Evaluating Jaminan Kesehatan Jembrana

Jaminan Kesehatan Jembrana, is a local health financing scheme in Jembrana Regency, Bali Province, Indonesia

The government of Jembrana regency in the province of Bali initiated a local health financing scheme namely Jaminan Kesehatan Jembrana (JKJ). It is a strategic program in the decentralization era in Indonesia to reform human development in the health sector. The government of Jembrana regency developed JKJ in order to increase the efficiency and quality of health services in Jembrana, as the funding of JKJ program was allocated from the available budget that was transferred to government health providers. The program also provides open-competition among government and private primary health providers in Jembrana, as service fee is the same in all providers in JKJ network. JKJ also developed to reduce financial barrier to access primary health care. The uniqueness of JKJ program in Indonesia as best practice program to enhance the life quality of population in Jembrana invited Unit Penelitian dan Latihan Epidemiologi Komunitas Fakultas Kedokteran Universitas Udayana (UPLEK FK UNUD) to evaluate the program. The evaluation research was approved by the Regent of Jembrana on behalf of the government of Jembrana Regency. UPLEK FK UNUD conducted JKJ evaluation in April-September 2005 and was financially supported by World Health Organization (WHO).

JKJ evaluation was aimed to provide recommendation whether the program should be continued, with or without improvements, or terminated at once. The assessments were conducted on the aspects of legal, financial, program coverage, organization, management information system, utilization trends and consumer satisfaction. The evaluation objective was developed as several research questions to obtain information on regional laws that support the legalization of JKJ, the sources of JKJ funding, the validitiy of JKJ cash flow, the technical design characteristics of JKJ scheme, the percentage of Jembrana population registered in the JKJ scheme, the population groups that are registered as JKJ beneficiary, the characteristics of JKJ organization, how JKJ patient information are utilized by decision makers in health sector in Jembrana, the primary health care utilization trend in Jembrana and consumer (providers and patients) satisfaction with JKJ program.

JKJ evaluation research was designed as one-group-research, where evaluation research is only conducted on one program only, without any comparisons with similar programs in other locations. This is due to nonexistence of local health financing scheme in Bali province at the time the evaluation was planned.

In order to obtain valid and complete information on JKJ program, particularly to answer all of the research questions, the evaluator approached various informants in the government of Jembrana regency, primary health care providers and beneficiaries of JKJ program. The informants were selected by purposive and random sampling.

Key findings
The legal aspect of JKJ program is weak, as the formation was only based on the Regent’s decree. The parliament of Jembrana regency still delays the formation of such law due to contents of the draft of regional law or Peraturan Daerah which stated that JKJ program to be administered by government corporation, a profit-oriented establishment.

The expenditure of health sector in Jembrana, which is represented by budget allocation for Jembrana health authority (Dinkessos) in 2002 – 2005, varies from four to eight percent of total budget of Jembrana government or APBD. The budget allocation for health in Jembrana is still far from what Governors and Regents in Indonesia agreed upon in 2003; to allocate 15 percent of APBD for health. However, the government of Jembrana regency has started to put more focus on health development, by increasing expenditure budget for Dinkessos and JKJ program.

JKJ program is mainly funded by the regional budget of Jembrana government to subsidize premium cost of JKJ beneficiary. It also received block grant from the government of Indonesia and Bali province to subsidize complete health services for the poor (from primary health services to hospitalization care). In addition to those funding, JKJ program received funding from PT. Askes (Persero), a nation-wide health insurance provider for government employee, to administer health care services for Askes beneficiaries in Jembrana, who are automatically eligible as JKJ beneficiaries. All funding for JKJ is pooled by Dinkessos, and then transferred to the organization of JKJ (Badan Penyelenggara or Bapel).

Before JKJ program was implemented, the government of Jembrana regency always subsidized the government health services institutions (Puskesmas or community health centers and hospital) in the average amount of Rp 7.1 billion per year. In 2003, the first year of JKJ program, the government allocated Rp 3 billion, or shifted 43 percent of the available budget for JKJ. In 2004, subsidy for JKJ program was Rp 4.65 billion, or 66 percent of the available budget. In 2005, Jembrana government provided Rp 7.1 billion in total to subsidize JKJ program or the same amount of fund for government health services institutions before JKJ program was implemented. These facts indicate the uprising trend of JKJ budget allocation, as an impact of the escalating primary health care utilization in Jembrana in the presence of JKJ program. The upward trend is caused by the retrospective provider payment system and no cost sharing applies for the patient. High utilization may benefit the society, as there is no financial barrier to access primary health services, thus JKJ beneficiaries can obtain services with no delay. However, this condition will lead to huge financial burden to Jembrana government and unsustainability of JKJ program.

Financial analysis on JKJ report also found significant differences in payments and revenue of claim payment accounts. Claim payments for public patient and Askes patient groups exceeded their funding, but claim payment for the poor has always been less than its funding. It indicates that block grant for the poor is not yet utilized appropriately to reduce poverty from the health perspective.

In the administration of JKJ itself, the evaluators found the existence of two organizations, Bapel and Tim Pengelola, both formed by the Regent. Each has similar responsibilities to manage the administration, financial, socialization and marketing of JKJ program. However, only Bapel has the authorization to establish contract with JKJ health providers. Both coordinators of Bapel and Tim Pengelola are core personnel in Jembrana health authority or Dinkessos and providers in JKJ network. These facts indicate weak coordinations of responsibility and authority among Dinkessos, Bapel and Tim Pengelola.

Providers in the JKJ network, both government and private, are allowed to serve JKJ beneficiaries within Jembrana regency, with no district boundaries. This condition ensures broader access to primary health services to all population of Jembrana. With regard to service standards, Bapel/Tim Pengelola JKJ published JKJ therapy standard. However, JKJ program does not have any comprehensive standards for health promotion and preventive care to enhance the health status of Jembrana population.

The evaluators found that JKJ program was not managed professionally and effectively. It is indicated by the inability to conduct routine monitoring due to imbalance between work load and staff capacity, also standard changes of JKJ program without legal contract amendments. Since the initial stage of JKJ program, there has never been any utilization review and description of epidemiological aspect of JKJ beneficiaries. The JKJ administration did not reckon that such information will assist decision makers in the Jembrana health authority to manage effective public health programs. Over time, the mechanism will enhance the health status of Jembrana population, thus will reduce the financial burden to subsidize JKJ program.

Currently, only 44 percent of the population in Jembrana is registered as JKJ beneficiary. The government of Jembrana regency targeted 80 percent of Jembrana population should be covered in the JKJ program by end of 2005. However, based on the work capacity and staff qualification of JKJ administration, as well as the poor participations in obtaining household card as requirement of JKJ card, the target of JKJ card distribution is difficult to achieve.
On the other hand, provider’s participation rate in the JKJ program is high. Most of the providers in Jembrana have been employed by JKJ program; 100 percent of government health care providers, 83 percent of physician population, 83 percent of dentist population and 84 percent of midwife population in Jembrana. The attractive package that ensures income is the main reason of provider’s high coverage in the JKJ program.

As the benefits of JKJ program to all its consumers surpass the negative aspects of its administration, internal consumers (providers) and external consumers (patients) allegedly stated they are all satisfied with the program. Yet, if analyzed per consumer group, the evaluators found different facts. Physicans and dentists are more likely to be satisfied with JKJ program, compared to the midwives. Patients of midwifery services in government institutions are more likely to be satisfied compared to same services in private practitioners. Patients who are male, older, own permanent card and have higher education level are less likely to be satisfied with JKJ program compared to other JKJ patients.

Conclusion remarks
As JKJ program is a local health financing scheme and only valid in Jembrana regency, JKJ program is not portable and would not benefit the JKJ beneficiaries should they have health-related problem out of Jembrana. In addition, the risk pooling of JKJ program is small, thus the impact is higher premium cost of the program. Moreover, there is no vertical equity in JKJ program because there is no payment difference based on income. In the near future, such program should cover broader population and region, also apply cross subsidy from the rich to the poor, or from the healthy to the sick population.

Nevertheless, as JKJ program is an innovative step by the government of Jembrana regency to improve human development in the region, the evaluators recommended that JKJ program should be continued. Yet, several aspects of JKJ administration should be modified in order to ensure the achievement of JKJ’s objectives and its sustainability. The most crucial aspect to improve JKJ program is the legalization of JKJ program in the way of establishing regional law on JKJ. Other parts that should be reformed to enhance the effectiveness and efficiency of JKJ program are its technical and management aspects, i.e. (1) reforming the payment model (cost sharing for patient and prospective payment for provider), (2) expanding the benefit package to include hospitalization and specialized care to ensure financial protection for the population (additional premium and or cost sharing apply), (3) inclusion of health promotion and preventive services in JKJ therapy standards, (4) restructuring the organization and management of JKJ program, (5) increasing the operational fund for JKJ program, (6) conducting JKJ utilization review, (7) applying family physicians principles in JKJ scheme, (8) simplifying the administrative procedures to apply JKJ card for the indigent population, (9) better management of JKJ fund for the indigent in order to reduce poverty from health perspective, and (10) empowering the community health centers (Puskesmas) by providing incentives to conduct public health programs.

Denpasar-Bali-Indonesia, November 21, 2005
Prof. dr. A. A. Gde. Muninjaya, M.P.H. – Principal Investigator
Nirmala Trisna, Ak., M.A., – Investigator, Project Coordinator
Drs. Yahya Anshori – Assistant Investigator

Unit Penelitian dan Latihan Epidemiologi Komunitas
Fakultas Kedokteran Universitas Udayana, Bali
uplek@denpasar.wasantara.net.id
www.uplek.org