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A critical analysis of purchasing arrangements under BPJS in Indonesia

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Presentation on Strategic Purchasing given at the iHEA World Congress in Milan, July 2015

Published in: Health & Medicine
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A critical analysis of purchasing arrangements under BPJS in Indonesia

  1. 1. A Critical Analysis of Purchasing Arrangements under BPJS in Indonesia Yulita Hendrartini, University of Gadjah Mada , Indonesia iHEA, Milan; Tuesday 14 July, 2015 Gadjah Mada University
  2. 2. Introduction: Roadmap to UHC in Indonesia Transformation from 4 existing schemes to BPJS Kesehatan (JPK Jamsostek, Jamkesmas, Askes PNS, army) Coverage of various existing schemes 148,2mio 121,6 M covered by BPJS Keesehatan 50,07 M covered by other schemes 257,5 M (all Indonesian people) covered by BPJS Kesehatan Activities: Transformation, Integration, Expansion 86,4 M poor 2 Consumer satisfaction measurement every 6 month Benefit package and sevices review annually
  3. 3. Key actors in SHI National Social SecurityCouncil Financial Autority Agencycontrol control
  4. 4. KEY ACTOR Social Health Insurance National government agencies (MoH, MoF, MoS, Provincial and district governments Providers of care Insurer (BPJS) Oversight of scheme X Financing scheme x X Setting parameters (benefits package, definitions of poor, etc.) X X Accreditation/Empanelment of providers X X Enrollment x X X X Financial management/planning X X Actuarial analysis / premium setting X Setting rate schedules for services/reimbursement rates X X Claims processing and payment X X (District level) Service delivery X X Developing clinical information system for monitoring/eval X x x Monitoring local-level utilization and other patient information X x Monitoring national aggregate information X Customer service x X X ROLE OF KEY ACTORS
  5. 5. Health Financing in SHI Resource collection Pooling Purchasing Government contribution for poor and near poor: Rp. 19.225 (USD 1.5) PMPM BPJS as single purchaser PHC public & private providers: capitation Public and private Hospitals : DRGs (INA-CBG) based payments vary according to region 3 rd class IP for poor 2 nd class IP for non poor 1st class for non poor (depends on premium) Civil servant and military: 5% of monthly wages 2% from employee 3% from employer Laborers: 5% of monthly wages 1% from employee 4% from employer Self funded / informal sector: From Rp 25.500 – 59.500 PMPM (2.0 USD – 4.5 USD)
  6. 6. Summary: Mechanism for strategic purchasing Principle agent relationship on going proccess Key Challenge Purchaser - government • Organizational structure • Capacity building for DHO • Negotiated budget • Unclear role of stakeholder • Lack of data for monitoring • Updating • Lack of health facilities investment Purchaser - citizen • Review benefit package annually • Patient satisfaction review • Lack of citizen voice • Limitation of Customer rights Purchaser - provider • Prospective Payment • Selection and credentialing • Setting indicator • Capitation not effective • DRG tariff inadequate • Inequity provider distribution • Lack of quality control • Lack of fraud prevention
  7. 7. Gaps in government actions to promote strategic purchasing • Unclear organizational roles • Accountability lines between BPJS / purchaser and the Ministry of Health (and District Health Office) • Inadequte monitoring activities • Data limitation and lack of DHO capacity to monitor the program • Problems in reducing the inequity of services. • Limited budget to developing new health service infrastructure and deploy strategic human resources
  8. 8. Gaps in relation to role of citizens and population in strategic purchasing • The needs, preferences and priorities of citizens in determining service entitlements is not clear in the policy design and implementation.  Many regions where community needs are not met  indicates that there is no mechanism to ensure beneficiaries can access available services, especially the marginalized groups  Lack of evidence on health needs  no evidence that citizens can participate in the process of determining health needs and priorities  No representation in purchasing boards  Limitation of patients’ rights legislation
  9. 9. Gaps in relation to providers in strategic purchasing • Purchaser (BPJS) has inadequate credentials and capacity to contract  especially in government providers • Poor monitoring mechanisms to control health services moral hazard (potential fraud) • No fraud regulation • Provider response to prospective payment system (capitation and DRG payment)  problems:  Provider ability/capacity to respond to incentives  accept limitation Lines of accountability  detection potential Fraud
  10. 10. Factors affecting first year of SHI implementation in Indonesia  The SHI system is quite new, so actors will need time to settle into new relationships and respond to incentives  BPJS is a new office to managed huge membership  need more staff, developt IT system to monitor provider performance and governance stewardship  Strengthened and developed PHC role as gatekeeper and capacity building DHO to supervised  New Drug formulary for PHC  Skill Training and refreshing course  to promote primary doctor competencies
  11. 11. Strategic purchasing: Conclusion SUPPORTING FACTORS •Strong political support for BPJS •The benefit package under the scheme will be clearly defined and includes full spectrum of health concerns. • Autonomy for purchaser in day- to-day management decision- making and operations •BPJS capacity to claim audit timely payments to providers (max 14 days) CONSTRAINING FACTORS •Limited BPJS resources  regular operation of the BPJS offices •Limited of BPJS capacity to purchase stragically  pricing policy regulated by MOH  capitation payment too high for PHC govrnment •Limited capacity of BPJS to monitor provider performance, service utilization & quality, and publicly report on provider & purchaser performance
  12. 12. Recommendations • Strategic purchasing alone cannot deal with the problems of underlying inequity in distribution of infrastructure  need the collaboration between central and district government to built infrastructure • Ensure structural or functional integration of public health programs into purchasing • Enforce purchaser accountability by making data accessible to the public and relevant stakeholders • Strengthen the quality control of health service and fraud prevention, detection and prosecution. • Indicators related to strategic purchasing need to be added in to the SHI and BPJS monitoring system • Change the management culture of command and control
  13. 13. www.wpro.who.int/asia_pacific_observatory http://resyst.lshtm.ac.uk @RESYSTresearch The research is a collaboration between RESYST and the Asia Pacific Observatory on Health Systems and Policies. RESYST is funded by UK aid from the UK Department for International Development (DFID). However, the views expressed do not necessarily reflect the Department’s official policies. More information: http://resyst.lshtm.ac.uk/research-projects/ multi-country-purchasing-study

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