Challenge and opportunity to expand health care financing on OH

Services for Informal and Small Scale-medium Enterprises Workers

in Indonesia

Hanifa M. Denny1

Health insurance in Indonesia

The government of Indonesia has started to enact health insurance program for government

employee/civil servant and military since 1968 based on Presidential Decree No. 230/1968.

With the Decree, Ministry of Health established “Badan Penyelenggara Dana Kesehatan” or

Health Care Financing Agency. In 1992, the government changed its status from government

agency into PT. ASKES (Persero) or Limited Liability Company owned by Government. 1 In

general, PT. ASKES (Persero) provides insurance coverage for government employee/ civil

servants, retired government employee/ pensioner, retired militaries and their families/

military pensioner; all corporate workers; and all corporate pensioners or retired workers ; all

community that have paid the insurance fee by themselves or by the government. 2

Another type of Health Insurance Company is PT ASABRI. PT ASABRI is the Military Social

Insurance Company, State Owned Enterprises (SOEs) that are specific to sympathize Army

personnel, police and civil servants Members of the DoD / police in order to improve the

welfare of soldiers, police officers and civil servants DoD / police. The General Social Insurance

Company of the Armed Forces of the Republic of Indonesia (Perum ASABRI) established under

the Government Regulation Number 45 Year 1971 on August 1, 1971, and subsequently

established as the anniversary of ASABRI. In its development efforts to improve motion, then

1 Chair of the Department of Occupational Safety and Health, Post Graduate Program in Health Promotion, Diponegoro University, Semarang, Indonesia and is working on her research on Occupational Health Services for Informal Sectors in Indonesia for the Doctorate Program in Occupational Health, College of Public Health, University of South Florida, Tampa, Florida, USA and . Email: hanimd@hotmail.com; hanifadenny@mail.usf.edu

based on Government Regulation Number 68 Year 1991 ASABRI establishment of the Public

Corporation (Perum) was transferred into a Limited Liability Company (PT), so that became PT

ASABRI (Persero). PT ASABRI is a State Owned Enterprises (SOEs) owned by the Minister for

State Enterprises. 3

Social Security for Indonesian Workers

Non-government employee who work in a corporate is mandated to be a member of Social

Security for Indonesian Workers which is managed by PT. JAMSOSTEK or other private

insurance companies with better coverage. PT. JAMSOSTEK is a government owned Limited

Liability Company which provide social insurance for workers in private own companies. PT

Jamsostek (Persero) provides protection 4 (four) courses, which include the Employment

Accident Insurance Program (JKK), Death Benefit (JK), Old Age Security (JHT) and Health Care

(JPK) for the entire workforce and his family.4 The PT. Jamsostek members in 2010 hit 9.12

million or 79% of its target. 5

Health insurance coverage for the poor and near-poor.

Indonesian government also provides health insurance coverage for the poor and near-poor

that is provide through the "Jamkesmas" program. “Jamkesmas” was initially started in 2005 as

the Askeskin (Health Insurance for the poor) was expanded in 2008 to target both the poor and

near-poor and currently targets almost a third of the population in the country. Official

estimates indicate that Jamkesmas covered almost 72 million people in 2009.

Along with the implementation of autonomous region in Indonesia, there is a phenomenon that

most of local governments have started to implement “Free Medical Service Campaign.” The

campaign is intended to win the election to become the leader at provincial and municipality

levels. In one side this campaign is very beneficial for health sectors as long as the local

government handle it effectively and efficiency.

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Health Care Financing for Informal Sectors Workers

In Indonesia, the economic backbone for microeconomics relies on workers who mostly work

for small-scale & medium enterprises and informal sectors. This population generates up to

64% of the Indonesian gross domestic product. [6] On the other hand, their awareness on safe

and healthy work practice as well as their workplace condition remains poor. [7] Workers in

informal sectors are vulnerable to unsafe and poor working conditions. Unfortunately, the

actual implementation of the laws in occupational health in Indonesia does not cover the need

of occupational health services for informal sectors.

The Act on occupational health in Indonesia is stated in law No. 36 in 2009 on Health, Section

XII. This law mandates the Ministry of Health to provide health service with regard to

improvement of productivity of workers, to provide occupational health services, to prevent

workers from occupational diseases and to promote workers’ health as well as to set up the

standards in Occupational Health. [8]

Challenges and Opportunities

The Indonesian health policy mandates local government to build one health center for every

30,000 inhabitants and one sub-health center for every 10,000 inhabitants. A public health

center has staff of at least one physician (general practitioner), several nurses and midwives,

other health related personnel and administrative staff. A sub health center has at least one

nurse or a midwife plus few administrative staff to provide a very basic health services to the

community. 9 In 2010, Indonesia had recorded 9,005 community health centers, while

Integrated Health Posts is accounted for 266,827. Moreover, 5107 Occupational Health Posts

(POS UKK) have been set up in 26 of 32 provinces in Indonesia.

Our qualitative study in 2007 explored the strengths, weaknesses, opportunities, and threats

(SWOT) of PUSKESMAS to implement OHIS program in Indonesia. We used open-ended

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questionnaires to interview 56 government officers, 8 house members, 32 PUSKESMAS officers,

128 POS UKK volunteers, 72 stakeholders and academia from 8 provinces of Sumatra and Java

Islands.

We found out that the strengths of PUSKESMAS in Indonesia to provide services in OHIS were

the availability of PUSKESMASes in every sub-district; the funding from central government in

OHIS; 70% of PUSKESMASes in the study had started to deliver OHIS services; availability of

5107 POS UKKs; and availability of OHIS guidelines. The weakness were the limitation of

campaign and training in OHIS; the limitation of health workers’ capabilities in OHIS services;

and lack of local governments awareness on OHIS.

The opportunities were the fact that informal sectors were accounted for more than 60% of

workforce in Indonesia and numerous stakeholders as well as academia, which had been

providing support and collaboration to serve OHIS program. The threats were the existing

policy that put occupational health out of the “minimum services standard” required for

PUSKESMAS; the uncertainty of informal sectors in their business cycles; the mobility of the

workers; and the spread out of the location informal sectors along Indonesia’s Islands. 7

In conclusion, future improvement on health care financing for informal sectors and small

medium scale of workers in Indonesia should focus on advocacy to provincial and local

governments to expand the mechanism of health care financing system for informal sectors and

small scale-medium scale enterprises workers.

Sources:

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1 http://www.ptaskes.com/info-perusahaan/14/Sejarah%20Singkat2 http://www.jamsostek.co.id/content/news.php?id=25843 http://www.asabri.co.id/profileperusahaan.php4 http://www.jamsostek.co.id/content/i.php?mid=25 http://www.jamsostek.co.id/content/news.php?id=15716 BPS. National Labour Force Survey 2010, Statistics Indonesia,

http://dds.bps.go.id/eng/tab_sub/view.php?tabel=1&daftar=1&id_subyek=06&notab=37 Denny H, Azwar R, Purnami CT. Analisa situasi kesehatan kerja di sektor informal pada 8

Propinsi di Indonesia. Laporan kegiatan survei disampaikan ke Direktorat Bina Kesehatan Kerja. Belum dipublikasi. (Situational Analysis of Occupational Health in Informal Sectors of 8 Provinces in Indonesia. Official survey report submitted to the Directorate of Occupational Health, Ministry of Health of Indonesia, 2007).

8 Undang Undang Nomor 36, Tahun 2009 Tentang Kesehatan, Republik Indonesia. Retrieved from: http://www.pppl.depkes.go.id/_asset/_regulasi/UU_36_Tahun_2009%5B1%5D.pdf

9 http://staff.ui.ac.id/internal/140163956/material/36YearsofSocialHealthInsuranceinIndonesia.pd