NATIONAL HEALTH INSURANCE

Health insurance can improve access to health care for the insured  population and protect  hemfromthe financial burden of diseases. For example, a study found that uninsured children in the US were less likely to have a regular source of primary health care, and they used medical and dental care less often. Studies from China and the US have revealed that immunisation of children was positively associated with coverage by health insurance schemes (Jia L, at all, 2014).

The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, considerable investments have been made to increase health access for the poor. This strategy is in line with WHO recommendations to improve equity by reducing out-of-pocket expenditures for poor households and allocatingmore resources to those in need. The result of Indonesia’s UHC initiative is the roll-out and implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jaminan Kesehatan Masyarakat (Jamkesmas) [health insurance for the population] program (Mohamad I. Brooks, 2017)..

Program JKN adalah bentuk reformasi dibidang kesehatan yang bertujuan untuk mengatasi

permasalahan fragmentasi dan pembagian jaminan kesehatan. Permasalahan ini terjadi dalam skema Jaminan Kesehatan Masyarakat (Jamkesmas) dan Jaminan Kesehatan Daerah (Jamkesda) yang mengakibatkan biaya kesehatan dan mutu pelayanan yang tidak terkerdali. Jaminan Kesehatan Nasional (JKN) merupakan bagian dari Sistem Jaminan Sosial Nasional (SJSN) yang dilakukan melalui mekanisme asuransi kesehatan sosial yang bersifat wajib (mandatory) (Khariza, 2015).

Sementara itu menurut Peraturan  Menteri Kesehatan No.71 Tahun 2013, yang dimaksud dengan Jaminan Kesehatan adalah jaminan berupa perlindungan kesehatan agar peserta memperoleh manfaat pemeliharaan kesehatan dan perlindungan dalam memenuhi kebutuhan dasar kesehatan yang diberikan kepada setiap orang yang telah membayar iuran atau iurannya dibayar oleh pemerintah.

The Askeskin program was designed to increase access and quality of health services  for the poor through operational funds provided to puskesmas [community health center] in the form of capitation payments and a fee-for-service health insurance  scheme reimbursed through a quasi-governmental agency. The Askeskin program provided block grants through this agency to target the poor through the distribution of Askeskin health insurance cards and payment of hospital

claims. In 2008, the Askeskin program was expanded to include the near-poor as part of the new Jamkesmas program. Jamkesmas beneficiaries were required to sign up for health insurance cards. Households in the lowest twowealth quintiles were eligible for Jamkesmas and targeting

was done through a mixture of geographic and proxy means testing. The benefits of Jamkesmas included free health services in community health centers and 3rd class wards (basic level) in government hospitals and designated private hospitals. Jamkesmas beneficiaries were entitled to

comprehensive maternity benefits, including antenatal care, institutional delivery, and postnatal care (Rokx C, at all, 2009).

Even though total health expenditures (THE) per capita increased from US$20 to US$107 between 2002 and 2012, Indonesia’s expenditure on health as measured by the percent  of gross domestic product (GDP) on total health expenditure is low compared to the other countries in the

WHO South-East Asia Region (SEAR): 2.9% compared to regional average of 4.2% in 2012 (World Bank, 2015).

China’s public health insurance system covers the largest number of population in the world, however to be precise, the system itself is fragmented rather than integrated. At present, there are three major types of public insurance—the New Rural Cooperative Medical Scheme (NCMS), the Urban Employee Basic Medical Insurance (UEBMI), and the Urban Resident Basic Medical Insurance (URBMI), covering 95% of the entire population in China. The three insurance is designed according to the permanent residence registration system (aka the “Hukou” system) and/or the person’s employment status. The Hukou System classifies people as rural or urban residents based on their places of birth, which is not easily transferable from rural to urban residence. For example, due to the Hukou System, rural people migrating and living in urban areas may still remain in their rural residence status. The three insurance targets different populations, and Hukou becomes the main barrier to shifting across these insurance plans (Jin Y, at all, 2016).

In Germany and Chile, substitutive private health insurance coexists with social health insurance schemes which cover the majority of their respective populations (Thomson S, at all, 2013). Although only a minority of the population in each country is covered by private health insurance, the choice between private and social insurance plays an important role in both countries’ health systems and crucially shapes the boundaries between the private and public health systems, and the regulation, financing and provision of each (Rothgang H., at all, 2005). One of the most discussed results of choice between private and social health insurance is risk segmentation (Thomson S, Mossialos E., 2006).  In both countries, it has been argued that this phenomenon is a direct consequence of choice. The funds from those who are able to afford and choose private health insurance are pooled separately from mandatory social health insurance wage deductions, creating strong incentives for private insurers to select for those who can afford private health insurance (Sapelli C., 2004).

The growing momentum for quality and affordable health care for all has given rise to the recent global universal health coverage (UHC) movement. As part of Indonesia’s strategy to achieve the goal of UHC, considerable investments have been made to increase health access for the poor . This strategy is in line with WHO recommendations to improve equity by reducing out-of-pocket expenditures for poor households and allocating more resources to those in need (WHO. The world health report, 2010). The result of Indonesia’s UHC initiative is the roll-out and implementation of various health insurance schemes targeted towards the poor and near-poor, including the Jaminan Kesehatan Masyarakat (Jamkesmas) [health insurance for the population] program.

The 2012 Indonesian Demographic Health Survey (IDHS) included responses from 45,607 women of reproductive age (15–49 years old). Background characteristics for the complete IDHS 2012 dataset are presented in the Appendix. Among all Indonesian women of reproductive

age, close to two-thirds (63.0%) had no health insurance coverage. About one-fifth (19.1%) of all Indonesian women had Jamkesmas health insurance; a similar proportion (17.9%) had other forms of health insurance schemes (Mohamad I. Brooks, 2017).

The interest in Willingness To Pay (WTP) for health insurance arises in settings where on the one hand access to healthcare is mostly contingent on Out-Of-Pocket Spending (OOPS) by health seekers, and on the other hand health insurance schemes must know upfront how much

they could charge as premium, to ensure their financial sustainability. This is particularly relevant in Low- and Middle-Income Countries (LMICs); by one estimate, only 5–10% of population in sub-Saharan Africa and South Asia are covered by social healthcare schemes that are funded by the state, and in many middle-income countries the effective cost coverage of

mandatory health insurance schemes ranges from 20 to 60%, leaving even insured persons

exposed to considerable OOP (Nosratnejad, S., At All, 2016).

In 2012 the UN General Assembly, in the framework of the Resolution on ‘universal health coverage’, called upon Member States “to ensure that health financing systems evolve so as to avoid significant direct payments at the point of delivery and include a method for prepayment of financial contributions for health care and services as well as a mechanism to pool risks among the population in order to avoid catastrophic health-care expenditure and impoverishment of individuals as a result of seeking the care needed” (Soini EJ., 2012). Other factors may also affect WTP. For example, when the concept / value proposition of “insurance” is unclear, or when households consider their ability to avail health care as slim (e.g. because the service provider is too far away, or because of previous negative experiences), they may report a lower WTP (Spaan E., At All, 2012).

Strategies in this review are defined as measures used to expand health insurance coverage. These strategies canmainly be grouped into the following categories:

  1. Strategies adopted during design

Modifying the eligibility criteria: this strategy included legislation or regulations to make uninsured populations eligible for health insurance schemes. For example, in the US, in California’s poverty expansion programmes for Medicaid infants are eligible for Medicaid if their parents’ income is up to 200% of the FPL; children under 6 years old are eligible if it is up to 133%; for children 6 to 15 years up to 100%; and for children 15 years and older up to 83% of the FPL (Aizer A. 2002).

  1. Strategies added to programme implementation

Modifying enrolment: this refers to any methods of improving or simplifying the enrolment procedures, including programmes that help families with the paperwork and other aspects of the application; positioning eligibility workers in schools or health facilities; authorising more entities to interview applicants; and shared eligibility with other insurance or public

programmes. For example, the state government of Californiaworked with community-based organisations to provide application assistance to families who were potentially eligible for Healthy Families (California SCHIP) or Medicaid (Buchmueller, 2007).

Improving management and organisation of insurance schemes: this refers to strategies that aim to improve the capacity  of insurers to manage the insurance schemes, including better

information systems and training staff for better and more  effective outreach and management. For example, in order to enrol Latino children, many states in the US have supported staff development and training in cultural competency to include  appropriate family members (Zambrana 2004).

 

REFERENCES

 

Aizer A., 2002, Covering Kids: efforts to increase the health insurance coverage of poor children. University of California, Los Angeles.

Buchmueller T, Lo Sasso A, Wong KN., 2008, How did SCHIP affect the insurance coverage of immigrant children?. Health Care Economics and Policy

Jia L, Yuan B, Huang F, Lu Y, Garner P, Meng Q,  2014, Strategies for expanding health insurance coverage in vulnerable populations (Review). The Cochrane Library

Jin Y, Hou Z, Zhang D, 2016, Determinants of Health Insurance Coverage among People Aged 45 and over in China: Who Buys Public, Private and Multiple Insurance. PLoS ONE 11(8)

Khariza, HA., 2015, Program Jaminan Kesehatan Nasional: Studi Deskriptif Tentang Faktor-Faktor Yang Dapat Mempengaruhi Keberhasilan Implementasi Program Jaminan Kesehatan Nasional Di Rumah Sakit Jiwa Menur Surabaya, Kebijakan dan Manajemen Publik Volume 3, Nomor 1

Mohamad I. Brooks, 2017, Health facility and skilled birth deliveries among poor women with Jamkesmas health insurance in Indonesia: a mixedmethods study, Brooks et al. BMC Health Services Research

Nosratnejad, S., Arash Rashidian, A.,  Dror, DM., 2016, Systematic Review of Willingness to Pay for Health Insurance in Low and Middle Income Countries, Journal.pone.0157470

Peraturan  Menteri Kesehatan No.71 Tahun 2013Tentang Pelayanan Kesehatan Pada Jaminan Kesehatan Nasional.

Rokx C, Schieber G, Harimurti P, Tandon A, Somanathan A. 2009,  Health Financing in Indonesia: A Roadmap for Reform (1st ed.). Washington DC: World Bank Publications

Rothgang H, Cacace M, Grimmeisen S, Wendt C., 2005, The changing role of the state in healthcare systems. Eur Rev

Sapelli C., 2004, Risk segmentation and equity in the Chilean mandatory health insurance system. Soc Sci Med.

Soini EJ., 2012, Contingent valuation of Eight new treatments: What is the clinician’s and politician’s willingness to pay?, The Open Complementary Medicine Journal. Apr 20

Spaan E, Mathijssen J, Tromp N, McBain F, Have A, Baltussen R., 2012, The impact of health insurance in Africa and Asia: A systematic review. Bulletin of the World Health Organization. Sep 1; 90 (9):685–92. doi: 10.2471/BLT.12.102301 PMID: 22984313

Thomson S, Busse R, Crivelli L, van de Ven W, Van de Voorde C., 2013, Statutory health insurance competition in Europe: a four-country comparison. Health Policy.

Thomson S, Mossialos E., 2006,  Choice of public or private health insurance: learning from the experience of Germany and the Netherlands. J Eur Soc Policy.

WHO. The world health report, 2010. Health systems financing: the path to universal coverage. Geneva: WHO

World Bank., 2015, World Development Indicators 2015 (1st ed.). Washington DC: World Bank Publications

Zambrana RE, Carter-Pokras O., 2004, Improving health insurance coverage for Latino children: a review of barriers, challenges and State strategies. Journal of the National Medical Association

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