Politics of National Health Insurance
of Indonesia: A New Era of
Universal Coverage
Hasbullah Thabrany
Institute for Social Security,
University of Indonesia
hasbullah.thabrany@ui.edu
H Thabrany/ISS UI
1
Conditions of 2004
• Government financing mainly trhough supply side
subsidy: inappropriate, lost and corrupt
• Access to Primary care is OK, but quality is poor
• High and uncertain out of pocket: public hospital
charge fee for service
• High burden of out of pocket: 100% - 240% of
monthly income for a single hospitalization: 83%
households needed inpatient care experiences
catastrophic health expenditures
• Corporatization and “privatization” of public
hospitals: increasing financial barriers
H Thabrany/ISS UI
2
H Thabrany/ISS UI
3
H Thabrany/ISS UI
4
H Thabrany/ISS UI
5
The Driving Forces for Reforms
1. Amendment of the Constitution, 2002
2. Political Agenda?
3. Perceived Gaps
4. Academic Exercises and International Pressures
H Thabrany/ISS UI
6
H Thabrany/ISS UI
7
H Thabrany/ISS UI
8
H Thabrany/ISS UI
9
H Thabrany/ISS UI
10
H Thabrany/ISS UI
11
Political Process
• The Indonesian Law process
– Government submit a Bill-discuss by
Parliament and the Government
– Parliament initiate a Bill-response by the
Government by sending ‘partner’ to be
discussed together
• Both initiatives solicit ideas, concepts, etc
from the public
H Thabrany/ISS UI
12
H Thabrany/ISS UI
13
Political Interventions during
Process
• In each step, stakeholders may intervene.
• Supports by donors: GTZ, EU, ILO, WHO, ADB,
AUSAID
• During the process in the Parliament, demos of to support
or to reject the Bill have been made by Employer and
Employee Associations
• Opinions also published through News and Articles in
newspapers and magazines
• International Bussiness Chamber of Commerces,
frequently voiced their oppositions
• An analysis, threatening the Government, was sent by a
USAID consultant
• Organized meetings by NGOs supported by USAID to
voice opposition with the concept
H Thabrany/ISS UI
14
The Askeskin, Government
Sponsored Insurance for the Poor
• Starting January 2005, the new government,
promising free health care before, paid the first
contribution for 36,7 million the poor.
• Administration of the scheme undertook by Askes,
the administrator for National SHI for civil
servants. 40 years experienced with more than 280
branch offices
• Criticisms and complaints were sent, especially by
HMOs (JPKM)
H Thabrany/ISS UI
15
Two Months After Government
Paid the First Contribution
• The law was challenged to the Constitutional Court by
provincial legislative, East Java Province, claiming the HI
is a provincial jurisdiction. It was rejected
• Two years after Askes administered, accusation of
mismanaged fund by Askes voiced by some MoH officials
• In 2008, administration by Askes was truncated to only
membership administration. Claim by hospital paid
directly by MoH
• Financial audit was undertaken. No misconduct was found.
But the official at MOH continue to administer the fund by
themselves
H Thabrany/ISS UI
16
After almost five years, the law has not been
implemented and objections are on:
• Mandatory system
• Monopolistic system/central government
control system. Although it is actually by a
quasi-government autonomy body
• Shared contribution by employees
• Integration of the system into a single scheme
• Demand for provincial control on fund
management
H Thabrany/ISS UI
17
Conclusion
• Indonesia has long implemented social health insurance,
but it grows very slowly due to inconsistent
implementation of SHI principles
• Current SHI implementation needs improvement in
benefits, premiums, management, and payment to
providers. This improvement is being undertaken
• A National Health Insurance Program was passed, but
many resistances and trials (including political “lipsticks”
promising “free health care” by candidates of governors)
are being voiced
H Thabrany/ISS UI
18
Thank You
H Thabrany/ISS UI
19