31333A. Bank and Other Financial Institutions

Universal Health Coverage under Badan Penyelenggara Jaminan Sosial

Policy and System, Readiness, Response, and Cost-Benefit Analysis

of Indonesia’s New Social Security Providers

By:

YULIA RATNASARI

3124039

International Business Networking

The Faculty of Business and Economics

University of Surabaya

November 2013

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I. INTRODUCTION

Social Security Action Committee urged the government and Indonesia’s House of

Representative (Dewan Perwakilan Rakyat – DPR) to organize insurance Indonesian state

owned enterprises (Badan Usaha Milik Negara - BUMN). Since cost sharing from different

security providers often happen, it potentially creates moral hazard and treatment class

preference. Therefore, those four BUMNs are merged into one social security provider. The

four BUMNs are Limited Liability Company (Perseroan Terbatas – PT) Askes (Asuransi

Kesehatan), PT Jamsostek (Jaminan Sosial Tenaga Kerja); PT Taspen (Tabungan dan

Asuransi Pensiun); and PT Asabri (Asuransi Sosial Angkatan Bersenjata Republik Indonesia).

The legal bases for these changes are the Law No. 40/2004 on National Social

Security System (referred as Sistem Jaminan Sosial Nasional or SJSN Law) and the Law No.

24/2011 on Social Security Administrative Bodies (referred as Badan Penyelenggara Jaminan

Sosial or BPJS Law). BPJS is a public and non-profit legal entity which provides social

security. The new social protection program will cover all Indonesians, including formal and

informal sector workers. BPJS provides five insurance benefits which are health, pension, old-

age savings, death benefits and worker accident.

However, the merger of BPJS potentially creates Pareto efficiency: a state of

allocation of resources in which it is impossible to make any one individual better off without

making at least one individual worse off. Hence, there are current and potential issues

regarding to the implementation of the BPJS. This paper will discuss the effects of the SJSN

and BPJS Laws on the Indonesian pension and health coverage systems. To understand the

purpose and effect of the SJSN implementation, this paper will also give a brief overview of

the current programs as well as their challenges. Furthermore, the writer will analyze the key

required actions in responding the dissatisfaction groups, which are the general practitioner

doctors, ABRI, low income classes and private hospitals.

II. METHODS

Using online research methods (ORMs) and watching forum from television, data was

obtained. Since several data are difficult to be obtained, the writer read various published

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reports, Indonesia’s fiscal budget, blogs, and online newspapers. Also, the writer watched

Executive Forum BPJS and Eight Eleven Show of BPJS on MetroTV to gain insight of the

current Road Map.

III. RESULTS

1. Current system

The current pension system is fragmented and varies by labor market groups - civil

servants, the military and formal sector workers. Each segment has different benefits and a

different administrator, and the system of supervision and enforcement is a challenge. Risk

averse causes people to buy health insurance. For formal sector company, fringe benefits

allow workers to have insurance as a bonus, which is compulsory.

Firstly, PT Askes provides health insurance for the poor, all citizen and bureaucrats.

Jaminan Kesehatan Masyarakat (Jamkesmas) is part of Indonesia’s efforts to alleviate

poverty. Those who suffer from poverty and cannot afford health insurance including

vagabonds, beggars, abandoned children and poor people without identity. The contribution

paid by the government is only 6,000 IDR per capita monthly. Another, health Insurance

PJKMU (General Public's Health Insurance Program) is made for people from the local

government. For citizen who wants to be member of Askes, 39,000 IDR per capita monthly

must be paid by the participants in Askes Social. Askes Social members are civil servant

(Pegawai Negri Sipil – PNS), State Officials, Pension Recipients (Retired PNS, retired

Ministry of Defense, Veteran (Veteran Benefits and Non Veteran Benefits) and the

Independence Pioneers and family members. The membership of current system is not

compulsory. Hence, the one who pays will get the service. However, Jaminan Kesehatan

Utama (Jamkestama) and Jaminan Kesehatan Mentri (Jamkesmen) are the highest standard of

treatment in PT Askes and paid by the government as fringe benefits. Jamkesmen members

are the ministers and certain officials (those with ministerial rights) and their families during

the period of performance of their duties. Lastly, Jamkestama is a Health Insurance Program

for the Chairman, Vice Chairman, members of the House of Representatives, CPC, and

judicial commission, the Judge of the Constitutional Court and the Chief Justice of the

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Supreme Court. Unfortunately, not all the Jamkesmas members get the benefits from PT

Askes.

Secondly, PT Jamsostek provides old-age benefits (provident funds), death benefits,

healthcare and maternity benefits, and workplace accident benefits for formal sector

employees, which is compulsory. Jamsostek also runs voluntary schemes for employees in

informal sector economy. PT Jamsostek, the insurance generated from the employer and

employee. Employer’s contributions occupational accident is 0.24% - 1.74% of monthly

wage, old age pension (Jaminan Hari Tua - JHT) is 3.7% of monthly wage and death benefits

is 0.3% of monthly wage, also the health benefits: 3% (single) or 6% (married) of monthly

wage. While, the employee’s contribution to old age pension plan is 2% of monthly wage.

Thirdly, PT Asabri provides old-age benefits (saving scheme and pension) for armed

forces (Tentara Nasional Indonesia – TNI), police personnel (Kepolisian Republiik Indonesia

– Polri) and civil servants employed in Military and Police Offices (PNS Pertahanan dan

Keamanan – PNS Hankam). The fee for pension is 3.25% multiplied by the sum of salary

base and kids and wife allowance in PT Asabri.

Fourthly, PT Taspen runs old-age benefits (saving scheme and pension) for PNS. The

participants must pay 4.75% from the sum of salary base, kids and wife allowance monthly to

get the service.

The aims of BUMN are easy to recognize by their names. PT Taspen, PT Jamsostek,

PT Asabri, and PT Askes are form of Persero mean that the companies’ aim is for seeking

profit and increasing the welfare of the society. The weaknesses of current system is lack of

accountability, discrimination, and. PT Askes‘ Customer Satisfaction Index is 88.13 in term

of excellent operational, people development and the information and technology in 2013.

2. SNJS System

Fachmi Idris, the head of PT Askes stated that the members of BPJS in January 1,

2014 are approximately 16.8 million of Social Askes, 96.7 million of Jamkesmas,

approximately 10 million of Jamsostek and approximately four millions of PT Asabri. The

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new system is compulsory for all citizens even though the citizen already has health insurance

in other institution. (See Appendixes Table 1)

Based on BPJS Law, BPJS consist of two bodies, which are BPJS I and BPJS II. The

BPJS I will handle health care insurance, while the BPJS II is expected to deal with workers

social welfare. The aims of the two bodies are to create transparency and prevent violations or

potential violations that could affect the BPJS’s future tasks.

Firstly, all Indonesian citizens must become the participants of health insurance

managed by BPJS I. The members are classified into two groups: Contribution Assistance

Recipients (Penerima Bantuan Iuran – PBI); and non PBI. PBI members are around

96.7million (latest confirmation from Team for Accelerating Poverty Reduction (Tim

Nasional Percepatan Penanggulangan Kemiskinan - TNP2K). PBI consist of the poor, near

poor and totally disabled persons as stipulated in SJSN Law who contributions are paid by the

government. Non PBI participants consist of wage workers and their family members, as well

as non- wage workers and their family members. Wage workers are those who work and

receive wages or salaries, such as: TNI, Polri, PNS, state officials, non-PNS, private

employees, and other who meet the criteria as wage workers. Non-wage workers are people

who work outside employment relations or independent workers. They do not work but have

an ability to pay health insurance tuition. Including in non-wage workers are: investors,

employers, pension recipients or former state officials with pension rights, veterans, and

pioneers of independence or other non-workers who can meet the criteria as wage workers.

The membership of Health BPJS for all Indonesian citizens is compulsory even if they

already have other health insurance.

The premium for PBI is 19,225 IDR and financed by national fiscal budget (Anggaran

Pendapatan dan Belanja Negara - APBN) for 19.9 trillion annually. On the other hand, 22,200

IDR per person monthly must be paid regularly by non PBI to have healthcare treatment in

Class I; 40,000 IDR per person monthly, for participants to have healthcare treatment in class

II; and 50,000 per person monthly, for participants have healthcare treatment in class III.

BPJS holds a principle of pooling of risk, where there is a cross subsidize funds from those

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who pay high premium to the lower one. Hence, the benefits that citizen can acquire is not

limited in the amount of premium payment.

Since the enactment of BPJS Law on November 25, 2011, the government has been

working on a roadmap that will provide guidance for the implementation of BPJS and SJSN

programs. The roadmap of the health insurance program would be implemented in two stages,

transition in 2014 full health coverage in 2019. Firstly, PT Askes is going to be transformed to

BPJS I and started to serve health matters, work accidents, and death start from January 1,

2014, statuted on Pasal 60 ayat (1) BPJS Law. Secondly, PT Jamsostek is transformed to be

BPJS II which administers pensions and social security of manpower on January 1, 2014

statute on Pasal 62 ayat (2) huruf d BPJS Law and will be start to operate in July 2015.

Thirdly, PT Asabri, will be BPJS II to serve at the latest in year 2029 statuted on Pasal 65 ayat

(1) BPJS Law. Fourthly, PT. Taspen will be provide old-age benefits as BPJS II for at the

latest in year 2029 based on Pasal 65 ayat (1) BPJS Law. The demission of PT Askes and PT

Jamsostek are going to be done without liquidation. On the other hand, PT Asabri and PT

Taspen are not yet clearly stated.

The operation of BPJS is supervised using tripartite, which are the National Social

Security Council (Dewan Jaminan Sosial Nasional - DJSN), Financial Service Authority

(Otoritas Jasa Keuangan – OJK), Supreme Audit Agency (Badan Pemeriksa Keuangan –

BPK) and a trusted public accountant. 

IV. ANALYSIS

Regarding the Pareto Efficiency, the new resource allocation creates better off some parties

and worse of the other parties.

Firstly, PT Taspen, PT Jamsostek, PT Asabri, and PT Askes are form of Persero mean

that the companies’ aim is for seeking profit and increasing the welfare of the society. While,

BPJS is wholly aim to increase the welfare of the society.

Secondly, Indonesian Doctors Association (Ikatan Dokter Indonesia - IDI) complained

that they were paid by low fees. From 85,000 general practitioners, one doctor will

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approximately handle approximately 4,000 patients. However, the value of capitation is still

unknown, but it will be approximately 6,000 IDR per patient. Capitation of payment simply

defined as the payment based on capita or multiplied by the number of person. Therefore, the

payment of capitation for each doctor is:

6,000 IDR x4000 patients monthly x12 months∈a year=288,000,000 IDR annually

However, the value of 288 million IDR is a lump sum, which also includes operational

expense, miscellaneous expense, utilities, supplies, and also the medicines. Therefore, it is not

the amount of salary per doctor received. Statute on Health Ministry Regulation 416 of PT

Askes, the service fees for doctor is 40% from the amount of capitation value. Hence:

40 % x288,000,000 IDR=115,200,000 IDR annually

Worse, the 115.2 million IDR cannot be said as doctor’s salary. Since the treatments are done

by a doctor and paramedics as a team, the salary is subtracted for the subordinators. IDI

assumed that the doctors will get 60% from 115.2 million.

60 % x 115,200,000 IDR=69,120,000 IDR annually=5,760,000 IDR monthly

The amount is relatively small comparing to the bus driver in DKI Jakarta, as Dr. Yustie

Amelia, volunteer doctor of Indonesia Bersatu said. Also, Nova Riyanti Yusuf of the

Democratic Party stated that it is even smaller than the barber which can get at least 7,000

IDR from one customer. Even worse, the earnings are before taxes and have not included the

fee to extend doctor’s permit practice. Recalling doctor’s tuition fee to graduate from

university, the amount is too small and even undervalue the skills and professionalism of

doctors.

Thirdly, ABRI and their families were just allowed to have treatment at Bhayangkara

Hospital as a special military hospital with current system. In addition, ABRI premium were

managed by Pusat Layanan Kesehatan (Pusyankes). After BPJS are implemented, ABRI are

able to use their insurance at other hospitals and citizens are allowed to be treated at

Bhayangkara Hospital. Bhayangkara Hospital is going to be handed to BPJS. While ABRI

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will receive the same benefits and rights even after the premiums are managed by non-TNI

and Polri institution. Simply put, ABRI and their families are expected to get higher quality of

treatment since they can utilize other hospitals. However, the increase of healthcare facility

also increases the Health Care Fund (Dana Pemeliharaan Kesehatan- DPK). Initially, the

salary deduction for DPK is two percent. It is going to be increased by three percent to five

percent by January 2014. In 2014, the three percent are subsidized by the government. While

initially, civil servants set aside 4% of their monthly salary to pay for health insurance, which

only pay 2% and the rest are paid by the government.

Fourthly, for the informal sectors labor seems contradict to the new system. The

Presidential Regulation on Health Insurance (No. 12/2013), issued subsequent to the Road

Map, states that the contribution from the informal workforce will not be covered by the

government, but individuals will need to pay their own contributions (President of the

Republic of Indonesia, 2013). Complexities involved in including the informal sector include

unstable incomes of non-wage laborers, which undermine their ability to make regular

contributions. If informal workers are unable to pay regular contributions, will they be subject

to user fees to access services? Will there be penalties for those who do not contribute? Some

workers may currently be covered by Regional Health Coverage (Jaminan Kesehatan Daerah

– Jamkesda) schemes, but the government plans to take off these schemes for integration into

the BPJS. How if the new system likely to increase the number of poor? Should informal

sector laborers be exposed to high health costs?

Fifthly, the poor health insurance encounters three issues. First, the data from TNP2K

and Central Agency on Statistics (Badan Pusat Statistik – BPS) must be exact. Otherwise, it

cannot serve the main target of BPJS. TNP2K and BPS already expand the variable of poor

parameter from 14 to be 26. The poor have been experiencing barriers in accessing service by

encounter into stigma in self-identifying as poor. Second, 19,225 IDR per person is unknown

whether it is enough or not. For example, a liver transplant could cost from 500 million IDR

to 1 billion IDR, adding that it would be impossible for the government to pay for this. Third,

the key barriers to accessing health insurance for the poor and those living in remote areas, as

evidenced by the underutilization of Jamkesmas benefits by the poor. Approaches for

reaching the poor is the issues that currently faced by Jamkesmas. One of the activities

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planned in the Road Map is a mapping of groups and subgroups within the community, which

may include the differential issues faced in accessing existing schemes. The DJSN will be the

lead agency, in coordination with the Ministry of Communication, Ministry of Health and PT

Askes. Standardization and sustainability are challenges that BPJS encounter. In promote

area, doctors and facilities must have standard, so there will be no gap in giving the services.

Sixthly, private sector and its willingness degree to participate are still unclear,

particularly private hospitals. It is not clear if reimbursements to the public and private sectors

will be the same or whether these will take into account the different costs incurred. If the

private hospital acquires same funding, the incentive of public participation will be declined.

However, if the private hospital unwilling to participate, the patient can be decreased.

Seventhly, insurance is not harmed by the Muslim and can be a trigger to increase the

attractiveness of capital market. In Syariah Bank, there is an Islamic insurance named

Takaful. Muslims support the BPJS as long as the fund is not invested on over-speculative

instrument. Also, from the huge amount of funds collected from the premium, it can increase

the market attractiveness by investing it at money market and capital market.

Eighty, question is arose why society need to pay the social security while the citizen

already pay taxes. Taxes and BPJS fee have different purposes. Taxes are paid for general

funding, for example for infrastructure, PNS salaries, and so forth. Also, it is for public goods,

everyone gets the benefit. Meanwhile, BPJS has a specific purpose, which is for the five

insurance benefits. Higher expenditure since taxable income does not include premium. This

double expenditure can lead into declining of tax or BPJS participation.

Ninthly, there is a discrimination of PNS, TNI, and Polri who got a health coverage

and pension insurance for life. While, informal and formal workers did not get equal benefits

using the old system. Also, Jamsostek only provide services for formal workers, while no

government institution provide services for informal sectors. Jamsostek only cover health

benefits up to 55 years old. In this case, everyone will be better off after BPJS implemented

since everyone will have health insurance for a life time.

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Tenthly, For Jamsostek fee is approximately 10% from the monthly wage. The

employer paid 8% and the employee paid 2% on average. However, BPJS for manpower fees

has not been decided on November 24, 2013. Elvyn Masassya, Managing Director of PT

Jamsostek proposes that the JHT will be 8.5%. Overall, total fees of the monthly wage are

15%, 9% contributed by the employer and 6% will be paid by the employees. On the other

hand, the fee for pension is 3.25% multiplied by the sum of salary base and kids and wife

allowance in PT Asabri. In BPJS, the fee has not been decided yet. In this case, the fringe

benefit and the policy of BPJS II are still unclear. Also, the increasing in percentage can

decrease the participation of BPJS II. Otherwise, it can be a burden for the employee because

the salary is reduced.

Lastly, DPR got 46,800,000 IDR annually with the highest standard of treatment using

Jamkestama with the judicial commission, the Judge of the Constitutional Court and the Chief

Justice of the Supreme Court using the old system. Further, Jamkesmen for ministers and

officials with their families are paid by the government with the unstated amount. Conversely,

the Jamkesmas only subsidized 6,000 IDR monthly per capita. Using SJSN System, the poor

is better off by getting 19,225 IDR per capita monthly. However, the premium must be paid

for Jamkesmen and Jamkestama members are still unclear. This can lead into continuous

adverse selection. (see Appendixes Table 2)

V. CONCLUSION

Based on cost and benefit analysis, BPJS Law should be implemented. Indeed, adverse

selection for the Jamkesmen and Jamkestama are still happening. However, the government

promises a better quality and higher accountability of the BPJS. Generally, every premium for

the five benefits is increased. TNI/Polri and PNS will not be complaining since their salaries

are going to be increased by 6% in 2014 to anticipate the expectation inflation rate of 4.5%

(Chatib Basri, Minister of Finance in RAPBNP 2014 press conference, August 2013). Further,

the 2% increase in the cut of TNI/Polri salaries is going to be subsidized by the government.

BPJS will be successful if and only if IT is utilized in an effective way to avoid double

counting in membership. Also, the data of poor identification must be exact and adjusted

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periodically since mobilization often happen. BPJS should negotiate more rather than

designing. BPJS should clarify the domestic pressures; therefore, the funds can be distributed

fairly among remote areas. Another, the tripartite supervisor of BPJS must have standard and

corrective action must always be done during transition period

Increase in premium should also deliver the promise in quality enhancement. On the

other hand, quality is strongly related with the doctor’s performance. Hence, the salary for

general practitioner should be re-negotiated at the amount must be agreed in both behalf. All

parties must contribute to the success of BPJS. In short, BPJS should be implemented but the

representative of all related parties must also contribute to the decision making process.

Hence, universal health coverage can be fully achieved by support from all Indonesian

citizens.

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References

http://doddyrizqi.blogspot.com/2012/11/bpjs-solusi-atau-masalah-baru.html

http://www.thejakartapost.com/news/2012/06/20/doctors-want-higher-pay-under-social-

security-providers-scheme.html

http://www.itjen.depkes.go.id/public/upload/unit/pusat/files/BUKU%20SAKU%20FAQ

%20BPJS.pdf

http://en.hukumonline.com/hole/default/info/guid/lt4ebaa4fd34b9c

http://www.bumn.go.id/askes/publikasi/berita/mou-sosialisasi-bpjs-antara-pt-askes-dan-

persatuan-wredatama-ri/

http://personalfinance.kontan.co.id/news/bpjs-berlaku-bagaimana-nasib-askes-kita

http://aiphss.org/health-insurance-national-social-security-system-jk-sjsnat-a-glance/

http://www.poskotanews.com/2013/10/12/layanan-kesehatan-anggota-tnipolri-dikelola-bpjs/

http://kesehatan.kompasiana.com/medis/2013/07/28/asuransi-kesehatan-untuk-kemhan-dan-

tnipolri-580371.html

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http://www.bumn.go.id/askes/tentang-kami/rencana-kerja/

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http://www.antarajatim.com/lihat/berita/82909/pemerintah-naikkan-uang-pensiun-tni-dan-

polri

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ke-angka-1-milyar.html#.Uo9APeKjH08

http://lusianamargareth.blogspot.com/2012/11/tranformasi-asabri-menjadi-bpjs.html

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Gaji-PNS-TNI-Polri-Naik-6

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Appendixes

Table 1.

TYPE OF HEALTH INSURANCE, 2012 PERSONSParticipants in Health Insurance for Civil Servants (Askes PNS) 17,274,520

TNI/Polri (military and police) 2,200,000

Jamkesmas Participants* (Ministry of Health) (health insurance for the poor) 76,400,000

JPK Jamsostek Participants (workers’ social security) 5,600,000

Jamkesda/PJKMU Participants (regional governments’ health insurance) 31,866,390

Corporate Insurance (self-insured) 15,351,532

Commercial Health Insurance Participants 2,856,539

Table 2

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