September 1, 2005
Publication:
Ash Center for Democratic Governance and Innovation, Harvard Kennedy School
As part of its mandate to alleviate poverty in Indonesia, the World Bank is undertaking a series of case studies to promote better service provision, especially for poor and disadvantaged people. The case studies were chosen from the many innovative practices seen in Indonesian local government in recent years, through a competitive outreach process managed by the World Bank. Donors, non-governmental organizations, and local government staff were contacted and encouraged to submit proposals regarding innovative service delivery work that they either were undertaking or knew about.
 
The Jaminan Kesehatan Jembrana (JKJ) health insurance reform scheme in Jembrana District, Bali, touches upon a theme that is central to making services more pro-poor, to wit, the use of private providers to expand service coverage and improve quality by increasing competition. The Jaminan Kesehatan Jembrana (JKJ or Jembrana Health Insurance) scheme begun in Jembrana District, Bali Province in March 2003 provides free primary healthcare to all members; free secondary and tertiary care is also provided for poor members. The scheme has improved the access of both poor and non-poor citizens to healthcare. Before JKJ, only 17 percent of district citizens were covered by any kind of health insurance; now, 63 percent are covered. The percentage of ill people who sought treatment in Jembrana more than doubled from 40 percent in 2003 to 90 percent in 2004. For the poor, the increase was from 29 to 80 percent. Increased access of the poor to health services is due primarily to the inclusion of private providers in the JKJ scheme. Though on paper, out-of-pocket healthcare costs have increased sharply for poor non-members, in practice most public providers still provide free care for all poor clients. This increases access of even non-member poor to healthcare, but subjects them to the discretion of providers who have the legal right to refuse them free services. Meanwhile, JKJ registration requirements have kept many of the poor from joining.
 
JKJ's attempts to become self-financing have focused recently on a new one-membership-card-per-person system (rather than the old one-card-per-family scheme), and this is likely behind a drop in membership of the poor, from 66 percent in 2004 to 22 percent (re-registered under the new system) by May 2005, since many poor families cannot afford to re-enroll all members. By increasing access to private providers, JKJ has increased competition between public clinics and private doctors for clients. JKJ has also improved both healthcare quality and client satisfaction. It is likely that JKJ's enforcement of strict standards on equipment, treatment, medication, and referral has contributed to the improvement. JKJ does not, however, appear to be financially sustainable. There has been a rapid, unbudgeted increase in district spending on JKJ. JKJ's inclusion of non-poor citizens adds greatly to its cost--in 2004, 95 percent of the Rp. 9.5 billion in JKJ claims were made for services to non-poor clients. The informal inclusion of poor non-members also increases JKJ costs, as those who provide free services to poor non-members are in fact usually reimbursed by JKJ. Finally, investment in JKJ administration is grossly inadequate, and JKJ's legal basis is challenged by a 2004 law centralizing health insurance.

 

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