Central Government, District/Local Government
District/Local Government
Reform summary: 
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Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme, Askeskin, in 2004. In 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, an MoH-run “insurance” program which now covers over 76.4 million poor Indonesians. Asuransi Kesehatan Masyarakat Miskin, or 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.

Indonesia introduced the first phase of its plan to achieve universal health coverage through a mandatory public health insurance scheme, Askeskin, in 2004. In 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas, an MoH-run “insurance” program which now covers over 76.4 million poor Indonesians. Asuransi Kesehatan Masyarakat Miskin, or 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.

The program reimbursed providers in two ways: (i) a capitation payment provided to Puskesmas (health centers) based on the number of registered poor; and (ii) a fee-for-service payments covering third-class hospital beds reimbursed through P.T. Askes (a state-owned insurer). All public hospitals were automatically qualified as providers, while Askes contracted with private (mostly non-profit) hospitals individually.

Changes to Askeskin implemented in 2005 resulted in differences in two major areas: First, rather than being a purely government-run program, it provided a block grant to P.T. Askes, which then targeted the poor with Askeskin cards and reimbursed hospital claims; second, the beneficiary cards in Askeskin were individually targeted rather than the household cards used in previous programs.

By 2008 Askeskin had expanded enrollment to cover over 70 million people. Then in 2008, Askeskin evolved into Jaminan Kesehatan Masyarakat, or Jamkesmas. Many district governments have followed the lead of Jamkesmas and established 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.

There are several important differences between the prior Askeskin program and the Jamkesmas program. Jamkesmas is managed by Depkes (Ministry of Health) and P.T. Askes is no longer involved, except in managing the enrollment of members and the distribution of Jamkesmas cards. In addition, district health offices now directly manage contracting and claims processing. And Jamkesmas now contracts with many private hospitals whereas Askeskin utilized mainly public providers.

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.

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.

Funding: 
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The Jamkesmas scheme is funded by the central government from general tax revenue. Beneficiaries are not responsible for premium payments nor are they charged a copayment at the time of visit.

The Jamkesmas scheme is funded by the central government from general tax revenue. Beneficiaries are not responsible for premium payments nor are they charged a copayment at the time of visit.

A paramount question of importance in Indonesia is the solvency of the Jamkesmas program. Increasing utilization of health care will concurrently increase the cost of health insurance, particularly for the poorest populations covered by Jamkesmas as currently there is no co-payment provision within the program. While utilization of Puskesmas services has increased, the capacity of local service delivery may not be able to keep pace with increasing demands without further collaboration with private primary health care providers.

Currently, it is the responsibility of the local government to finance the gap between the actual cost of insuring its population and what the central government provides via Jamkesmas reimbursements. Without further support for the poorest localities, this growing responsibility will become more problematic. The central government recognizes this problem, and in order to continue to strive towards universal coverage, it is considering how it might introduce strategies to develop further approaches to co-finance service delivery at the local level.

The proposed funding requirements for the operational costs of preventive and promotive service delivery is under active consideration within the parliament at this time and known as the “BOK” fund.

Population covered: 
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Though the scheme has never been formally marketed, Jamkesmas has enrolled more beneficiaries than any other Indonesian health insurance plan. Its target population is defined using an annually administered national survey known as the SUSENAS according to daily household consumption estimates.

Though the scheme has never been formally marketed, Jamkesmas has enrolled more beneficiaries than any other Indonesian health insurance plan. Its target population is defined using an annually administered national survey known as the SUSENAS according to daily household consumption estimates.

SUSENAS is a social and economic household survey used to define total household consumption for GDP estimation purposes. Based on standard definitions of the poor in terms of daily household consumption, the total number of poor has been defined. The sub-national distribution of this total has also been defined in a similar manner.

P.T. Askes remains the administrator of membership in the Jamkesmas program since it has operated the program since 2005. P.T. Askes has a contract with the MoH to administer the membership part of the program separate from other programs. P.T. Askes obtains a list of the number of persons eligible each year from the Central Bureau of Statistics which is a part of Bappenas (the national planning agency). P.T. Askes then distributes the cards and registers enrollees into the program.

The Ministry of Home Affairs (MoHA) is responsible for the development of a national identity card to be distributed throughout the entire population. When this card has been distributed, it will become the basis for enrollment into the national health insurance program.

Jamkesmas is not being formally marketed, as it has been oversubscribed since its inception in 2008.

Benefits package: 
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Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited.

Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited.

Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan.

Service delivery system: 
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Jamkesmas beneficiaries are able to seek care at both public and private outlets, though covered ambulatory services are solely public. The scheme contracts with 926 hospitals for service provision, including 220 private hospitals for certain procedures. Health services across each public scheme in Indonesia are delivered by a mix of providers, with most schemes relying heavily on the public sector for delivery of care.

Jamkesmas beneficiaries are able to seek care at both public and private outlets, though covered ambulatory services are solely public. The scheme contracts with 926 hospitals for service provision, including 220 private hospitals for certain procedures. Health services across each public scheme in Indonesia are delivered by a mix of providers, with most schemes relying heavily on the public sector for delivery of care.

Institutional structures: 
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Presently, five main actors are involved in the administration of the Jamkesmas 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) public and private providers of care, and (5) the insurer/third-party administrator.

Presently, five main actors are involved in the administration of the Jamkesmas 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) public and private providers of care, and (5) the insurer/third-party administrator.

A revised institutional structure of Indonesia’s Jamkesmas scheme is currently being developed. The table below summarizes the roles and responsibilities of all of the organizations involved in implementing national health insurance, including Jamkesmas:

National Soc Sec Council (DJSN)National government agencies (MoH, MoF, MoHA, Menkokesra, Bappenas)Provincial and district governmentsProviders of careInsurer/TPA (Askes/ Jamsostek)
Oversight of schemeX (LR)X (SR)
Financing schemeXX
Setting parameters (benefits package, definitions of poor, etc.)X (LR)X (SR)
Accreditation/Empanelment of providersXX
EnrollmentXXX
Financial management/planningX (LR)X (SR)
Actuarial analysisX (LR)
Setting rate schedules for services/reimbursement ratesX (LR)X (SR)
Claims processing and paymentX (Under Review)XX (District level)
Outreach, Marketing to beneficiaries X
Service deliveryX
Developing clinical information system for monitoring/evalX (LR)X (SR)
Monitoring local-level utilization and other patient informationX (LR) X (SR)
Monitoring national aggregate informationX (LR)
Customer serviceXX

LR = long run; SR = short run

Note that the Ministry of Finance has an office overseeing insurance programs and carriers of all types. They also have actuarial capacity available when required.

Provider payment mechanisms: 
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While the Jamkesmas benefit package is standardized at the national level, districts are able to set the reimbursement rates for various services based on local conditions. Though the scheme initially utilized a fee-for-service reimbursement mechanism Jamkesmas began transitioning to a DRG provider payment system in 2009. All hospitals are being incorporated into the DRG payment process by the end of 2010.

While the Jamkesmas benefit package is standardized at the national level, districts are able to set the reimbursement rates for various services based on local conditions. Though the scheme initially utilized a fee-for-service reimbursement mechanism Jamkesmas began transitioning to a DRG provider payment system in 2009. All hospitals are being incorporated into the DRG payment process by the end of 2010.

Jamkesmas has “verificators” in every network hospital. These verificators have been put in place to assure reimbursements are made only for documentable claims with a full medical record. Verificators process claims and send them electronically to the MoH. Verificators have standard review procedures which they follow to document every case. These standards were developed by the MoH. Once the MoH receives the claim, it begins the reimbursement process to providers.

While there has been broad experience with contracting public and private providers through the publically-funded schemes, the contract mechanisms have not used reimbursement or payment policies strategically to drive improvements in quality or efficiency. There are examples in maternal health where the current reimbursement system by Jamkesmas has created the wrong incentives for providers, such as not reimbursing midwives for pre-delivery care if there is post-partum hemorrhage. In addition, once a patient is referred to the hospital, the hospital receives a full reimbursement for delivery, while the midwife receives no fee, thereby discouraging midwives from referring patients to hospitals for complications as they would lose income.

Monitoring and evaluation: 
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While there are no formal evaluations of the Jamkesmas scheme, the Indonesian government and many international organizations, including the World Bank and GTZ, are collaborating to improve the program to address both policy and implementation challenges.

While there are no formal evaluations of the Jamkesmas scheme, the Indonesian government and many international organizations, including the World Bank and GTZ, are collaborating to improve the program to address both policy and implementation challenges.

Data from the government suggest that Jamkesmas has made a significant impact. A high level of coverage has been achieved within less than 2 years, reaching 76 million poor and near poor enrollees. Total utilization of services has also 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.

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