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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

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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

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The Driving Forces for Reforms

1. Amendment of the Constitution, 20022. Political Agenda?3. Perceived Gaps4. Academic Exercises and International Pressures

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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

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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

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)

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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

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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

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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

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Thank You