Jampersal (Maternity Insurance) as a
step towards universal coverage and
health equity: experience of Indonesia*
Soewarta Kosen
Health 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
Proportion of Population with
health insurance
5.61
12.45
3.33
20.83
43.98
57.78
Askes PNS&TNI POLRI
Jamkesmas
Asuransi Swasta & Lain
56.02
Jamsostek
Jamkesda
Local Health Insurance (JAMKESDA) exists in
250 districts/cities
Tidak memiliki Jamkes
4 Provinces with Universal Coverage:
South Sumatra, South Sulawesi, Bali,
Nanggroe Aceh Darussalam
Punya Jamkes
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 $)
Seven Development Area of
BAPPENAS, 2008
Wilayah Sumatera
Share PDRB thdp
Nasional
Pertumb. Ekonomi
21,55%
4,65%
Pendaptn perkapita
9,80 jt
Penduduk miskin
7,3 jt (14,4%)
Wilayah Kalimantan
Share PDRB thdp
Nasional
Pertumb. Ekonomi
Wilayah Sulawesi
Share PDRB thdp
Nasional
Pertmbh Ekonomi
7.72%
Pendapt perkapita
4,98 jt
Pendudk miskin 2,61 jt (17,6%)
8,83%
Wilayah Papua
Share PDRB thdp
Nasional
Pertmbuh Ekonomi
1,28%
5.26%
Pendaptn perkapita
8,96 jt
Pendaptn perkapita
13,99 jt
Pendudk miskin 1,21 jt (9%)
Pndudk miskin
Wilayah Jawa Bali
Share PDRB thdp
Nasional
Pertumbh Ekonomi
4,60%
0,60%
0,98 jt (36,1%)
62,00%
5.89%
Pendapt perkapita
11,27 jt
Pendudk miskin 20,19 jt
(12,5%)
Source : Statistics Ind. 2008
Note:
based on constant prices
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 Maluku
Share PDRB thdp
Nasional
Pertumbh Ekonomi
0,32%
4,94%
Pendaptn perkapita
2,81 jt
Pendudk miskin 0,49 jt (20,5%)
6
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 postdelivery 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
0
INDONESIA
35
Irian Jaya Barat
41 41
Papua
52
Maluku Utara
60
Maluku
72
Sulawesi Barat
Gorontalo
Sulawesi Tenggara
58
Sulawesi Selatan
70
Sulawesi Tengah
26
30
Kalimantan Timur
Sulawesi Utara
57
Kalimantan Selatan
34
Kalimantan Tengah
46
Kalimantan Barat
60
Nusa Tenggara Timur
80
Nusa Tenggara Barat
35
Bali
Banten
39
Jawa Timur
28
D.I. Yogyakarta
43
Jawa Tengah
30 25
DKI Jakarta
Jawa Barat
39
Kepulauan Riau
43
Bangka Belitung
42
46
Lampung
37 39
Bengkulu
46 47
Sumatera Selatan
Jambi
40
Riau
Sumatera Barat
50
Sumatera Utara
NAD
Per 1.000 Kelahiran Hidup
Infant Mortality Rate decreases from 35 to 34 per 1000 live births, with disparity
among provinces
Angka Kematian Bayi (Per 1.000 Kelahiran Hidup)
Per Provinsi Tahun 2007
Angka Nasional
34
74
59
46
51
41
36 34
26
20
19
10
Source: DHS 2007
MDG target for IMR: 23 per 1,000 live births by 2015
10
Maternal Mortality Rate, Indonesia 1994 - 2007
450
Angka Kematian Ibu
400
390
Sasaran RPJM
350
AKI Per 100.000 KH
334
307
300
250
228
226
200
150
MDG Target
100
102
50
0
1994
1997
2002
2007
2009
2015
Tahun
Source: DHS
11
Infant Mortality Rate by
quintile of income
60
56
Disparity by quintile
of income
47
50
40
33
29
30
26
20
10
Malnutrition among
children under fives by
quintile of income
0
Q1
Q2
Q3
Q4
Q5
Sumber data : SDKI 2007
25
22.1
19.5
20
18.1
16.5
13.7
15
10
5
0
Kuintil 1
Kuintil 2
Kuintil 3
Kuintil 4
Kuintil 5
Kekurangan Gizi
Sumber data : Susenas, 2007
12
Equity
Index
1.67
94.8
57.9
Proportion of Safe Delivery (attended by trained
health personnel) by expenditure Quintile
(Susenas 2006)
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
Faskes
Jamkesmas
RS Pemerintah
1200
1012
954
1000
RS Swasta
855
800
665
650
582
600
400
337
304
273
200
0
2008
2009
2010
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 “bottleneck” 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