Rapid assessment of health insurance programs for the poor in Indonesia

Presenter: Budi Hidayat, World Bank Jakarta, Indonesia

Abstract

The Government of Indonesia has opted to reallocate a portion of its fuel subsidy savings towards pro-poor programs, among others in health sectoral through introducing Askeskin program. The Askeskin program was designed to cover health costs for the poor who might otherwise curtail their expenditures on healthcare due to the effects of the fuel price increase. A study was done to give policy-makers a rapid assessment of how beneficial these programs have been to the poor and whether their objectives are likely to be achieved.

A mix quantitative and qualitative study of the Askeskin was carried out in early 2006. It was done in six provinces; two districts were randomly selected in each of these provinces and within each the study team visited 1 hospital, 2 puskesmas and interviewed puskesmas service users and non-users. The qualitative study included a review of the programs’ design, guidelines and operations manuals, program implementation and short-term program impacts. Assessment of program implementation focused on program design, coverage, targeting and implementation activities such as socialization, monitoring and evaluation (M&E), complaint-handling systems, fund utilization and short-term impacts. Assessments included in-depth key informant interviews, focus group discussions as well as observation. Data for the quantitative assessment were derived from two sources: the Second Governance and Decentralization Survey and Survey Social Economic National 2005 and 2006 panel datasets.

Key findings are as follows. The Askeskin program adopts insurance principles through providing health benefits to its beneficiaries in secondary and tertiary healthcare, and provides block grants for primary healthcare. About 16 million health cards were distributed (out of an originally planned 60 million) under Askeskin that give access to all public hospitals, health centers and some private hospitals. The targeting mechanism relied on the direct cash transfer beneficiary list and was slightly pro-poor in targeting, but problems occurred with the targeting of individuals as opposed to families. The program was socialized only to some service providers and government, and there was no clear socialization for beneficiaries. The M&E was not carried out systematically (e.g., there was a lack of reporting upwards and an absence of feedback, among others) due to unclear funding for this activities. The complaint-handling systems consisted of informal mechanisms only. The funds were utilized for doctors’ services, medical supplies and medicines. Regardless of the aforementioned problems above, the program significantly increased demand for third-class hospital services and health-center services, as well as providing for improvements in health center facilities and services. Average third-class bed occupancy rates increased from 58 percent in 2003 to 60.6 percent in 2004 and 67.7 percent in 2005. The visit rate for the poor has increased nationally by over 15 percent (the program’s goal), and referrals by 8.4 percent (less than the 12 percent target rate).