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Some of these functions for specific groups (for example, higher income
earners)andtypesofservicescanbeaccomplishedthroughprivateorpublic
financingarrangements.Therearenoonesizefitsallsolutions,andgeneric
modelssuchassocialhealthinsurance(SHI),nationalhealthservices(NHS),
and private voluntary health insurance (PVHI) are, individually, extremely
limitedinprovidingthespecificpolicydirectionneededtoachievethehealth
financingandhealthsystemgoals.Mostcountrieshealthfinancingsystems
represent combinations of these models. In fact, the new SHI model,
generallyknownasmandatoryhealthinsurance,explicitlyrecognizesthisfact
bybeingcharacterizedasamodelinwhichthepoorarecoveredthroughthe
general government budget (an NHS characteristic), while other groups are
financedthroughmandatoryindividualcontributions,employercontributions,
orboth(anSHIcharacteristic).Insomecountries,higherincomeindividuals
opt out to use higherquality or higheramenity private services, which, in
effect,allowsscarcepublicfundstobeconcentratedonthepoorthroughuni
versal coverage. Getting this balance right is difficult because it requires a
goodquality public system, one that betteroff citizens will continue to
politicallysupport,eventhoughonoccasiontheymaygooutsidethepublic
systemforbetteramenitiesandqualityforcertainservices.
IndonesiasHealthFinancingPrograms
TheevolutionofIndonesiashealthfinancingprogramshasarichhistory.This
evolutionstartedduringthecolonialperiodandischaracterizedbythechange
fromtraditionalmedicinerootedintheChinesesystemtoWesternmedicine
(Boomgaard 1993). In the early twentieth century, the Dutch established a
mandatoryhealthinsuranceschemeforcivilservants. 1 Theproviderwasthe
governmental hospital, which supplied a free, comprehen sive package of
benefits.In1938,allcivilservantsandtheirfamilieswereincludedunderthe
samebenefitpackage;in1948,a3percentcopaymentforinpatientservices
wasintroduced.
AfterIndonesiagaineditsindependencein1945,theregulationregardingcivil
servantshealthinsuranceineffectduringtheDutchIndiesgovernmentwent
into effect for government officers through the early Asuransi Kesehatan
(Health Insurance), or Askes, scheme (GuadizPadmohoedojo 1995). The
budgetwasprovidedtotheMinistryofHealth(MoH)andhospitalswere
reimbursedforservicesprovidedtocivilservantswithsalariesbelowafixed
ceiling. Health services were free of charge in public hospitals and
reimbursableinprivatehospitals.Forinpatientservicesa3percentcopayment
wascharged.Thereimbursementsystemworkedasfollows:Healthinspectors
attheprovincelevelverifiedclaimsthatwerebroughttothereimbursement
officeinthecentralMoHoffice.Afterverification,theclaimwasbroughtto
the State Exchequer Office, which would pay the MoH. Early problems
identifiedinthisschemeincludethosethatmoderninsuranceschemescontinue
tosuffer:moralhazard,highcoststothepublicbudget,highadministrative
costs,andnoncoverageofretiredofficers.
AskesPersero,thepredecessorto P.T.Askes,wasestablishedin1968under
PresidentialInstructionNo.230/1968tofinanceanddeliverhealthinsurance
services to both active and pensioned civil servants, including their direct
family members. In addition, Ministry of Health Regulation No. 1/1968
providedP.T.Askeswithexclusiverightstomanageitsowninsurancefundto
supportadministrativeandfunctionaloperations.Startingin1991,P.T.Askes
broadened its market and product coverage to the provision of commercial
healthinsuranceprogramstothepublic.In1992,the JaminanSosialTenaga
capacity.Suchfiscalcapacitydependsonbothlocalrevenueraisingcapacity
andtheflowoffundsthroughtheintergovernmentalfiscalsystemsinwhich
somefundsareearmarkedbycentrallevelgovernment,whileothersarenot,
andformulasusedforredistributingfundsfromcentraltolocalgovernments
oftendonotreflectlocalneedandfiscalcapacity.
Althoughtheconceptatfirstappearssimple, 2 districtsareresponsiblefor
implementing health services. The complexity of the flows of funds some
targeted to health, others not; some payments made through insurance
organizations, and others made directly to public providers (hospitals,
Puskesmas,andpersonnel)makeforanintricate,inequitable,inefficient,and
fragmented set of financing flows (World Bank 2008c). Moreover, recent
studiesalsoindicatethatmanypoordistrictsarereceivingmuchhigherlevels
offundingthanpreviously,buthavebeenunabletospendthesefundsbecause
oflocalabsorptivecapacityconstraints.Othercases,despiteincreaseddistrict
spending,littleeffectivepovertyreductionhasoccurredinsomeofthepoorest
districts(FenglerandHofman2007).Asofmid2009,itisdifficulttogeta
clearpictureoftheextentofcoverage.Reliabledataonthenumbersofpeople
with formal health insurance coverage are lacking. Figure 3.2, using 2007
SurveiSosialEkonomiNasional(NationalSocioeconomicSurvey),orSusenas,
surveydata,indicatesthatin2006onlysome26percentoftheIndonesian
populationwascovered,largelythroughtheJamkesmasprogramforthepoor.