Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms in Kabupaten Tabanan, Bali : A Case Study

Based on the notion that good health is one of the basic right of all citizens, the Government of Indonesia (GoI) has promoted programs on health care financing for the poor. One of these programs is the Jaminan Pemeliharaan Kesehatan (JPK). In 2003, the pilot project on JPK for the poor (JPK-Gakin) started in 15 districts and two provinces, and was expanded to additional regions the following year. Since April 1 2004, PT Askes, a profit oriented private insurance company, was assigned as the insurer of the nonprofit health insurance scheme for the poor (the JPK-Gakin) in district Tabanan. With respect to PT Askes it is important to see in what ways does the prominent role of PT Askes influence the dynamics of health service delivery and how different is PT Askes from other insurers (the non-profit - public institutions) in managing the JPK-Gakin scheme. The Tabanan case demonstrated that the supervision and monitoring by the Dinas Kesehatan (DinKes) of an insurer like Askes runs the risks of being less effective because PT Askes is a relatively well-established institution that is totally independent of the DinKes. Moreover, there is a difference in the level of expertise and experience between PT Askes and the Dinkes regarding the management of insurance schemes. Therefore, the supervision and monitoring of PT Askes by the DinKes tends to be formal instead of actual. This difference in the level of expertise and experience can also be a barrier for the DinKes to negotiate the cost and coverage of the scheme with PT Askes. PT Askes as the insurer is also barely involved in the promotion and socialization of the program and the identification of the poor as their potential clients. Obviously, the JPK-Gakin scheme can secure primary health care for the poor (the gakin) at the puskesmas, but this does not necessarily mean that the poor will receive good quality care. In general, the health care at the puskesmas is quite limited both in term of quality and variety. The implementation of the JPK-Gakin scheme including adequate capitation for the puskesmas from this scheme would certainly not change this condition easily as it relates to more complex factors such as the availability of good medical staffs, instruments and facilities. The most positive effect of the JPK-Gakin scheme on the provision of health care for the poor is the possibility to get secondary and tertiary health care that is usually unaffordable for the poor. Nevertheless, for a range of different reasons, the majority of Gakin patients are not referred to the hospital. There are cases where the poor refused to be referred to the hospital although it was necessary because they were insecure about the additional costs that were not covered by PT Askes. Thus, although the JPK-Gakin scheme does secure the right of the poor to get medical treatment at the hospital, it cannot secure the actualization of it.