Kebijakan Strategis untuk mengurangi ketidak adilan dalam mencapai Universal Health Coverage

Transkripsi

1 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

2 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

3 The Shortage of BPJS Sumber: Data klaim Bulan Pelayanan Jan s/d Des 2014 (Bulan Pembebanan s/d Jan 2015) dari BPJS, Maret Pardede,

4 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

5 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)? Bagaimana isu Ketidak adilan? Poor community paid by central government budget (PBI)? The ex PT Askes and PT Jamsostek members and formal sector? The Non-PBI Mandiri? How is equity issue is managed? 5

6 The Analysis Revenue Collection Pooling Purchasing 6

7 Tax Non-tax Health Financing (simplified) 489 ( 72.9 T) Local Gov MoH Other Ministries Pemda APBN (67,5 T) (19.93 T) PBI Primary Care BPJS Out pof pocket Non-PBI ex PT Askes Referral Care Non-PBI Mandiri Private Insuran ce 4 T l.k 20 T NHA 2009 : (18 T) 7

8 Tax Non-tax Revenue Colelection 489 ( 72.9 T) Local Gov MoH Other Ministries Pemda APBN (67,5 T) (19.93 T) PBI Primary Care BPJS Out pof pocket Non-PBI ex PT Askes Referral Care Non-PBI Mandiri Private Insuran ce 4 T T NHA 2009 : (18 T) 8

9 Pooling Two Big Pools 1. Ministry of Health 1. BPJS 1. APBN 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

10 Tax Non-tax What happened in the two Big Pools? APBN Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce 10

11 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

12 The new Hospital financed by private sector RS Kemkes Pemprov Pemkab Pemko Kementeri an lain TNI POLRI Swasta non profit Swasta Updated BUMN

13 Specialists Distribution

14 Tax Non-tax BPJS: Local Gov MoH Other Ministries Pemda APBN PBI Primary Care BPJS Out pof pocket Non-PBI ex PT Askes Referral Care Non-PBI Mandiri Private Insuran ce Kelompok sakit More Sick Members in the Voluntary Group Kelompok sehat 14

15 Pajak Pendapatan Negara bukan Pajak Adverse Selection problems in Non-PBI Mandiri Kemenkes APBN PBI BPJS Non-PBi PNS, Jamsostek dll dll Non-PBI Mandiri Askes Swasta Kelompok sakit Kelompok sehat Kementerian lain Pemda Pendapatan Asli Daerah Pelayanan Primer: Pelayanan Rujukan Dana dari Masyarakat langsung 15

16 The health risk in BPJS pool Non-PBI-Mandiri (Voluntary Group) Not poor, some rich. Kelompok sakit Kelompok sehat PBI members (poor member) Kelompok sakit Kelompok sehat Non-PBI (ex PT Askes )More Healthy members Kelompok sakit Kelompok sehat 16

17 Tax Non-tax What Happened in Purchasing? APBN Non-PBI ex PT Askes 489 ( 72.9 T) Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce 17

18 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 INA- CBG (DRG) type of payment 18

19 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

20 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

21 Tax Non-tax Who get the most from BPJS APBN Claim Ratio Less than 90% (Nov 2014) Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce In Nov 2014: Claim Ratio is around 1300% 21

22 Tax Non-tax The possibility: PBI Budget is used by Non-PBI Mandiri (Pekerja Bukan Penerima Upah) APBN Claim Ratio Less than 90% Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce In Nov 2014: Claim Ratio is around 1300% 22

23 Wheter UHC can be achieved in 2019? 23

24 Scenario 1: Optimistic Scenario 2: Pessimistic.

25 JKN increases geographical inequity, and also socio-economic inequity DIY NTT Zero UHC pessimistic scenario

26 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

27 More Strategic Policy using Health Sector Reform Concept Control Knobs Goal Pembiayaan/Fin ancing Pembayaran/Payme nt Pengorganisasian/O rganizing Regulasi/Regulation Promosi/Promotion Access Quality Efficiency Cost Equity? Status Kesehatan/ Health Status Kepuasan Publik/ Public Satisfaction Perlindungan Resiko/ Risk Protection (Harvard University-WB) 27

28 Proposed Strategic Policies in Financing to reduce in-equity 28

29 Pajak Pendapatan Negara bukan Pajak Short-term Policy recommendation in Financing APBN Non-PBi PNS, Jamsostek dll dll Kemenkes PBI BPJS Non-PBI Mandiri Askes Swasta Kementerian lain Pemda Pelayanan Primer: Pelayanan Rujukan Dana dari Masyarakat langsung 29

30 Tax Non-tax More Budget for MoH to improve the supply side APBN Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce 30

31 More MoH and local government budget to finance new health services and hospitals RS Kemkes Pemprov Pemkab Pemko Kementeri an lain TNI POLRI Swasta non profit Swasta Updated BUMN

32 More MoH budget for redistribution of Specialist

33 Tax Non-tax Do not increase the premium for PBI APBN Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce 33

34 Tax Non-tax Increase the premium for the middle and rich members APBN Non-PBI ex PT Askes Local Gov MoH Other Ministries Pemda PBI Primary Care BPJS Out pof pocket Referral Care Non-PBI Mandiri Private Insuran ce Aim: To reduce Claim Ratio 34

35 To reduce in-equity: there should be fundamental change in BPJS 35

36 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

37 Pajak Pendapatan Negara bukan Pajak Compartment in BPJS Kemenkes Kementerian lain Pemda Pendapatan Asli Daerah APBN PBI Pelayanan Primer: BPJS Rp Rp Rp Pelayanan Rujukan Dana dari Masyarakat langsung Non-PBi PNS, Jamsostek dll dll Non-PBI Mandiri Askes Swasta 37

38 Thank-you 38