The government’s national health insurance scheme, BPJS Kesehatan, aims to cover 95% of the population by 2019. With more than 189 million current members, BPJS Kesehatan aims to maintain the sustainability of National Health Insurance (JKN) and Indonesia Health Card (KIS) programs, increasing the satisfaction of participants and creating efficiencies in implementing its work programs. By Eko Prasetyo
As the Director of the Social Security Administrator for Health, or BPJS Kesehatan, Prof. Fahmi Idris is a crucial figure in improving the provision of health benefits for all Indonesian citizens.
In an exclusive interview with GlobeAsia, Fahmi said that in addition to its core functions, the agency is also working to mitigate various issues, including potential fraud, a balance sheet mismatch and the transformation to a digital platform. It is also implementing Presidential Instruction No. 8/2017 to strengthen the synergy between BPJS Kesehatan and 11 government institutions and ministries.
National Health Insurance
BPJS Kesehatan has been working together with the Directorate General of Population and Civil Registration to incorporate the use of electronic ID cards (e-KTP) on a card reader. Each individual’s citizenship number, or NIK, will serve to prevent any duplication in the registration process for JKN-KIS participants.
“Members of BPJS Kesehatan will have to carry their e-KTP to ensure they are the person eligible to receive services. We are also aiming to assist the government in urging people to have electronic identity cards. In the future, we are also aiming to implement fingerprint identification to further avoid any fraud, as fingerprints cannot be duplicated,” Fahmi said.
The use of card readers took effect on December 21 last year. In a pilot project, the agency’s South Jakarta branch received 155 visits by persons using the card reader system.
“By the end of 2018, we want every branch office to have at least one card reader. The use of fingerprints has also been applied to health facilities for certain services, such as hemodialysis. This is also done to validate patients undergoing hemodialysis and optimize the data collection of participants,” he added.
Indonesia is aiming to implement Universal Health Coverage (UHC), with Jakarta, Aceh and Gorontalo making a head start to apply it into their public services, triggering what is expected to be increased public satisfaction with the agency’s services.
“We are urging the people to protect themselves in terms of health risks, as we are also optimistic that everyone will have been informed by way of our publicity before we embark on a more regulatory process, or even law enforcement, to ensure all citizens become members of BPJS Kesehatan,” he said.
“Based on survey results in 2017, the satisfaction rate of JKN-KIS participants has reached 79.5%, while the satisfaction index of health facilities serving patients was at 75.7%.”
With the principles of openness, prudence and accountability, BPJS Kesehatan operates on a cycle of contribution receipts and expenditures on benefits that are managed by taking into account the principles of good governance.
In this respect, the agency is very focused on good governance and is subject to monitoring by various institutions ranging from its own Internal Supervisory Unit (SPI) through to the National Social Security Council (DJSN), Financial Services Authority (OJK), Supreme Audit Agency (BPK) and the Corruption Eradication Commission (KPK). BPJS Kesehatan is also audited by an independent public accounting firm and has been awarded 25 unqualified results, meaning its accounts are completely in order.
Current account mismatch
BPJS Kesehatan basically calculates its programs, including JKN-KIS, on the principle of having a balanced budget at the beginning of each fiscal year. General principles include balanced expenditures and revenues, as well as sourcing its main revenues from participant contributions.
By actuarial calculation, the current contribution is not in accordance with the ideal amount, thus creating a mismatch in the current account balance.
“I am avoiding the term deficit, as it sounds scary to most people and we have called it a ‘mismatched condition’. BPJS does not work alone to formulate the budget, but with the Ministry of Finance in coordination with the Ministry of Health,” Fahmi said, adding that the government has several options to overcome the shortfall in revenue.
“First is to increase the level of contributions. However, this is not an option because the government does not want to burden the people.
Second is to reduce health service benefits, but we won’t implement this either since the people would be impacted. Third, according to PP 87/2013, the government should inject additional funds through the state budget. This is our current option,” Fahmi said.
This represents the government’s commitment to keep the state present in the process of providing health insurance for the people, he added.
“Let us, the government, think about the sources (of funding).”
BPJS Kesehatan is strongly urging improved synergy between related ministries and institutions to strengthen the impact of health services in Indonesia.
The government is also making efforts to control the deficit. In accordance with a ministerial meeting last November, several efforts are to be made by BPJS Kesehatan, as well as other stakeholders in terms of sustainability of the JKN-KIS program.
The first is the involvement of regional governments, followed by achieving increased efficiency in health service provision without abandoning the quality of health services. The government also plans to use part of the excise revenue from cigarette sales to cover the mismatch in BPJS Kesehatan’s current account balance.
Mitigating other issues
The success of the JKN-KIS program relies on the synergy of various elements, as BPJS Kesehatan is not the sole player in the equation. Fahmi said that BPJS Kesehatan is strongly urging improved synergy between related ministries and institutions to strengthen the impact of health services in Indonesia.
“We are grateful that President Joko Widodo has regulated this in a presidential instruction, as the next step would be a review of various regulations to ensure the services are well-implemented with effective and efficient costs,” he added.
“On the other hand, quality control and cost control standards are helpful for fraud prevention, as these standards can be traced to actions that may lead to potential fraud. Therefore, if quality control and cost control are running well, the risk of potential fraud should decrease.”
The potential for fraud in the JKN-KIS program extends to participants, health facilities and providers of medicine and medical equipment. The fraud prevention measures should involve not only BPJS Kesehatan, but also every related stakeholder, including the KPK through the establishment of the JKN Fraud Prevention Task Force.
3 million members have registered with BPJS Kesehatan Mobile JKN platform.
The implementation of cost-sharing for some health services is also prone to moral hazards, as BPJS Kesehatan has the objective of educating participants and at the same time promoting the quality of services provided, by applying appropriate services for JKN-KIS participants in accordance with the clinical pathway, qualifications and efficiencies.
The government will also intervene by encouraging local governments to commit 10% of their regional budgets for the health fund, while enforcing coordination between the Ministry of Finance and Ministry of Home Affairs to utilize 75% of cigarette excise, while implementing 50% of the tax revenue share from local governments to finance health services.
Fahmi is also promoting the use of digital technology as one of the leading innovations of BPJS Kesehatan, dubbed Mobile JKN. “Almost all of a patient’s needs can be resolved through the application, so they do not need to visit our representative offices. It is similar to mobile banking,” Fahmi said. “More than 3 million members have registered with our mobile JKN platform.”
The service is supported by 24-hour customer services by phone and linked to care centers, a drop box and online registration, as well as the development of a customer integrated management system to ensure the well-being of members. “Users can also switch to the nearest health facility listed in the mobile application, to make it easier for users to access health services.”
The agency is also aiming to ease payments for membership contributions through mini-markets and e-commerce platforms. “So there is no reason not to pay unless they do not have the funds — where we have other measures to serve them,” added Fahmi.
The next innovation, the Health Facility Information System (HFIS), will be digital schedules at each health facility, allowing members of the public to know when to visit the nearest and most convenient hospital or clinic.