Kebijakan Strategis untuk mengurangi ketidak adilan dalam mencapai Universal Health Coverage
Strategic Policy for narrowing inequity in Universal Health Coverage programs
Laksono Trisnantoro Universitas Gadjah Mada InaHEA 2nd National Meeting, Jakarta, 9th April 2015 1
What Happened in 2014 • JKN dimulai 1 Januari 2014 • Situasi supply-side dalam keadaan tidak seimbang.
- SDM dokter dan kesehatan tidak merata - Pelayanan kesehatan tidak merata
• Di awal tahun 2015, berbagai sumber menyatakan bahwa BPJS kekurangan 2 – 5 Triliun
• JKN started in January 2014 • Supply side is extremely not well distributed across Indonesia - Human resources - Health facilities
- In 2015 some report shows that BPJS is shortage of 2-4 Triliun
2
The Shortage of BPJS
Sumber: Data klaim Bulan Pelayanan Jan s/d Des 2014 (Bulan Pembebanan s/d Jan 2015) dari BPJS, Maret 2015.
•
Pardede, 2015
3
Who Gets What in 2014? • Siapa yang mendapatkan dana BPJS? • Apakah masyarakat yang membutuhkan?Ataukah justru masyarakat menengah ke atas di kota-kota besar?
• Who get what from BPJS expenditure? • Whether the poor or the better of community? • Whether people in the remote area or in the big cities
4
In more specific, which member group? • Kelompok masyarakat miskin yang dibayar melalui PBI? • Kelompok Non-PBI eks PT Askes Indonesia dan PT Jamsostek? • Kelompok Non-PBI Mandiri (Pekerja Bukan Penerima Upah)?
• Poor community paid by central government budget (PBI)? • The ex PT Askes and PT Jamsostek members and formal sector? • The Non-PBI Mandiri?
Bagaimana isu Ketidak adilan?
How is equity issue is managed? 5
The Analysis • Revenue Collection • Pooling • Purchasing
6
Tax Income
Non-tax Income
Health Financing (simplified) Non-PBI ex PT Askes
(67,5 T)
APBN (19.93 T)
PBI
MoH Other Ministries 489 ( 72.9 T)
Pemda
Local Gov
Primary Care
BPJS
l.K 20 T
Non-PBI Mandiri Private Insuran 4 T ce
Referral Care
Out pof pocket
NHA 2009 : (18 T)
7
Tax Income
Non-tax Income
Revenue Colelection Non-PBI ex PT Askes
(67,5 T)
APBN PBI
MoH Other Ministries 489 ( 72.9 T)
Pemda
Local Gov
(19.93 T)
Primary Care
BPJS
+20 T
Non-PBI Mandiri Private Insuran 4 T ce
Referral Care
Out pof pocket
NHA 2009 : (18 T) 8
Pooling 1. APBN
Two Big Pools 1. Ministry of Health 1. BPJS
1. MoH (47,5 T)—incl. PBI • Other Ministries (13,5 T) • Local Government (6.5 T of APBN)
2. BPJS Kesehatan • PBI (19,8 T) plus • Non PBI-ex PT Askes • Non PBI-Mandiri 9
Tax Income
Non-tax Income
What happened in the two Big Pools? Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries Pemda Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket 10
Ministry of Health Pada tahun 2014 • Dana investasi kecil untuk penambahan pelayanan kesehatan dan sumber daya kesehatan
In 2014: • Small Budget for Hospital Investment • Human Resources budget stagnant
11
The new Hospital financed by private sector 800 700 600 RS
500 400 300 200 100 Kemkes
Pemprov
Pemkab
Pemko
Kementeri an lain
TNI
POLRI
Swasta non profit
Swasta
BUMN
2012
32
85
411
86
3
105
29
654
237
77
2013
32
89
447
88
3
115
39
727
468
75
2014
33
96
455
92
3
118
41
724
599
67
Updated
34
97
459
92
5
127
43
733
694
66
Specialists Distribution
Tax Income
BPJS:
Non-tax Income
Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries Pemda Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
More Sick Members in the Voluntary Group
Referral Care
Out pof pocket
Kelompok sakit
Kelompok sehat 14
Pajak
Adverse Selection problems in Non-PBI Mandiri
Pendapatan Negara bukan Pajak
Non-PBi PNS, Jamsostek dll dll
APBN
Kelompok sakit
PBI
Kemenkes Kementerian lain Pemda Pendapatan Asli Daerah
BPJS
Pelayanan Primer:
Non-PBI Mandiri
Kelompok sehat
Askes Swasta
Pelayanan Rujukan
Dana dari Masyarakat langsung 15
The health risk in BPJS pool • Non-PBI-Mandiri (Voluntary Group) Not poor, some rich .
Kelompok sakit
• PBI members (poor member) Kelompok sakit
• Non-PBI (ex PT Askes )More Healthy members
Kelompok sakit
Kelompok sehat
Kelompok sehat
Kelompok sehat 16
Tax Income
Non-tax Income
What Happened in Purchasing? Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries 489 ( 72.9 T)
Pemda
Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket 17
BPJS, Purchasing and Payment Mechanism • Kapitasi untuk pelayanan kesehatan primer, dan
• Capitation for Primary Care
• Klaim untuk pelayanan kesehatan rujukan berbasis INA-CBG.
• Claim, based on INACBG (DRG) type of payment
18
The facts in 2014 • Kapitasi tidak terkait kinerja FKTP • Tidak ada batas atas (plafond) di RS dalam melakukan klaim. • Sistem Pencegahan dan Penindakan Fraud belum berjalan • Daerah dengan SDM lengkap, RS banyak, teknologi tinggi akan menyerap dana BPJS banyak
• Capitation is not linked with performance indicators • There is no upper limit for hospital in claiming the services • Fraud Prevention, Detection, dete rrence, and prosecution system is not yet established • Regions which have many doctors, health services, and high technology equipment get the fund more 19
The Risk of this current condition of financing • Health facilities in remote areas become more lagged behind • The distribution of human resources for health will suffer • Not efficient primary care • Fraud will be uncontrollable and make the use of resources become less efficient • Adverse selection problems • PBI budget is used by the middle and higher income group
• Pembangunan RS dan faskes di daerah terpencil tidak dapat mengejar ketinggalan • SDM kesehatan semakin tidak merata • FKTP tidak efisien • Klaim INA-CBGs tidak dijamin efisiensinya karena fraud tidak terkendali • Problem Adverse Selection semakin meningkat • PBI (APBN) disinyalir menanggung biaya pelayanan kesehatan Non PBI (mandiri) 20
Tax Income
Non-tax Income
Who get the most from BPJS
APBN
Claim Ratio Less than 90% (Nov 2014)
PBI
MoH Other Ministries Pemda Local Gov
Primary Care
Non-PBI ex PT Askes
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket
In Nov 2014: Claim Ratio is around 1300%
21
Tax Income
The possibility: PBI Budget is used by Non-PBI Mandiri (Pekerja Bukan Penerima Upah)
Non-tax Income
APBN
Claim Ratio Less than 90%
PBI
MoH Other Ministries Pemda Local Gov
Primary Care
Non-PBI ex PT Askes
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket
In Nov 2014: Claim Ratio is around 1300%
22
• Wheter UHC can be achieved in 2019?
23
Scenario 1: Optimistic Scenario 2: Pessimistic.
JKN increases geographical inequity, and also socio-economic inequity DIY
NTT
Zero 2014
2015
2016
2017
UHC pessimistic scenario
2018
2019
Proposed Strategic Policy to reduce inequity 1. Using more reform approach in JKN; Not only Financing; 2. Short term recommendation in Financing Policy (Revenue Collection, Pooling and Purchasing). 26
More Strategic Policy using Health Sector Reform Concept Control Knobs Goal Status Kesehatan/ Health Status
• Pembiayaan/Fin ancing • Pembayaran/Payme nt • Pengorganisasian/O rganizing • Regulasi/Regulation • Promosi/Promotion
Access Quality Efficiency
Kepuasan Publik/ Public Satisfaction
Cost
Equity? (Harvard University-WB)
Perlindungan Resiko/ Risk Protection
27
Proposed Strategic Policies in Financing to reduce in-equity
28
Pajak
Short-term Policy recommendation in Financing
Pendapatan Negara bukan Pajak
Non-PBi PNS, Jamsostek dll dll
APBN PBI
Kemenkes Kementerian lain Pemda
BPJS
Pelayanan Primer:
Non-PBI Mandiri Askes Swasta
Pelayanan Rujukan
Dana dari Masyarakat langsung 29
Tax Income
More Budget for MoH to improve the supply side
Non-tax Income
Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries Pemda Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket 30
More MoH and local government budget to finance new health services and hospitals 800 700 600 RS
500 400 300 200 100 Kemkes
Pemprov
Pemkab
Pemko
Kementeri an lain
TNI
POLRI
Swasta non profit
Swasta
BUMN
2012
32
85
411
86
3
105
29
654
237
77
2013
32
89
447
88
3
115
39
727
468
75
2014
33
96
455
92
3
118
41
724
599
67
Updated
34
97
459
92
5
127
43
733
694
66
More MoH budget for redistribution of Specialist
Tax Income
Non-tax Income
Do not increase the premium for PBI Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries Pemda Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Out pof pocket 33
Tax Income
Increase the premium for the middle and rich members
Non-tax Income
Non-PBI ex PT Askes
APBN PBI
MoH Other Ministries Pemda Local Gov
Primary Care
BPJS
Non-PBI Mandiri Private Insuran ce
Referral Care
Aim: To reduce Claim Ratio
Out pof pocket 34
To reduce in-equity: there should be fundamental change in BPJS
35
Needs compartment in BPJS • In BPJS there should be compartment based on source of income and expenditure
Aim: • To prevent the budget from PBI to be used by Non-PBI-mandiri members (State budget for the poor should be used by the poor) 36
Pajak
Pendapatan Negara bukan Pajak
Compartment in BPJS BPJS
APBN
Rp
PBI
Rp
Kemenkes Kementerian lain Pemda Pendapatan Asli Daerah
Non-PBi PNS, Jamsostek dll dll
Rp
Non-PBI Mandiri Askes Swasta
Pelayanan Primer:
Pelayanan Rujukan
Dana dari Masyarakat langsung 37
Thank-you
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