Disclaimer: The views expressed in this paper/presentation are the views of the author and do not

necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors,
or the governments they represent. ADB does not guarantee the accuracy of the data included in this
paper and accepts no responsibility for any consequence of their use. Terminology used may not
necessarily be consistent with ADB official terms.

Governance Challenges for Expanding Universal

Health Coverage in the Presence of Informality in
Indonesia
Teguh Dartanto
The Poverty and Social Protection Research Group
LPEM FEB-UI

The National Health Insurance for Universal Health Coverage Meeting

ADB Headquarter Manila, September 27-30, 2016

11/10/2016

1.1 A Long Journey to Jaminan Kesehatan Nasional (JKN)

The first stage of

UHC:
1998-2013
focusing to low
and vulnerable
groups
The second phase
of UHC:
Integrating all
insurance
system and
covering nonpoor working in
the informal
sector

11/10/2016

1.2 Briefly Overview of JKN System

Key features of JKN:

A Single carrier of BPJS

Kesehatan
Compulsory for all
residents (including
foreigner living at minimum
6 months) to register in
JKN
Contribution system
Self-enrolled for Informal
Sectors
Comprehensive package
Referral system

11/10/2016

Note: Any additional family members such as parents and parents in law may be
registered with a contribution rate of 1 per cent per person per month.
Source: Authors compilation
4

1.3 Governance Challenges on A Single Carrier of BPJS

Kesehatan
Institutional transformation followed by the transfer of participants, programs,
assets and liabilities, and rights and obligations.
Institutional challenge: Integrating different system & corporate culture into
BPJS Kesehatan:

Civil Servant, Retiree, Veteran PT. ASKES

Formal private sector JPK JAMSOSTEK
Police and Military ASABRI
JAMKESMAS & JAMKESDA Ministry of Health, Local Gov. & PT. ASKES

Different benefits for each type of insurance a single national standard (equity
in services) some groups decrease and others increase;
Rejection by health professionals due to asymmetric information and lack of
socialization changing the payment system (INA CBGs-Indonesia Case Base
Groups);
Wait and see private health service providers to join JKN program;
11/10/2016

2.1 Roadmap to Achieve UHC

86,4 million of PBI

Source: BPJS Kesehatans presentation material

111,6 million of BPJS

Kesehatan
148,2 million covered by any types
of health insurance

All residents covered by

BPJS Kesehatan

60,07 million of other health

insurance

90,4 million uncovered by health

insurance

2012

Activities:
Conversion, Integration, Expansion

73,8 million uncovered by

health insurance

2013

2014

Satisfaction rate 85%

2015

Integrating membership of JPK Jamsostek, Jamkesmas,

Askes PNS, TNI Polri into BPJS Kesehatan

2016

2017

2018

2019

Integration JAMKESDA and other types of insurance into BPJS Kesehatan

Integrating ASABRI into BPJS

Kesehatan

Making system and

proseduce of
membership and
premium collection

Mapping on
Company and
socialization

Syncronized data of coverage: JPK Jamsostek,

Jamkesmas dan Askes PNS/Sosial -- NIK

Expanding coverage for workers in Big, Medium, Small and Micro Enterprises
B

20%

50%

75%

100%

M
S

20%

50%

75%

100%

10%

30%

50%

70%

100%

Measuring consumer satisfcation every six month

Study on improvement of benefits and services every year

11/10/2016

100%

2.2 Coverage: Pre- and Early Stage of JKN

11/10/2016

2.3 Current Progress of JKN Coverage

Coverage of Membership BPJS Kesehatan (by 09/09/2016)
180

168.8
160

Insurance Coverage by 2015

156.38

140

133.36

Million

120

117

Uninsured
27%

100

91.17
80

60

Slowing down of coverage of informal sectors: from more than

1 million/month in 2014 to only 500 thousand/month in
2015/2016

40

53.59

BPJS
Kesehatan
62%

9%

38

21.4

24.3

20

Private &
Others
2%
Jamkesda

87

86.4

86.4

11.68

8.76
June-14

Dec-2014

23.36
14.22

13.9

5.5
3.66
Jan-14

19.7

June-15

Dec-15

Sept-16

Government Subsidy (PBI)

Formal Workers (PPU-PNS, TNI, POLRI, BUMN, BUMD, Private Sector)
Informal Workers/Sector (PBPU and BP)
Ex-Jamkesda (Subsidized by Local Government)

11/10/2016

Total

Source: Authors compilation from BPJS Kesehatan

and Susenas 2015
8

2.4 The Missing Middle Problem: The Current NHI System

Source: Author

Source: Author Calculation based on Susenas 2014

11/10/2016

11/10/2016

10

3.1 Responses of Non-Poor working in informal Sector to the New JKN System
(Survey in April 2014)
Reasons not Join JKN yet but Want to Join JKN

Dartanto et al. (forthcoming) shows that

Willingness to Pay (join) of workers in
informal sector to JKN (econometric
estimation):
Necessary condition increased
availability of health services
Sufficient condition improving
insurance literacy
Income do not the main obstacle
High risks people tends to join JKN

Source: Dartanto et al. (forthcoming)

11/10/2016

11

3.2 Attracting Health Service Providers to Join JKN System

Condition in 2013

Percentage of Health Facilities

joining the JKN System (09/2016)
General Practioners

14

Private Clinics

42

Puskesmas

93

Hospital

81

Source: LPEM FEUIs estimate, 2014

11/10/2016

20

40

60

80

100

Source: Authors Estimation

12

3.3 Availability of Health Services and Insurance Coverage

Provincial Data Level

Improving access to health facilities will expedite the expansion of universal health coverage
Source: Authors compilation based on BPJS Kesehatan database and Podes 2014
11/10/2016

13

3.4 Integrating Jamkesda into JKN System (20014-2015)

SNGs having established JAMKESDA (except Papua) tend not to
integrate their system into JKN
DKI Jakarta and Aceh integrate their
Jamkesda into JKN since 2014

Some other SNGs start to integrate to their system into

JKN 13 Provincial JAMKESDA managed by PT
ASKES

Some SNG reluctant to join JKN due to expensive premium

compared to their own system 20 Provincial JAMKESDA
managed by their own system.

Source: Authors compilation based

on BPJS Kesehatan database

11/10/2016

14

Sustainability Issues
ADB-LPEM FEB UI Report 2015

11/10/2016

15

3.6.1 Utilization and Claim Ratio by Types of Membership

Poor and Near Poor

(Government Subsidy)

Total Member (person)

Utilized Member
(person)

95,015,106

Formal Sectors

23,456,697

Self-Enrolled
Member (Informal
Sector/PBPU)
13,882,595

Total Member

132,354,398

3,608,629

4,492,821

4,510,874

12,612,324

Utilization Rate (%)

3.80

19.15

32.49

9.53

Av. Premium
(IDR/Capita/Month)

18,668

62,349

11,318

25,638

Av. Medical Cost

(IDR/Capita/Month)

8,813

72,629

73,036

26,859

47.21

116.49

645.32

104.76

Avarage Claim Ratio (%)

Deficit of BPJS
Kesehatan:
2014:
IDR 3.1T ($235M)

2015:
IDR 5.8T ($440M)
2016 projected
IDR 6.8T ($515M)

Source: BPJS Kesehatan Desember 2014 in ADB-LPEM Report 2015

11/10/2016Su

16

3.6.2 Sustainability of Premiums Payment of Self-Enrolled Member (Informal

Sectors)
Most Reasons For Joining NHI (%)
Divre II
Divre IV

15
13

Divre X

14

Total (Nasional)

14

34

15

40

17

40

38

32
20

17

16

Health Condition When Register NHI

(%)

4
12

23

25

6
7

Divre II

25

Divre IV

19

Divre X

Protection when they are sick

Reducing cost of health treatment

Health is priority

Others

Divre IV

23

77
Sick

Not sick

Reasons of Not Routine of Payment

Premium (%)

30.5

24.26

69.5

75.74

Divre II
Divre IV

10

29
15

Divre X

Divre X
Total

29.56

70.44

28.1

71.9

Not routine
11/10/2016

76

Premiums Payment (%)

Divre II

Source: ADB-LPEM
Report 2015

81
24

Total
Unhealthy condition

75

Total

19
19

14

21
22

44

18
23

41

31

32

24

Difficulty of Access to Payment

Uncertain Income

Forgot the Schedule of Payment

Others

39

Routine
17

3.6.3 Why do Workers in Informal Sector not pay premium regularly?

Source: ADB-LPEM Report 2015

11/10/2016

18

3.6.4 Sustainability of Premium Payment of Self-Enrolled JKN Member

(informal sector)
Almost one fourth of members registered when they sick they tends to stop to pay
the premium when they do not use services moral hazard;

Almost one third of self enrolled member (peserta mandiri) are not pay premium at a
sustainable way;
Income stability (Income) is still dominant factor for payment sustainability especially
for those living in outside Java where most of them highly depends on agriculture
activities;
Knowledge of social insurance are still important to promote sustainable of payment;

Sanction (2% fine) are not effective in promoting sustainable payment;

Availability of health services are important to boost the payment sustainability;

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19

Regulatory Reforms and Improving Stakeholder

Awareness

11/10/2016

20

4.1 Making Better and Sustainable JKN: Regulation Reforms

Tackling issues in informal sector
Type of Reform

Initial Stage of JKN (2014)

2014Q4-2016

Expected Outcome

Registration System

Individual based

Family based

Expanding coverage

Utilization

Directly register and use the

services (no waiting period)

7 days after the first payment of

premium (waiting period)
BPJS Reg. No. 211/2014

Reducing moral hazard and

expanding coverage

Premium
(IDR/Capita/Month) for
informal sector (nonwage recipient)

1.
2.

1.
2.

Improving sustainability and

reducing the deficit of BPJS
Kesehatan

Penalties of Irregular
Premium Payment

PBI (Gov. Sub): IDR 19,255

PBPU (informal sector)
Class-1: IDR 25,500
Class-2: IDR 42,500
Class-3: IDR 59,500

PBI (Gov. Sub): IDR 23,000

PBPU (informal sector)
Class-1: IDR 25,500
Class-2: IDR 51,000
Class-3: IDR 80,000

Perpres No.12 & No.111/2013

Perpres No.19 & No.28/2016

1. Deadline every 10th

2. 6 months of grass period
3. 2% penalty of premium

1.
2.
3.
4.

Deadline every 10th

Suspension of services
No penalty of 2%
Penalty charge of 2.5% of
total inpatient cost (if
hospitalized) within 45 days
after activation/payment

Note: increase the premium

may disincentive to join JKN
Improving sustainability and
reducing the deficit of BPJS
Kesehatan
(effective 1 July 2016)

Perpres No.19 & No.28/2016

11/10/2016

21

4.2 Promoting Mutual Understanding between Stakeholders:

UHC Not Cost but Investment on Healthier Future

Strong narrative reasoning about the importance of UHC is necessary to promote understanding
among stakeholders
11/10/2016

22

3.7 Providing Strong and Rigorous Evidence :

JKN as a Milestone Step with Promising Outcome
Variables

Health Insurance
Coverage (in %)
Health Expenditure percapita (in IDR) (t-1)

Life Expentancy

0.0290***
(4.08)
0.410***
(3.36)

Gross Enrollment Ratio

(Senior High School)

0.101***
(7.42)

GRDP Per-Percapita

0.693**
(2.56)

Variables

Life Expectancy (in year)

Capital per Labor

Observations
Adjusted R-squared
F

t statistics in parentheses
="* p<0.10
11/10/2016

0.0149*
(1.95)
0.413***
(13.62)

Gross Enrollment Ratio

0.0206***
(3.46)

Dummy East Indonesia (1:yes 0:otherwise)

-0.275***
(-6.11)

Constant

-2.637***
(-2.95)

Observations

Dummy East Indonesia Region

(1:yes
0:otherwise)

GRDP Per-Capita

341

-2.162***

Adj R2

0.693

(-6.02)

F stat

152,7

349
0.547
109.2

100% UHC increase life expectancy by 2.9 year

Above evidence of how important of UHC
are probable more convincing and acceptable to Ministry of
Finance
23

Key Messages
An implementation of the national health insurance (JKN Program):
on the Right Track, but Many Problems;
The current path of coverage UHC in 2019 seems unachievable;

The Missing Middle Problem (non-poor working in the informal

sector): problems in expansion and sustainability;
Availability of health services and insurance literacy are important for
expansion coverage and sustainability;
Reforms are done, but outcome still needs a time;

Providing strong and rigorous evidence for improving stakeholders

awareness;
11/10/2016

24

THANK YOU
Any inquiry
Teguh Dartanto (Head of Research Group), E-mail: teguh@lpem-feui.org
Chairina Hanum (Project Manager of Research Group), E-mail: hanum@lpem-feui.org

11/10/2016

25