WHO

ARE THE REAL JAMKESMAS BENEFICIARIES?

Firdaus Hafidz, Rizki Tsalatshita, Febtiana Tia Pika
All citizens, particularly the poor and near poor, are having similar potency to face financial hardship while seeking health services they need. People who are not covered by health insurance are vulnerable to the so called catastrophic health events (1) due to out-of-pocket (OOP) payment which dominates most health care service provision in most developing countries (2). To protect Indonesian citizens, the government of Indonesia initiated a health insurance program for the poor in 2005, known as Askeskin which later changed to Jamkesmas in 2008. It was considered as an initial step of realization process to achieve the universal health coverage which was already mandated within the SJSN law No. 40, issued in 2004. By analyzing Susenas data from 2009 until 2011, this article will reveal the percentage of Jamkesmas holders of all insured citizens, its distribution whether it is already on target or not as well as reveal its utilization by its real beneficiaries. Health Insurance Coverage and Ownership Hitherto, 63% of Indonesian citizens have been protected by health insurance. According to the Ministry of Health, Jamkesmas has protected as many as 76,4 million poor and near poor citizens, or approximately 32% of whole population (figure 1) have been protected through this program (3). Figure 1. National Health Insurance Coverage 2011

% HEALTH INSURANCE NATIONAL COVERAGE IN 2011

UNINSURED; 87.055.320 ; 36,88%

JAMKESMAS; 76.400.000 ; 32,36% JAMSOSTEK; 5.183.479 ; 2,20% ASKES PNS dan TNI POLRI ; 17.364.265 ; 7,36%
COMPANY INSURANCE 6,428,714 2.72% PRIVATE INSURANCE & OTHERS 2,856,539 1.21%

JAMKESDA; 31.866.892 ; 13,50%

Insured 63,18 %

Source: Ministry of Health However, a discrepancy exists between Ministry of Health data and Susenas 2009 2011 data where proportion of Jamkesmas ownership is only 20% according to Susenas data. On the other 1

hand, most of uninsured citizens (55%) increased in 2010 ( Figure 2). It indicates that majority of citizens are still uncovered by health insurance and susceptible to catastrophic health events. Figure 2. Proportion of Health Insurance Ownership during 2009 2011
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year 2009 Year 2010 Year 2011 55% 57% 57% 25% 4% 8% 7% 9% 21% 5% 7% 9% 21% 6% 8% Other types of insurance Jamkesmas Jamsostek Askes Uninsured

Source (46) Who Owns Jamkesmas Based On Socioeconomic Groups By classifying population into five quintiles of Jamkesmas ownership according to per capita expenditure, Figure 3) has revealed that of all the groups, the first quintile which represents the poorest socio-economic group has the largest proportion of Jamkesmas owners. Distribution of Jamkesmas owners are equal every year. It shows that the higher socio-economic group, the lower proportion of Jamkesmas ownership. Despite, there are 5% of the wealthiest socio-economic group still happen to own Jamkesmas, while this scheme is actually intended only for the poor and near poor groups.

Figure 3. Proportion of Jamkesmas Ownership Based on Quintile

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Year 2009 Year 2010 Year 2011 35,70% 34,83% 35,49% 27,00% 27,23% 25,81% 20,05% 20,20% 20,03% 5 4 3 2 1 4,57% 12,67% 4,80% 12,95% 5,39% 13,29%

Source (46) A World Bank analysis, using Susenas 2009 data, showed that Jamkesmas owner is more secured from catastrophic health shocks compared to households who own other type of insurance or none. It is pointed out by low OOP and catastrophic expenditure insidence among households who own Jamkesmas (7).

The Real Jamkesmas Beneficiaries Looking further, the actual proportion of Jamkesmas holders utilizing Jamkesmas services when sick can be viewed in figure 4. Generally, no prominent difference exists in each quintile during 2009 until 2011. Proportion of Jamkesmas utilization was increasing every year within the poorest and near poor quintile compared to the middle to the wealthiest quintile. Eventhough the absolute value has evidenced that Jamkesmas beneficiares lie in quintile 1 and 2, figure 4 indicates that only less than half of Jamkesmas holders are using Jamkesmas services.

Figure 4. Jamkesmas Holder Utilizing Jamkesmas Services during 2009 2011

45,00% 40,00% 35,00% 30,00% 25,00% 20,00% 15,00% 10,00% 5,00% 0,00% Q1 Q2 2009 Q3 2010 2011 Q4 Q5 40,09% 37,54% 41,01% 40,37% 40,12% 39,64% 40,17% 38,27% 37,75% 37,03% 35,77% 36,77% 35,08% 33,69% 33,28%

Source (46) Several researches indicated that a number of problems which lead to low Jamkesmas service utilization are (1) access to health care facilities especially in rural and remote areas of the country; (2) travel time to reach the facilities; (3) transportation cost burden; (4) tendency of Jamkesmas holders to choose alternative medicine or leave the diseases untreated rather than seek the formal health care services; (5) negative perception toward Jamkesmas service quality where many of puskesmas (primary health center) lack qualified personnel including a doctor and diagnostic equipment, perfunctory medication and lengthy waiting times; (6) inadequate knowledge about Jamkesmas program among community where some of Jamkesmas holders dont understand yet about the procedures and benefits they can obtain. Some people also presume that Jamkesmas can only be used up to puskesmas level (811). Therefore, it is necessary for the government along with related stakeholders to increase socialization of Jamkesmas and fix the access to healthcare services by developing strategic mechanism to tackle uneven distribution of health professionals particularly doctors, improving patient referral mechanism efficiently and equipping health facilities with more basic medical tools and equipments as well as training of how to use the tools for health personnels. By looking at figure 4, it is considered that data collection of Jamkesmas holders are generally right on target. However, a considerable margin of Jamkesmas ownership which is occured between the Ministry of Health data and Susenas data makes the evaluation of distribution and membership data update important despite the fact that Jamkesmas will be integrated under new social health protection scheme which will start on January 1st 2014.

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