Public Health in the Decentralization Era Towards Universal
Coverage
Ni Luh Putu Arum Puspitaning Ati
Faculty of Public Health, Universitas Airlangga, Mulyorejo, Surabaya, Indonesia
Keywords: Universal coverage, Decentralization, Health financing, Health services, Managed care.
Abstract: Every citizen has the right to have access to quality health services, at a reasonable cost. To ensure universal
coverage, it is important for governments to take policy measures aimed at expanding pre-paid systems and
reducing as quickly as possible dependence on out-of-pocket systems. The objectives of this research was to
find the efficiency administrative, which is necessary to limit the number of insurance companies. This goal
can be realized by developing a broader and fairer system of pre-effort financing through taxes, social health
insurance, or a mixture of both systems. Through the positive elements of “managed care”, the government
can establish regulatory and control mechanism on the demand side and the provision of health services, in
order to control the cost, quality, access of health services for all citizens in Indonesia. For the long-term and
well-performing insurance companies in managing insurance on a national scale continue to function as
private and social health insurance managers in parallel with national health insurance (Jamkesmas)
managed by the government. The government needs to strengthen the regulation on the financing side and
the provision of services in the system of insurance, so that every citizen can actually access quality health
services at affordable cost.
1 INTRODUCTION
Health is not viewed as a citizen’s right but also an
investment capital that determines the productivity
and economic growth of a country. Therefore the
state is concerned that all its citizens are healthy
("health for all"), so there is a need to institutionalize
universal health services. There are two fundamental
issues for the realization of health services with
mental health, namely how to finance health services
for all citizens, and how to allocate health funds to
provide health services effectively, efficiently and
equitably.
The appropriate financing system for a country is
a system capable of supporting achievement.
Universal coverage is a health system in which
every citizen has fair access to quality, promotive,
preventive, curative and rehabilitative services, at a
reasonable cost. Scope of the universe consists of
two core elements: (1) Access to fair and quality
health services for every citizen; and (2) Fire
Protection of Communities Using Health Services
(WHO, 2005).
Fair access to health services uses the principle
of vertical justice. The principle of vertical justice,
the contribution of citizens in health financing based
on ability to pay (ability to pay), not based on health
condition / pain of a person. With vertical justice,
lower-income people pay lower cost than higher-
income people for health service of the same quality.
In other words, cost should not be an obstacle to
getting required health care (needed care, necessary
care) (Bhisma, 2011). This paper will further
discuss the strategy (dual health care system) for the
management of financing to achieve health care
coverage in Indonesia.
2 METHODS
A scientific study should use systematic compilation
techniques to facilitate the steps to be taken.
Similarly, the authors conducted in this paper, the
steps taken are through literature studies on reading
journals and research results that deal with the
insurance system and health financing. The data
Ati, N.
Public Health in the Decentralization Era Towards Universal Coverage.
In Proceedings of the 4th Annual Meeting of the Indonesian Health Economics Association (INAHEA 2017), pages 179-182
ISBN: 978-989-758-335-3
Copyright © 2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
179

obtained from this literature study can be used as a
reference analysis to discuss innovation of health
financing system in Indonesia.
3 RESULTS
Universal Health Coverage (UHC) is defined as
ensuring that all people have access to needed
promotion, preventive, curative and rehabilitative
health services, of sufficient quality to be effective,
while also ensuring that people do not suffer
financial hardship when paying for these services.
Universal health coverage has therefore become a
major goal for health reform in many countries
(WHO, 2017).
The Indonesia’s Universal Health
Coverage/Jaminan Kesehatan Nasional (JKN) was
launched on 1 January 2014 to initially cover around
120 M population who are already engaged in
various social health insurance (SHI) schemes under
one fund-management agency called Health-BPJS.
The targeted all population coverage is around 250
M people to be covered by 2019. With the targeted
coverage, JKN will be the world largest SHI (WHO,
2017). There are some JKN issues raised in this year
include:
a. Availability and equitable distribution of health
services in outer islands to serve JKN members
and overall quality of healthcare services
b. Provider payment: issues with long time laps for
government primary care facilities in receiving
capitation payment due to regulation on
decentralization; and low tariff set in INA-CBG
prospective payment.
c. Lack of JKN socialization activities for the
people at large and coverage issues of people in
the informal sectors.
d. Assurance of sustainable financing towards
UHC.
This paper looks at the potential for
decentralization in Indonesia to lead to better health
workforce recruitment, performance and retention in
rural areas through the creation of additional revenue
for the health sector; better use of existing financial
resources; and creation of financial incentives for
health workers. According to the rationale of
decentralization, smaller local entities that have
more autonomy and funds can better respond to
local needs and may also better manage human
resources. As explained in Fig. 1, decentralized
health financing systems are built around one or
more of the three main sources of health-care
finance: ministry of health, local government and the
community. Where the decentralized health
financing system relies on more than one source, the
sources are seen to be interdependent (as indicated
by two-headed arrows in Fig.1).
Source : WHO. Bulletin of The WHO. 2010
Figure. 1: Decentralized health financing and its links with
the health workforce
Decentralization, where it involves the dispersion
of human resource functions to the local
(government, health-care delivery or community)
level, is an especially challenging process as it is
influenced by various institutional and contextual
factors. Although financial resources are finite (but
well accounted for under decentralization),
decentralized health financing systems present
opportunities to maximize resource availability and
utilization. In particular, as shown in figure below,
three prominent sources facilitate this purpose: (i)
autonomy within the ministry of health or
decentralization of health-care delivery, (ii) local or
decentralized government resources, and (iii)
community resources (WHO, 2010). This paper
mainly focuses on strategy for achieving public
health in the decentralization era towards universal
coverage.
4 DISCUSSIONS
The dual financing system consists of two parallel
components, namely health financing for the formal
sector and the informal sector. The dual system has
been applied to the universal coverage policy in
Thailand since 2001 and has successfully achieved
the goal of equitable healthcare financing,
preventing catastrophic health spending and
impoverishment due to out-of-pocket healthcare
payments (Somkotra and Lagrada, 2008).
Community
Resource
- Microfinance
- Out of pocket payments
- Philanthropic resource
- Other private resource
Local
Government
Resource
- Locally generated
revenue
- Transfers from others
levels of government
Financial
Incentives
Financial
Incentives
Ministry of
Health Resource
- Budgetary resource
- Local non-tax revenue
(retained user fee,
donation, outsourcing,
etc.)
Financial
Incentives
Health
workforce
recruitment,
perfomance
& retention
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With a double-finance system, methods for the
formal sector go as they have been through the
Askes scheme, Jamsostek, and private health
insurance. But the coverage of the insurance
beneficiaries needs to be extended to include all
family members, not just the workers concerned.
The government needs to regulate the amount of
premium and regulation of health service provision.
Informal sector health financing can be done
through Jamkesmas and Jamkesda schemes, to
finance the health services of workers in the
informal sector, such as farmers, casual workers,
small traders, self-employed, unemployed, poor
families, near-poor families, almost non-poor
families, others, and his family. To achieve universal
coverage, quality health services must be accessible
to all citizens, not only poor, but also non-poor.
The implications of the wish to extend coverage
of Jamkesmas and Jamkesda schemes to all citizens
require more funds than the APBN or APBD to
finance the scheme. To do so requires the political
will of the government and parliament to reallocate
the state budget in such a way that there is sufficient
budget to run the universal coverage scheme of
health insurance. At the same time, it is necessary to
extend the coverage of social health insurance
(payroll tax-based insurance for workers in the
formal sector). On the other hand, to control health
costs, it is necessary to regulate demand-side health
cost control, by applying co-payment to prevent
moral hazard, even though poor and near-poor
families need to be freed from co-payment.
Starting from 2014 Jamkesmas managed by the
Social Security Management Agency (BPJS). In
accordance with the "big law of law" JAMKESDA
funds from each district and city will be more
efficient if pooled on a provincial scale, thus making
the risk of illness of the insurer to the average. The
pooling of JAMKESDA funds from each regency /
municipality at the provincial level is useful for the
cost of health services divided by all JAMKESDA,
thereby reducing the burden of certain district /
municipality Jamkesda that have participants with
greater relative risk of illness. Certainly need to
avoid overlapping insurance protection. The
coverage of Jamkesda insurance beneficiaries or the
health care benefits package should be differentiated
with Jamkesmas.
Funding at the provincial level is also useful to
prevent disparities in the benefits of health services
that can occur if Jamkesda is managed by each
regency / city, in addition to the usefulness of
insurance services can be used between regions
(portability). The social insurance system
(mandatory) always requires community solidarity,
solidarity and political commitment of district / city
governments to be willing to collect JAMKESDA
funds on a national scale.
Musrifah (2014) state that the forms of regulation
and government intervention that health is through
the creation of modern health institutions in line
with the order of universal healthcare. The existence
of direct local elections in Indonesia are very
influential on public policy in health financing.
National Health Insurance Program and the Health
Insurance (Jamkesda) is an instrument of the State to
make public welfare. When finished instrument
state, the second program is often used by politicians
to win the regional head elections (elections) or get
legitimacy. Therefore it needs to be a synergy
between the Central and Local Government relating
to the health insurance policy. The most important
thing in healthcare synergy between the Central and
Local Government is the problem of financing. The
poor and can not afford that contained in the Decree
of the Regent/Mayor will be financed from the state
budget, poor and can not afford beyond the quota are
borne by the local government with a source of costs
from the budget, financed the Workers' Group of the
respective institutions (PNS, Asabri, Jamsostek) and
group of individuals (the rich and very rich) pay for
themselves and those who are not covered by the
state budget and budgets.
In addition, it is important for BPJS to apply the
positive elements of “managed care”. BPJS needs to
be obeyed by important and professional people in
the field of providing managed health care services
with insurance system. The government and BPJS
apply regulatory on the demand side and the
provision of health services, in order to control the
cost, quality, and access of health services for all
citizens. On the supply side, BPJS needs to apply
quality control tools and health care costs, for
example by the selection method, and deselection, to
hospital, Puskesmas, and doctors, who provide
service in the pre-effort scheme (Bhisma, 2011).
JKN new policy could be implemented as a
whole, if it is consistent and commitment to the
mandate of the Health Act which requires a
minimum of 5% of the budget for health
development. If the 2014 budget are difficult to
change the implementation of at least JKN
conducted early in 2016, after realizing the
government's health budget by 5% of the total state
budget. Step by step, local governments are also
encouraged to commit to the health budget by 10%
of the total budget. Thus universal health coverage
will still be able to be achieved in 2019.
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5 CONCLUSIONS
Every citizen has the right to have access to quality,
promotive, preventive, curative and rehabilitative
services, at a reasonable cost. Through the positive
elements of “managed care”, the government can
establish regulatory and control mechanism on the
demand side and the provision of health services. To
ensure universal coverage, with SJSN Law no.
4/2004, it is important for the government to take
policy measures aimed at expanding the scope of
pre-paid system and reducing as soon as possible
reliance on out-of-pocket systems. With the
characteristics of the majority of citizens working in
the informal sector with uncertain income and some
others formal, the goal can be realized by developing
a wider and fairer system of pre-effort financing
through general taxes and extending the coverage of
payroll-tax (dual health care system).
REFERENCES
Bhisma Murti. 2011. Asuransi Kesehatan Berpola
Jaminan Pemeliharaan Kesehatan Masyarakat di Era
Desentralisasi Menuju Cakupan Semesta.
Disampaikan pada Seminar Nasional “Revitalisasi
Manajemen Puskesmas di Era Desentralisasi” di
Universitas Sebelas Maret, Surakarta.
Musrifah, Sri. 2014. Studi Implementasi Kebijakan
Transisi dari Jaminan Kesehatan Daerah
(JAMKESDA) ke Jaminan Kesehatan Nasional (JKN)
di KabupatenTuban. Tesis. Program Magister Ilmu
Politik, Fakultas Ilmu Sosial dan Ilmu Politik,
UniversitasAirlangga.
Somkotra T, Lagrada LP. 2008. Payments for health care
and its effect on catastrophe and impoverishment:
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in Thailand. Soc Sci Med.;67(12):2027-35.
WHO. 2005.Achieving universal health coverage:
Developing the health financing system. Technical
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Health Organization, Department of Health Systems
Financing, Health Financing Policy.
WHO. 2010. Emerging opportunities for recruiting and
retaining a rural health workforce through
decentralized health financing system. Bulletin of The
World Health Organization Volume 88, Number 5,
321-400.
WHO. 2017. Universal Health Coverage and Health Care
Financing in Indonesia. [Online]. Accesed on 05
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