Managing Insurance Fund in Community Health Centers

A Case Study in Bali Province, Indonesia

By: Nirmala Trisna Anakagungistri


The study was funded by World Health Organization Indonesia
under allotment no. INO HSP 001, OSER3.P2.A2.

Introduction

The social health insurance scheme for the poor in Indonesia, namely Jaminan Pemeliharaan Kesehatan Masyarakat Miskin or Askeskin, has been implemented since 2006. This program provides access for the poor individuals to health services in community health centers (Pusat Kesehatan Masyarakat or Puskesmas) and hospitals. In the initial year of its implementation, Askeskin’s beneficiaries include 60 million poor individuals. In 2007, the coverage was increased by Government of Indonesia, as the poverty in Indonesia grew significantly. Total beneficiaries of Askeskin in 2007 are 76.4 million poor individuals. As the administrators of Askeskin, government through Ministry of Health (MOH) appointed PT. Askes, as state-owned company that has been administering health insurance for government employees and their dependents.

Askeskin program applies different payment schemes every year to health providers, particularly to Puskesmas. For hospitals, Askeskin pays health services and drugs retrospectively, where hospitals have to submit claims to PT. Askes based on guidelines of covered services issued by MOH. On the other hand, Puskesmas is paid prospectively. In 2006, MOH decided to pay capitation to Puskesmas in the amount of Rp 1,000 per capita per month, that is paid through PT. Askes. Each Puskesmas should receive total fund according to proportion of poor individuals who reside in that respective area. However, in the implementation of Askeskin, there are districts with different policies of redistribution of capitation fund. District Health Office (DHO) applies additional criteria, as permitted in Askeskin guidelines, to disburse the capitation fund to Puskesmas. It is justified that Puskesmas is a technical service unit of DHO thus DHOs are allowed to impose their own policies according to local needs and specifications. In Puskesmas itself, capitation fund should be distributed according to a legal document that is authorized by Regent/Mayor or Head of DHO.

In the second semester of 2007, MOH issued a new guideline of Askeskin. Significant change is on payment scheme to health providers, particularly to Puskesmas. Askeskin fund to Puskesmas is not paid through PT. Askes and not in the form of capitation fund. MOH in 2007 pays block grant of Askeskin to Puskesmas through PT. Pos Indonesia (Indonesia Postal Service). The grant is specifically earmarked to pay basic health services, delivery and operational of Puskesmas. Puskesmas can disburse the block grant of Askeskin in their accounts of PT. Pos upon submitting Plan of Action (POA), which should be approved by Head of DHO.

Puskesmas as the gatekeeper of Askeskin, a social health insurance scheme in Indonesia, should be improved in the presence of Askeskin. Prospective payment scheme as a health financing means to Puskesmas can lead this organization to improve its administration in order to deliver quality health services. In the province of Bali, studies on how Askeskin fund is managed by DHO and Puskesmas are limited. Thus, this study was conducted with main objective to obtain information on how DHO and Puskesmas in Bali manage the Askeskin fund in the year of 2006 and 2007. Specifically, the research was aimed to explore criteria of fund distribution that are applied by DHO and the administration in Puskesmas with regard to Askeskin fund management. Due to limited time and resources, the study selected six districts in Bali, include Badung, Denpasar, Tabanan, Jembrana, Bangli and Gianyar.

Flow of Askeskin fund to Puskesmas

MOH has set that Puskesmas are paid prospectively in the scheme of Askeskin. In 2006, the payment mechanism was capitation fund, where the number of poor individuals in the respective area is the basis of calculating Askeskin capitation fund for each Puskesmas. In 2007, Puskesmas also receive advance payment to finance health services, delivery and operational of Puskesmas in providing services to the indigent.

The model of financing Puskesmas under Askeskin program is not fully implemented according to the guideline, due to differences in local needs and characteristics. In Bali, six districts have different flows of Askeskin fund to Puskesmas. Two districts, which are Badung and Denpasar, allow Puskesmas to receive directly the Askeskin capitation fund for efficiency. Districts of Bangli, Tabanan and Gianyar apply different policies with regard to distributing Askeskin fund to Puskesmas, which criterion include service utilization and administration fee to the government (DHO and district government). On the other hand, Jembrana has different scheme due to the establishment of Jembrana’s local health insurance administration (Badan Penyelenggara Jaminan Kesehatan Jembrana or Bapel JKJ). The JKJ scheme applies retrospective payment system to primary health providers.

Askeskin fund management in Puskesmas

Since the initiation of Askeskin, the prospective payment has not been transferred as it should be, that is prior to health delivery. The capitation fund, which mechanism is supported by Puskesmas as it did not require much paperwork, was transferred cumulative in the second semester of 2006 until early 2007. Block grant to fund Puskesmas in 2007 was paid in the second semester and not directly followed by detailed guidelines to distribute the grant. Almost all informants in Puskesmas and DHO are in favor of capitation mechanism due to its simplicity of paperworks.

By the time of interview and focus group discussion, there are several Puskesmas that have not yet received the technical guidelines. It is informed by respondents in Puskesmas and DHOs that Askeskin fund could not be managed according to the guideline issued by MOH due to transfer of fund and guidelines have been behind schedule. Other reasons are ineffective communication to diseminate policy and guidelines information among Puskesmas, DHO and PHO, as well as MOH, differences in interpretation of guidelines documents and limited capacity of Askeskin program officers. Interestingly, there are several Puskesmas that manage to distribute the available Askeskin fund according to specific local needs. However, administratively, the formal reports were prepared according to the guideline requirements. Other Puskesmas have not been able to spend the available capitation fund and kept large balance of fund. Puskesmas officials do not have clear directions on how to distribute the money as each district has the autonomy to implement technical guidelines. Most Puskesmas officials do not have the spirit to be innovative and take the responsibilty to spend the Askeskin fund for pro-the-poor services in order to eradicate poverty from health perspective. The utmost fear of Puskesmas officials is scrutinization by government auditors.

The classic problem that has been happening in Puskesmas and DHO, and adding problems to Askeskin program implementation, is limited capacity in government institutions. All Puskesmas in the study do not have proper accounting system nor financial report, due to inexistence of fully dedicated personnel for book-keeping/accounting. As consequence, DHO have limited outlook on Puskesmas resources availability in order to provide health services in its respective districts. DHO and Puskesmas officers are still new to the concepts of health insurance and strategic payment mechanism to providers. Related trainings and educations are limited, thus Askeskin program is merely formally implemented.

Closing

There are variations of Askeskin fund management in Puskesmas in six districts of Bali province. It is due to different policies implemented by each district government and DHO. Criterions applied to distribute Askeskin fund include utilization, efficiency and bureaucracy. Since 2006, Askeskin fund and operational guidelines have always been behind schedule of transfers. Puskesmas and DHO officials have limited capacity to properly manage Askeskin fund to improve health delivery coverage to the indigent.

Capitation mechanism is preferred by Puskesmas officers, however, should MOH decide to implement newly financing mechanism; the information should be early released so that health providers are properly trained. In the existence of Askeskin, Puskesmas have to be able to effectively manage the large fund coming to its institution. In order to improve health financing mechanism in Bali and Indonesia, hence to improve health services quality, capacity building of Puskesmas and DHO is hightly required. District governments should develop Puskesmas as service center, not profit center. Puskesmas should be allowed to manage all funds dedicated for Puskesmas in order to provide quality health services according to local characteristics. This should be supported by developing management information system between DHO and Puskesmas, including accounting system. Health financing that is supported by effective management and accounting in Puskesmas, will lead to quality health services and accountable government institutions.