Jampersal (Maternity Insurance) as a step towards universal coverage and health equity: experience of Indonesia* Soewarta Kosen Health Economics and Policy Analysis Unit, Center for Community Empowerment, Health Policy and Humanities, National Institute of Health Research & Development Ministry of Health Republic of Indonesia *Presented at the 4th Technical Review and Planning Meeting for the Health Policy and Health Finance Knowledge Hub, Melbourne October 2011

BACKGROUND Indonesian Constitution (1945) stated the right of every citizen to obtain health care Indonesian Health Law (2009): right to obtain safe, accessible and quality health care The government is responsible to provide quality health services Social Security Law enacted since 2004, however the implementation is still fragmented

COVERAGE OF HEALTH INSURANCE (2010) Distribusi Penduduk yang memiliki Jaminan Kesehatan (asuransi kesehatan) menurut Jenis Jaminan Local Health Insurance (JAMKESDA) exists in 250 districts/cities 4 Provinces with Universal Coverage: South Sumatra, South Sulawesi, Bali, Nanggroe Aceh Darussalam Proportion of Population with health insurance

HEALTH INITIATIVES Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) has been implemented since January 2005 for 76.4 million (the poor and the near poor) to cover free primary health care services including maternity care at community health center (Puskesmas) and in-patient services in hospital wards (third class). The Ministry of Health has managed the implementation since 2008, and directly distribute the fund to Puskesmas and hospitals A universal maternity Benefit (Jaminan Persalinan/ Jampersal) is implemented since January 2011 for all pregnant women who are not covered by any maternity scheme.

BACKGROUND Health Insurance for the Poor (Jaminan Kesehatan Masyarakat / Jamkesmas) is delivered through community health centers/ PUSKESMAS) and hospitals (public and private) Maternity Insurance is delivered through physician and midwife practitioners, community health center/PUSKESMAS, maternity clinic and hospital Fund is channelled from central to district/city through social assistance mechanism Total budget for both programs in 2011: 6.3 Trillion Rupiahs (800 Million Au $)

6 Wilayah Sumatera Share PDRB thdp Nasional 21,55% Pertumb. Ekonomi4,65% Pendaptn perkapita9,80 jt Penduduk miskin 7,3 jt (14,4%) Wilayah Jawa Bali Share PDRB thdp Nasional 62,00% Pertumbh Ekonomi5.89% Pendapt perkapita11,27 jt Pendudk miskin 20,19 jt (12,5%) Wilayah Nusa Tenggara Share PDRB thdp Nasional 1,42% Pertmbuh Ekonomi 3,50% Pendapt perkapita3,18 jt Pendudk miskin 2,17 jt (24,8%) Wilayah Kalimantan Share PDRB thdp Nasional 8,83% Pertumb. Ekonomi5.26% Pendaptn perkapita13,99 jt Pendudk miskin 1,21 jt (9%) Wilayah Sulawesi Share PDRB thdp Nasional 4,60% Pertmbh Ekonomi7.72% Pendapt perkapita4,98 jt Pendudk miskin 2,61 jt (17,6%) Wilayah Maluku Share PDRB thdp Nasional 0,32% Pertumbh Ekonomi4,94% Pendaptn perkapita2,81 jt Pendudk miskin 0,49 jt (20,5%) Wilayah Papua Share PDRB thdp Nasional 1,28% Pertmbuh Ekonomi0,60% Pendaptn perkapita8,96 jt Pndudk miskin 0,98 jt (36,1%) Source : Statistics Ind Note: based on constant prices Seven Development Area of BAPPENAS, 2008

REASONS TO IMPLEMENT JAMPERSAL High maternal, neonatal and infant mortality rates Coverage of deliveries in health care facilities: 55.4 % Decrease Contraceptive Prevalence Rate Problems of geographical and financial access Need to focus on delivery period and immediate post- delivery period (90 % of complications) that include: – Post delivery bleeding (28 %) – Toxaemia (24 %) – Infection (11 %) – Puerperal complication (11 %)

Neonatal mortality by Island group, Indonesia,

Neonatal Mortality by Wealth Group

10 Infant Mortality Rate decreases from 35 to 34 per 1000 live births, with disparity among provinces Source: DHS 2007 MDG target for IMR: 23 per 1,000 live births by 2015

Maternal Mortality Rate, Indonesia Source: DHS Angka Kematian Ibu

12 Disparity by quintile of income Infant Mortality Rate by quintile of income Sumber data : SDKI 2007 Malnutrition among children under fives by quintile of income Sumber data : Susenas, 2007

Proportion of Safe Delivery (attended by trained health personnel) by expenditure Quintile ( Susenas 2006) Equity Index 1.67

Objectives of Maternity Insurance To increase coverage of prenatal care, delivery attendance and puerperal care by trained health personnel To increase coverage of neonatal care by trained personnel To increase coverage of post-delivery family planning services To increase coverage of complication management for mothers and babies

FACILITIES FOR MATERNITY INSURANCE Contracted facilities (public and private) in all over Indonesia Facilities for normal pregnant women, delivery and puerperal period: * Community Health Center (Puskesmas) with or without in-patient facilities * Village Maternity Hut (Polindes * General Practitioner * Midwife Practitioner * Private Maternity Clinic Facilities for emergency obstetric & neonatal management or complications: * Puskesmas with basic obstetric-neonatal emergency facilities * Hospitals 15

Availability of referral facilities (public hospital and private hospital) for JamKesMas/Health Insurance for the poor,

DISCUSSIONS The Health Insurance for the poor is estimated utilized only 40 millions out of 76.4 millions of poor people Under utilization showed by areas outside Jawa, Bali and Sumatra Main obstacles: poor geographical access & transport facilities and limited availability of health facilities (qualified personnel, drugs, equipment, physical infrastructure) Need special efforts to fix the situation, to achieve objectives of Maternity Insurance

CONCLUSIONS Universal coverage of Maternity Insurance as well as future social health insurance will be less effective with identified obstacles The government should solve several bottle- neck that include: – hiring and placement of physicians in remote and poor area – Increase quality and distribution of midwives – Improve availability and distribution of quality health care facilities at primary and referral level – Improve availability and distribution of blood banks – Improve availability and distribution of Ob-Gyn and Paediatricians in referral facilities