Lesson from Indonesia: From Micro Health Insurance to the Birth of the Largest Single Payer System

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1 Lesson from Indonesia: From Micro Health Insurance to the Birth of the Largest Single Payer System Hasbullah Thabrany Center for Health Economics and Policy, Universitas Indonesia, Indonesia Presented at the Prince Mahidol Award Conference, Bangkok, January 24-28, 2012 Introduction After the New Order, during the Suharto era in , the Indonesian economy and health system grew significantly. In 1966, per capita Indonesia income was less than USD 300. In the early 1990s, the Indonesian economy grew on average 7% a year with Gross Domestic Products (GDP) per capita reached USD Between mid 1997 and end 1998 Indonesia suffered from severe drought, extensive forest fires and exchange crisis creating the worst economic crisis in Indonesian history. The Indonesian currency, Rupiah IDR, plunged 600% (from IDR 2,300 in June 1997 to IDR 15,000 per USD in January 1998). The real income per capita dropped to USD 600 resulting in massive laid off. It was estimated that more than 5.5 million Indonesians lost their jobs in The number of people living below poverty line plunged from 27 million to 85 million people over a year. 2 The international communities began to offer financial assistance to recover the economy and to protect the low-income citizens from devastating households economy. 3 The crisis triggered massive reforms in politic, economy, social security, education, and health sector. Social protection systems were installed. The immediate social protection programs covered distribution of subsidized rice, massive oil subsidies to prevent high inflation, massive bank bailouts, free health care for the poor, stimulus for opening new jobs, etc. However, those programs were temporary and funded by loan from ADB and the World Bank. Indonesia needed a sustainable social protection system funded from domestic sources. The relatively slow decrease in poverty level over a decade has proven that the social protection programs have not improved the economy of Indonesia. This phenomenon can be observed by looking relatively high growth of the economy since 1998 as shown in the Table 1. 4 From 1998 to 2010, the GDP grew about 15 times and the GDP per capita grew about five times. However, the reduction of poverty, using the National poverty line decreased less than half of the 1998 level. The paradox occurs due to the economic growths have not been in the real sector which absorb large employments. The poor design of social protection programs have not been successful in assisting the poor and the near poor to exit from poverty nor had

2 2 the programs solved the unemployment. The majority of labors in the formal sectors have not been covered by adequate health coverage. The informal sectors certainly had been in the worse condition without secure monthly income and without any health coverage. Table 1. Indonesian Economic Indicators, Indicators Unit Gross domestic product (GDP) Bill US-$ , GDP per capita, current prices US-$ 1, ,304 3,024 Economic growth % change YoY 8.2-6, Inflation rate % change YoY , Exchange rate, annual average IDR per US-$ 2,249 8,025 8,422 9,705 8,966 Labor forces (million people) Employed, formal sector (million people) Open Unemployment (million people) Partial unemployment (million people) Abstracted from The Central Bank of Indonesia, 2010 and Central Statistic Agency 2010 In 2010, there were 64,84 million of 116 million labor forces who work in the informal economy in Indonesia. In spite of good economic development, Indonesia is facing problems in providing health care for about 240 million people. Indonesia is facing tremendous challenges to provide health coverage especially for the growing informal sector and their family members. Employments on the formal sector had not grown as the speed of the growing labor forces. Normally, the informal sector is the immediate exit from poverty that is still very vulnerable from a devastating household economy once they are suffering from some what serious illnesses. Their incomes are low, near poverty line and no health coverage is available. Poor nutrition and lack of health coverage may prevent them from working properly. Once a social risk affect them, they may easily come back to the poverty. 5 The ILO Indonesia has been working hardly to ensure decent work and some social protections be provided. In 2002, ILO Indonesia wrote in as follows The current form of employment protection, especially income security for joblessness and retirement, is inseparably linked with the lack of an adequate social security system. Therefore, it is advisable that the development of a social security system that hedges the risks of old age and unemployment proceeds in conjunction with negotiation over labor regulation reforms. 6 Two years later, ILO Jakarta published a document, again, emphasizing the need to provide social protection of all. At that time, the number of labor forces was million and the informal sector was million. 7 However, until the end of 2010, the number of informal sector increased to 64,84 millions and the reform of social protection has not been implemented yet. The coverage for the formal sector has also not been expanded. Poorly, until now, Indonesia even has not ratified the 1952 ILO Convention C102 regarding Social Security (Minimum Standards). Boulton (2007), the Director of ILO Indonesia, politely stated the stagnant implementation of social security in Indonesia by saying However, Indonesia has faced a number of challenges in the implementation of the national social security system. 8 Now, a law regulation the National Health Insurance Corporation has been enacted in November The Indonesian people, as well as academicians, business communities, and the international

3 3 communities are focusing their attention on how good the Indonesia will implement the law. Opportunities and challenges are there. Previous Attempts of Resource Mobilization: from Commercial and Micro Insurance Schemes Attempts by Indonesia to expand health coverage started as early as the 1970s. During the Suharto era, massive expansions of primary health care (puskesmas) and district hospitals were made. Those public health facilities charged very little user fees to ensure affordability of health care. In addition, community programs to improve health of the people such as posyandu and other community movements were mushroomed. However, in the late 1980s, several international communities began to advocate cost-recovery of health services. Health services, especially, in public hospitals became more expensive and unaffordable. Efforts to mobilize resources to finance health care then became increasingly attracted attention by the health officials. Micro and Community Health Insurance Schemes Although at the beginning costs of health services were relatively low, the Ministry of Health already introduced a concept of micro financing scheme called Dana Sehat or health fund in the 70s. The initiatives were to complement massive expansions of public health care facilities. At that time, it was conceived that the government fund for health would not be sufficient. Under this assumption, the traditional low user fees in public health facilities was perceived inappropriate as those who were not poor did not need the government subsidies. Recommendations to increase user charges in public health facilities had been recommended by Gani et al (1997) 9 and YPKMI (1994) 10. However, higher user charges might pose a threat on access to health services by low-income groups. Therefore, mobilization of private funds to finance health care for their own health consumption was recommended. The Dana Sehat initiatives were introduced. The same initiatives have been also introduced in many developing countries such as reported by Musau (1999) 11, Atim et al (1998) 12, and Edmond (1999) 13 However, the health fund schemes in Indonesia had not address the access problems due to very low benefits and very limited coverage. Households had been spending very low percentage of their expenditure on health, ranging from 2-4% of the total monthly household expenditures. This low health expenditure represented low ability to pay for health services. Data from National Surveys (Susenas) showed that many households in low and lower middle income spent up to 80% of the household income on foods. Therefore there was little money left to purchase other services such as health care and education. Paradoxically, the Dana Sehat schemes were introduced mainly to the poor and low-income households by setting the contributions based on consensus among those households. The contribution was set very low, ranging from Rp 100 Rp 1,000 (between US cent) per household and the benefits were

4 4 mainly outpatient care at health centers. On the other hand, people could get access to health centers for Rp 1,000 (USD10 cents) per visit. This was one reason why efforts to mobilize resources through Dana Sehat had failed. There was no incentive for households to contribute to the health funds when the household could pay health services for the same amount of money. A study by Thabrany and Pujianto (1998) found that only 1.87% of the populations were member of health funds. There was about 47% higher utilization of health center services among the members compared to those who were non-members. Studies by Silitupen 14, Iriani 15, and Asnah 16 indicated that very few households paid contribution for more than two consecutive years. The studies found that drop out rates from the first year to the second year of health funds were between 60-90%. It was not surprising that since the introduction of these schemes in the 70s, there had been almost no progress on resource mobilization. After the social safety net program was introduced in 1999, following severe financial crisis in Indonesia, dana sehat schemes across the country practically terminated. 17 Traditional Health Insurance Before 1992, many big companies provided health benefits to their employees on voluntary basis. The scope of health benefits vary significantly from cash benefits, reimbursements, in kind benefits, or self provision of clinics or hospitals by the companies, depending on the size and location of the companies. There were no regulation mandating health benefits. Many smaller companies often did not (some still do not) provide health benefits at all. The bargaining power of labor unions has been very weak (because of the over supplies of cheap labors). An Insurance Act was passed in February 1992 permitting insurance companies to sell health insurance products. The Ministry of Finance was the main agency to regulate insurance companies. However, this Act does not regulate health insurance contract. It regulates practices of insurance business in Indonesia such as life insurance, general insurance, reinsurance, and other supporting insurance businesses. Based on this Act, insurance companies may sell any health insurance products such as traditional indemnity health insurance, managed care products, personal accidents, and other forms of health insurance. The Ministry of Finance is in charge of supervision, regulation, and controlling insurance industries mainly financial aspects such as solvency requirements. To stimulate the growth of commercial health insurance, the Employee Social Security Act (Jamsostek) was manipulated to provide opt out form employers to purchase commercial health insurance from both life and general insurance companies. The insurance companies started to sell health insurance as riders or as separate line of businesses. Many insurance companies that had have long relationships with businesses for life or general insurance could easily convince the business to purchase health insurance. Several foreign insurance companies such as Cigna, Aetna, and Allianz that have experiences abroad could easily transfer the knowledge and expertise in selling health insurance in Indonesia. Although there were relatively small number of companies that can afford to buy private health insurance, the market for health insurance has been promising. By 2010, 64 insurance companies sold various health insurance products (including personal accidents) covering about 7 million people. The

5 5 total premiums earned for health insurance products in 2010 was more than three times the amount of health insurance contribution received by the mandatory Social Security Scheme (Jamsostek). These traditional health insurance products have been the fastest growing business of health insurance in the country. However, we all should understand that the commercial health insurance will not be able to achieve universal coverage, nor does it do to egalitarian equity. The Failed of JPKM (HMOs) At the same time, the Ministry of Health (MoH) was looking for more formal health care financing schemes to reduce dependency on the government funding for health care. In the late 1980s, the MoH-USAID project provided promises of the so called (wrongly) prepaid health care. The MoH promoted the Health Maintenance Organizations (HMOs) model defined as noninsurance mechanism to justify control by MoH, not by MoF. The model was named JPKM stands for Jaminan Pemeliharaan Kesehatan Masyarakat or community health maintenance insurance. The JPKM/HMO is a commercial health insurance providing in kind benefits managed by various managed care organizations that are not insurance companies. The JPKM concept was promoted by Health Act of More significant actions to promote the development of JPKM had been done since Since then, the MoH had been actively promoting JPKM to various actors such as local governments, private businesses, private insurance companies, and communities at large. The promotion of JPKM aimed primarily at encouraging private sectors, mainly businesses, to conduct business of HMO/managed care products. A Ministerial decrees regulates requirements to meet capital requirements that are much less than the capital requirements for insurance companies under the Insurance Act (it can be less than 0.1% of the required capital for an insurance company). The MoH also regulated other products and procedures to conduct businesses of JPKM. Businesses that are willing to comply with and meet requirements will be granted a license by the Ministry of Health to sell managed care. However, those requirements were good only in theory; in practices no JPKM provided comprehensive health services, conduct quality assurance or utilization review and paying capitation to providers. Due to very slow development, after the crisis of 1998 the MoH, supported by loan from the Asian Development Bank (ADB) promoted further development of JPKM by allowing the social safety net funds to be used to develop JPKM. Under the social security scheme, the MoH provided funds to insure poor households, as described later. However, because of no knowledge of insurance, no control, and no ability to pay of the poor or near households, none of them succeeded to develop full JPKM. The massive failures gave good evidences for further reform of health care financing in Indonesia. Beside the MoH project, until 2003 there were 23 JPKMs established by investors covering less than 500 thousands individuals. Compared to the regulation of HMOs in America where at the beginning of HMO introduction, 96% of HMO were not-for profit organizations, 18 the JPKM regulation was much more liberal. The regulation requires that a JPKM company must be a legal for profit business entity. A business for profit entity would not conduct business to the low income, low profitability, and high health risks. Efforts to encourage businesses and insurance companies to sell JPKM and expand memberships have failed to expand coverage. The conflicting concept of JPKM, which would

6 6 combine business and social interests at the same time, and low capacity of the MoH to regulate, supervise, and understand the business of health insurance and the incompatible market in Indonesia were the main contributors for the massive failures of HMOs. Currently, the MoH is no longer regulate and license JPKM. The Social Safety Net Schemes The social safety net program at the first concept consists of three different financial assistances (from ADB loan of about USD 300 millions) to assure that the poor get access to necessary health services. There were three different programs in health sector: (1) The first program targeted high risk pregnant women by providing block grant of Rp 10,000 per poor household directly to a village midwife. The midwife then could use the fund to refer high-risk pregnant mothers to a health center or hospital for further treatments. This program increased access to hospital services for quite severe cases such as bleeding and complicated delivery. 19 (2) The second program was the promotion of JPKM. This program promoted the development of JPKM by providing public funds of Rp 10,000 per poor family to companies, cooperatives, or foundations seeking to establish an HMO in each district. The JPKM retained 8% of the funds for administration and marketing HMO products to non-poor household. The objective was that after two years the JPKM could expand membership to non-poor by selling the managed care products. Immediately, 354 JPKM were created the majority were established by civil servants, pensioners or cooperatives of civil servants within district health offices. They had no experience of developing and selling health insurance ever. After one year, under heavy criticism, this program was terminated and the funds for the second year were not disbursed. Evaluation of this project in East Java and in South Jakarta revealed that the JPKM had no prospect to do business of insurance (Retnaningsih ; Azwar ). (3) The third program was the assistance for health center services by providing block grant of Rp 10,000 per poor family to all health centers to recover some costs. The health center could use the money to buy drugs for the poor to supplement essential drugs supplied by the government. (4) In addition, public hospitals received some block grants for operational costs to care for the poor. The Birth of the Largest Single Payer System The Political Process When the per capita income of Indonesia achieved above USD 1,000 in the early 1990s, the government had come to conclude that social security system for labors in the private sector ought to be established. In 1992, a Labor Social Security System (nickname Jamsostek) was established. The system cover four mandatory programs: occupational injuries, provident fund (defined contribution) and death benefits. Although the law mandated all employers, the Government Regulation made health program as mandated only to employers that could not provide health benefits better than the one prescribed by under Jamsostek. Until 2003, only 1,2 million of 31 million labors in the formal sector were enrolled in health program of Jamsostek. 22

7 7 It was less than 5% of labors in the formal sectors. Among others, the low coverage was due to the opt out option provided by the government regulation. 23 Between 2000 and 2002, I chaired a team at the Universitas Indonesia to review Indonesian social protection systems under research grants from the National Planning Board (Bappenas) and the Office of Coordinating Ministry of Economic Affairs. The review indicated flaws of the Indonesian health financing/health insurance systems and the threats of future social problems unless a reform was made. At the same time, several international agencies warned the Indonesian Government that reforms on social systems and social protection systems ought to be undertaken to prevent severe future social problems. In 2001, the Vice President, Mrs. Megawati ordered her secretary to establish a team to review social security systems. When she became the fifth President of Indonesia then, in 2002 she issued a Presidential Decree establishing a Task Force to reform and design the National Social Security System (NSSS) or Sistem Jaminan Sosial Nasional (SJSN). In August 2002, the House of Representative (MPR) passed the Fourth Amendment of the Constitution amending Article 34 item 2 stating The state shall establish a national social security system for all citizens.. The Task Force consists of about 60 members was established representing various Ministries, existing social security carriers, and other relevant organizations. The large number of the Task Force members faced difficulties in making a uniform concept. After lengthy debates, finally the Task Force made the final Bill early 2004 and the President submitted the Bill on January 26, During the policy and concept development of the Bill all stakeholders (labor organizations, employers associations, business associations, local governments, and other stakeholders) were invited to contribute to the Academic Paper and the draft Bill. Several international agencies such as German Technical Assistance (GIZ), European Unions, the Asian Development Bank, the International Labor Organization, and the World Health Organization Representative provided several experts and grants. During National workshops with special employers and employee associations, resistances came out. Event during the process in the Parliament, many groups of stakeholders of employers and employee associations rejected the Bill. In addition to formal workshops, that are costly, social marketing and solicitations of the concepts and ideas were also made through various channels. The International Business Chamber of Commerce, claiming of having representatives from various major investor countries frequently voiced their oppositions to the Bill. In addition, fearing that the Bill would changed the status and the operation of existing social insurance carriers, two (of four) existing carriers silently and openly opposed the Bill. Even the Minister of Labor at that time initially opposed the Bill, perceiving that the Bill would put higher burden to workers. The oppositions stem from the following aspects: Mandatory system. Although it is universally practiced, it was surprising that employer associations, businesses, and even several government officials rejected the mandatory element of the social security. Many of them understood that a mandatory system would violate human rights, against fair business conduct, and would result in a poor management. They advocated to adopt market mechanisms. Rejection of mandatory contribution represents poor

8 8 understanding of social security concepts, as the answer to the market failures in social protection. They did not know that the market mechanism fails to protect every one because all people are short-sighted to their future risks. Integration of the social security systems. The current SS systems have been organized based on combination of the employment and the programs. The SS for private employees is administered by Jamsostek. Meanwhile, the SS for civil servants is administered by two different state enterprises (Askes and Taspen). The initial proposal of the National SS system in Indonesia would integrated all into a single public corporation. This integration later faced very tough resistances from two existing carriers, namely Taspen and Jamsostek causing delays in submitting the Bill. However, a compromise then was made to establish a National Social Security Council to harmonize and synchronize the administration of the existing SS systems. But, even up to March 2011, this integration remain intensively debated, creating further delay in SS reforms. Monopolistic/government control system. Several consultants of from the US came to advocate the private sectors to oppose monopolistic system. They advocated that the NSSS mandates employers and employees to purchase insurance from the private sectors. On paper, this concept sounds attractive. But, up to know, there is little evidence that private businesses have been successful in ensuring equitable SS system or in providing universal health coverage. Shared contribution. Initially, labor unions opposed share contribution. However, currently the majority of labor unions understood and willing to contribute for their health protection. Despite of all pros and contras, the law of the NSSS (law number 40/2004) was finally passed. The lengthy process indicated significant political influences was necessary to pass a law ensuring universal health coverage. After The Passage of the Law: Political Battles were Dominant After only four months the law was passed, the NSSS Law was judicially reviewed under the Constitutional Court (Mahkamah Konstitusi) to test against the Constitution. The law prescribed national SS schemes to ensure equity and fairness at all sub national levels. However, Local Parliament of East Java Province demanded that the NSSS be decentralized and given to local governments. They demanded that the National Social Security Carriers were dismissed. Fortunately, the Court rejected exclusive administration by local governments pertaining to no social justice would be established. The Court did acknowledge that local governments have the right to develop social security programs, without mention supplemental or complementary or the types of social security programs. The Court just mentioned that the local schemes must be under the framework of the NSSS. One of the most important Court decision was that the SS Carrier(s) must be established by a law. However, the Government failed to meet the deadline of October 2009 to establish the mandated non-for profit social security agency.

9 9 After the judicial review, several academicians and local governments have been trying to establish local schemes, but only for health coverage. The majority of local governments however, contracted the management of local schemes which were funded exclusively by local government budget to Askes, the National Carrier currently administering social health insurance for civil servants. Few local government were simply exempting user fees of public health centers to eliminate financial barriers to the local people. Few local governments exempted user fees of public hospital to eliminate financial barriers. Some local governments have tried to establish a local carrier because of no trust to Askes. Some local governments finally faced management problems due to lack of competencies. In 2010, inspiring by the failure of the government to draft a law regulating the SS Carrier(s), the Parliament took initiative to establish the law on SS Carrier as mandated by the Constitutional Court. In December 2010, finally the President appointed 8 (eight) Ministers as the Government Counterpart to develop the law. However, the dead-lock was occurred during the process. The source of dead-lock was simply on the regulation of the NSSS Carrier. The Parliament proposed a newly not-profit legal entity to be established guarded by a Tri-Partite body and regulated transparent administrative process of the NSSS Carrier. The Government team rejected the establishment of a new entity and regulating the NSSS Carrier. The Government team wanted the law just determining the existing carriers as the legal entities to administered the NSSS, maintaining a state enterprise status with which the Government has control over the social security fund. In February 2010, the President instructed Ministers, among other thing, to finalized the law of NSSS Carrier(s), a government regulation on subsidized contribution, and a presidential regulation on health coverage. Although the move invited a lot of media coverage, until end of 2010, there was no sign that the government would implement the law soon. Some scenarios of pension schemes for all employees were produced as the white paper for the implementation of the NSSS law (Wiener, 2008). 24 Several draft of implementing regulations had been circulated such as a draft of presidential regulation on national health insurance benefits and contribution, a draft of government regulation on subsidized contributions for the low income and (presumably) the informal sector. Yet, until the end of 2010, none of those drafts was signed by the President. In the same year, labor unions had already frustrated waiting for the implementation of the NSSS law. Although at the beginning many unions rejected the law, later they understood and supported the implementation of the law to protect labors, and all population, from having catastrophic disasters when one of their family members was suffering from a serious disease, death, or entering retirement age. In the labor day, May 1, 2010 about 100,000 labors demonstrated to the Palace demanding health insurance and pension for all for the whole life. Since the response from the Government was not considered inadequate, a Committee on Social Security Action (Komite Aksi Jaminan Sosial, KAJS), suit the President for not implementing the NSSS law. In the mean time, KAJS is threatening the Government to have a national strike, if the proposed reform of the NSS carrier is blocked. In May Day 2011, the KAJS again went strike to demand the Government to transform the existing state enterprise to establish a newly public not-for profit entity (Badan Penyelenggara Jaminan Sosial, BPJS)

10 10 administering social security for all. In July 2011, the Court decided that the government and the parliament as well guilty of neglecting the implementation of NSSS. The Establishment of the National Health Insurance Corporation (NHIC) Although, as described at the beginning that less than 10% of labors in the formal sector have a sustainable health coverage for themselves and their family, social protection for all labors is still far away. The KAJS (The Action Committee for Social Security) supported by more than 65 Labor Unions, NGOs, and Research Centers pushed hard to demand the government to implemented the NSSS Law as soon as possible. The moves by KAJS deems the most appropriate public pressure to ensure social security for all. Being aware of the high political nature of the implementation of the NSSS, KAJS organized collection of million signatures from labors to push the President to implement the law and to ensure social security for all. It was shameful if the government still hesitate to start the implementation for whatever reason. With more than USD 3,000 Gross National Income per capita, Indonesia is more than capable financially to start putting brick by brick to build a strong social security for all. After a long-battle in 2011 and under a heavy strikes on October 2011, finally the Government agreed to pass the BPJS law, establishing a National Health Insurance Corporation (NHIC). This corporation will start operating to administer universal coverage for all Indonesians starting January The NHIC will be the largest single payer to administer the NHI of Indonesia (INA- Medicare). The establishment of NHIC followed the same movement of a single payer system in Taiwan, the Philippine, and South Korea. The birth of the INA-Medicare poses management challenges to provide universal health coverage for 237 million people living in more than 5,000 islands of Indonesia. The advancement of communication and information technologies is expected to ease the implementation of INA-Medicare. The INA-Medicare would provide comprehensive health coverage in public and private providers using prospective payment systems. The payment levels may vary across regions. The fund will come form shared contributions of employees and employers (estimated at about 5% of monthly salary) and the government subsidies for the poor and near poor. The contribution for informal sectors who have no fixed monthly income will be set a nominal amount. Conclusion Efforts to mobilize funding from domestic resources have been in evolution in Indonesia starting with community insurance funds, commercial insurance, social safety nets, and social health insurance. The financial crisis of 1998 triggered failures and success of reform in health care financing. Finally, following universal system of social insurance model, Indonesia passed the National Social Security system in 2004 and the companion of the law of the National Health Insurance Corporation was passed in October Since a national health insurance and social security is always political, strong labors movements and pressures contributed significantly. The current law is expected to speed up universal health coverage in Indonesia.

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