Jampersal (Maternity Insurance) as a step towards universal coverage and

health equity: experience of Indonesia*

Soewarta KosenHealth Economics and Policy Analysis Unit,

Center for Community Empowerment, Health Policy and Humanities, National Institute of Health Research & Development

Ministry of Health Republic of Indonesia

*Presented at the 4th Technical Review and Planning Meeting for the Health Policy and Health Finance Knowledge Hub,

Melbourne 10 -11 October 2011

BACKGROUND

• Indonesian Constitution (1945) stated the right of every citizen to obtain health care

• Indonesian Health Law (2009): right to obtain safe, accessible and quality health care

• The government is responsible to provide quality health services

• Social Security Law enacted since 2004, however the implementation is still fragmented

COVERAGE OF HEALTH INSURANCE (2010)

Distribusi Penduduk yang memiliki Jaminan Kesehatan (asuransi kesehatan) menurut Jenis Jaminan

43.98

56.02

Tidak memiliki Jamkes Punya Jamkes

Local Health Insurance (JAMKESDA) exists in 250 districts/cities

4 Provinces with Universal Coverage:South Sumatra, South Sulawesi, Bali, Nanggroe Aceh Darussalam

Proportion of Population with health insurance

12.45 3.33

57.78

20.83

5.61

Askes PNS&TNI POLRI JamsostekJamkesmas JamkesdaAsuransi Swasta & Lain

HEALTH INITIATIVES

• Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) has been implemented since January 2005 for 76.4 million (the poor and the near poor) to cover free primary health care services including maternity care at community health center (Puskesmas) and in-patient services in hospital wards (third class). The Ministry of Health has managed the implementation since 2008, and directly distribute the fund to Puskesmas and hospitals

• A universal maternity Benefit (Jaminan Persalinan/ Jampersal) is implemented since January 2011 for all pregnant women who are not covered by any maternity scheme.

BACKGROUND

• Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) is delivered through 8.917 community health centers/ PUSKESMAS) and hospitals (public and private)

• Maternity Insurance is delivered through physician and midwife practitioners, community health center/PUSKESMAS, maternity clinic and hospital

• Fund is channelled from central to district/city through social assistance mechanism

• Total budget for both programs in 2011: 6.3 Trillion Rupiahs (800 Million Au $)

6

Wilayah Sumatera

Share PDRB thdp Nasional

21,55%

Pertumb. Ekonomi 4,65%

Pendaptn perkapita 9,80 jt

Penduduk miskin 7,3 jt (14,4%)

Wilayah Jawa Bali

Share PDRB thdp Nasional

62,00%

Pertumbh Ekonomi 5.89%

Pendapt perkapita 11,27 jt

Pendudk miskin 20,19 jt (12,5%)

Wilayah Nusa Tenggara

Share PDRB thdp Nasional

1,42%

Pertmbuh Ekonomi 3,50%

Pendapt perkapita

3,18 jt

Pendudk miskin 2,17 jt (24,8%)

Wilayah Kalimantan

Share PDRB thdp Nasional

8,83%

Pertumb. Ekonomi 5.26%

Pendaptn perkapita 13,99 jt

Pendudk miskin 1,21 jt (9%)

Wilayah Sulawesi

Share PDRB thdp Nasional

4,60%

Pertmbh Ekonomi 7.72%

Pendapt perkapita 4,98 jt

Pendudk miskin 2,61 jt (17,6%)

Wilayah Maluku

Share PDRB thdp Nasional

0,32%

Pertumbh Ekonomi 4,94%

Pendaptn perkapita 2,81 jt

Pendudk miskin 0,49 jt (20,5%)

Wilayah Papua

Share PDRB thdp Nasional

1,28%

Pertmbuh Ekonomi 0,60%

Pendaptn perkapita 8,96 jt

Pndudk miskin 0,98 jt (36,1%)

Source : Statistics Ind. 2008Note: based on constant prices

Seven Development Area of BAPPENAS, 2008

REASONS TO IMPLEMENT JAMPERSAL

• High maternal, neonatal and infant mortality rates• Coverage of deliveries in health care facilities: 55.4 %• Decrease Contraceptive Prevalence Rate• Problems of geographical and financial access• Need to focus on delivery period and immediate post-

delivery period (90 % of complications) that include:– Post delivery bleeding (28 %)– Toxaemia (24 %)– Infection (11 %)– Puerperal complication (11 %)

Neonatal mortality by Island group, Indonesia, 1990 - 2015

Neonatal Mortality by Wealth Group

10

Infant Mortality Rate decreases from 35 to 34 per 1000 live births, with disparity among provinces

Source: DHS 2007MDG target for IMR: 23 per 1,000 live births by 2015

Angka Kematian Bayi (Per 1.000 Kelahiran Hidup)

Per Provinsi Tahun 2007

25

46 47

37 3942

4643

3943

28

39

2619

35

46

34

72

57

46

30

58

26

35

60

41 41

52

74

59

51

4136 34

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60

70

80

NA

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Angka Nasional34

Maternal Mortality Rate, Indonesia 1994 - 2007

11Source: DHS

390

334

307

228 226

102

0

50

100

150

200

250

300

350

400

450

1994 1997 2002 2007 2009 2015

AK

I Pe

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MDG Target

Sasaran RPJM

Angka Kematian Ibu

12

Disparity by quintile of income

Infant Mortality Rate by quintile of income 56

47

3329 26

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4 Q5

Sumber data : SDKI 2007

22.1

19.518.1

16.5

13.7

0

5

10

15

20

25

Kuintil 1 Kuintil 2 Kuintil 3 Kuintil 4 Kuintil 5

Kekurangan Gizi

Malnutrition among children under fives by

quintile of income

Sumber data : Susenas, 2007

Proportion of Safe Delivery (attended by trained health personnel) by expenditure Quintile

(Susenas 2006)

57.9

94.8Equity Index1.67

Objectives of Maternity Insurance

• To increase coverage of prenatal care, delivery attendance and puerperal care by trained health personnel

• To increase coverage of neonatal care by trained personnel

• To increase coverage of post-delivery family planning services

• To increase coverage of complication management for mothers and babies

FACILITIES FOR MATERNITY INSURANCE Contracted facilities (public and private) in all over Indonesia

Facilities for normal pregnant women, delivery and puerperal period:

* Community Health Center (Puskesmas) with or without in-patient facilities

* Village Maternity Hut (Polindes* General Practitioner * Midwife Practitioner * Private Maternity Clinic

•Facilities for emergency obstetric & neonatal management or complications: * Puskesmas with basic obstetric-neonatal emergency facilities * Hospitals

15

Availability of referral facilities (public hospital and private hospital) for JamKesMas/Health Insurance for the poor, 2008 - 2010

2008 2009 20100

200

400

600

800

1000

1200

855954

1012

582650 665

273 304 337

Faskes Jamkesmas

RS Pemerintah

RS Swasta

DISCUSSIONS

• The Health Insurance for the poor is estimated utilized only 40 millions out of 76.4 millions of poor people

• Under utilization showed by areas outside Jawa, Bali and Sumatra

• Main obstacles: poor geographical access & transport facilities and limited availability of health facilities (qualified personnel, drugs, equipment , physical infrastructure)

• Need special efforts to fix the situation, to achieve objectives of Maternity Insurance

CONCLUSIONS

• Universal coverage of Maternity Insurance as well as future social health insurance will be less effective with identified obstacles

• The government should solve several “bottle-neck” that include:– hiring and placement of physicians in remote and poor area– Increase quality and distribution of midwives– Improve availability and distribution of quality health care

facilities at primary and referral level – Improve availability and distribution of blood banks– Improve availability and distribution of Ob-Gyn and

Paediatricians in referral facilities

TERIMA KASIH