HEALTH FINANCING : revenue collection, pooling and purchasing Yulita Hendrartini Magister Kebijakan Pembiayaan dan Manajamen Asuransi Kesehatan Universitas Gadjah Mada

Agents in health care financing

Definition of health care financing mobilization of funds for health care allocation of funds to the regions and population groups and for specific types of health care mechanisms for paying health care (Hsaio, W and Liu, Y, 2001)

Financing is More Than Mobilize Money & collect Pool the Risk Funds Allocate Resources Purchaser

Fungsi dan Tujuan Pembiayaan Kesehatan Meningkatkan dana untuk kesehatan secara cukup dan berkesinambungan. Dana ini untuk membiayai pelayanan paket esensial dasar dan perlindungan keuangan dari penyakit dan biaya katastropik berdasarkan aspek pemerataan Revenue Collection Mengelola dana-dana tersebut dalam pool risiko kesehatan yang efisien dan merata Pooling Purchasing & Payment Menjamin pembelian/ pemerolehan dan pembayaran pelayanan kesehatan yang efisien secara teknis dan alokatif Hsiao 2013 Flagship Course: Health Care Financing, Monday - November 5, 2007, Session 1

Mekanisme Revenue Collection Dari masyarakat Melalui mekanisme pemerintah/lembaga asuransi kuasi pemerintah Dari kantong pasien perorangan Yayasan-yayasan kemanusiaan Pajak langsung atau tidak langsung Pendapatan pemerintah yang berasal dari bukan pajak Kontribusi asuransi wajib dan potongan gaji Pembayaran premi ke pemerintah Grant dan pinjaman luar-negeri

Apa yang terjadi dalam Pengumpulan dana Kesehatan Pendapatan Negara bukan Pajak Pajak Non-PBi PNS, Jamsostek dll dll 18.89T APBN (67,5 T) Non-PBI Mandiri 2.24T PBI BPJS 19.93T Kemenkes Askes Swasta Kementerian lain Pelayanan Primer: Pelayanan Rujukan Kab/Kota 489 ( 72.9 T) NHA 2009 (dana masyarakat langsung) (18 T) Pemda Dana dari Masyarakat langsung Pendapatan Asli Daerah Trisnantoro, 2014

Pooling Pooling yaitu bagaimana pengumpulan dana dibagikan yang mempunyai risiko kesehatan diantara pengumpul dana /atau anggota kelompok (pool member) (World Bank, 2014). Dana yang dikumpulkan untuk kesehatan akan dibayarkan ke provider kesehatan, tempat penampungan (pools) dana bisa berbagai macam, seperti anggaran pemerintah pusat dan pemerintah daerah, asuransi kesehatan publik dan swasta, dan asuransi kesehatan berbasis masyarakat.

Pooling dana kesehatan 1. APBN Kemenkes (47,5 T)—termasuk PBI Kementrian Lain (13,5 T) Pemda (6.5 T dari APBN) 2. BPJS Kesehatan PBI (19,9 T) plus Non PBI-ex Askes,Jamsostek (18.89T) Non PBI-Mandiri (2.24T) Dua Pool besar: APBN BPJS

Apa yang terjadi dalam Pooling Pendapatan Negara bukan Pajak Pajak Non-PBi PNS, Jamsostek dll dll APBN Non-PBI Mandiri PBI BPJS Kemenkes Askes Swasta Kementerian lain Pelayanan Primer: Pelayanan Rujukan Pemda Dana dari Masyarakat langsung Pendapatan Asli Daerah Trisnantoro, 2014

Pooling & Purchasing Functions Not Separated by Revenue National Budget Local Budget Payroll Tax Donor Funds Private Funds Revenue Collection Pooling of Funds Pooled or not Pooled Pooling of Funds Health Purchaser or Purchasers Unified or Coordinated Benefits Package Health Purchasing Unified or Coordinated Provider Payment Systems Providers Population

Purchasing with Health Budget Funds Input-based line item budgets funding public facilities can be problematic if low budget level doesn’t fund all services provided in health facility Not clear to provider what services funded and what not funded Health budget purchasing better targeting or matching priority services & poor populations Output-based provider payment systems Key is unit of service—not building but services for people Financial incentives for desired service delivery improvements Align rather than fragment health purchasing Better targeting budget funds to priority services opens space or clear role for private funds

Pemahaman Purchasing Purchasing: Mekanisme pembayaran ke fasilitas kesehatan dan penyedia layanan kesehatan 3 komponen yaitu alokasi sumber daya, paket manfaat dan mekanisme pembayaran provider (Preker and Langenbrunner, 2005) Desain ini merupakan komponen kunci yang sangat penting untuk pemerataan akses yang adil dan perlindungan terhadap resiko keuangan.

Purchasing dalam JKN RASIO KLAIM 2014 - PEMBEBANAN (JUTA RUPIAH) IURAN PELKES RASIO KLAIM 40.719.862 42.658.702 104,76 % 38.242.870 111,55 % LAPORAN AKUNTANSI AUDITED Rasio klaim berdasarkan bulan pelayanan sebesar 114,60 % dengan beban klaim 12 bulan Bila dikurangi biaya operasional maka rasio klaim akumulasi 122,02%. Berdasarkan bulan pelayanan iuran POPB : 27.198 dan Biaya manfaat POPB : 30.486 Bila tanpa peserta PBPU, rasio klaim 84,29% RASIO KLAIM 2014 - PELAYANAN (DIKURANGI BIAYA OPERASIONAL BPJS ) (JUTA RUPIAH) IURAN PELKES RASIO KLAIM 40.719.862 46.665.539 114,60 % 38.242.870 122,02 % LAPORAN BOA, CPR & KEUANGAN DIOLAH

Peserta 133.273.918 Biaya manfaat 2014 42.658.702 * PBI –N : 86.399.836 PBI-D : 8.649.830 BP : 4.885.140 PPU : 24.288.688 PBPU : 9.050424 Biaya Pelayanan Rujukan Rp. 30.439.572 Biaya Pelayanan Primer Rp. 8.347.850 Biaya Non Kapitasi Non CBG’s, promprev Rp. 3.871.280 Jlh Faskes Rujukan : 1. 681 RS Pemerintah : 776 RS TNI-POLRI : 143 RS Swasta : 652 RS BUMN : 42 Klinik Utama : 68 Jlh faskes primer : 17.492 Puskesmas : 9.788 DPP : 3.984 Klinik pratama : 2.388 Faskes TNI-POLRI : 1.324 RS pratama : 8 Rata rata biaya per faskes Rp.39.77 juta/bulan Rata rata biaya per faskes Rp. 1,509 M/bulan * Cash basis

Peserta 147.675.544 Biaya Pelayanan Primer Rp. 4.953.108 Biaya manfaat sd Juni 2015 27.178.466 * Peserta 147.675.544 PBI –N : 86.426.543 PBI-D : 10.613.788 PPU swasta 18.347.445 Eks Askes : 19.534.154 PBPU : 12.753.614 Biaya Pelayanan Primer Rp. 4.953.108 Biaya Pelayanan Rujukan Rp. 22.270.069 Biaya Non Kapitasi Non CBG’s, promprev Rp. 816.879 Jlh faskes primer : 18.347 Puskesmas : 9.814 DPP : 4.314 Klinik pratama : 2.923 Faskes TNI-POLRI : 1.288 RS pratama : 8 Jlh Faskes Rujukan : 1.783 RS Pemerintah : 692 RS TNI-POLRI : 147 RS Swasta : 903 RS BUMN : 41 Rata rata biaya per faskes Rp.44,99 juta/bulan Rata rata biaya per faskes Rp. 2,081 M/bulan * Cash basis

Fund Collection Indicators Purpose The formal sector share of GDP Natural resources revenue as a share of total public budget Total health expenditure % GDP Potential resources available to finance public health spending Public sector spending as % GDP External health sector aid as % of GDP To measure resources specially available to the public sector The share of public health to total public expenditures Per capita total and public health expenditures To measure public sector allocation decisions, additional resources, and potential constraints The share of total health expenditures that are prepaid A broad measure of financial protection against out-of-pocket expenses

Pooling Indicators Indicators Purpose Means and distribution measure of: Share of co-payments to total health expenditures in each pool Membership in each pool Per capita spending in each pool Measures of the scale, depth of financial coverage, and existence of compensatory mechanisms across pools Share of administration expenses out of total spending in each pool Average ratio of transfers to estimated shortfall (or surplus) To measure the efficiency of pool management and effectiveness of compensatory mechanisms

Purchasing Indicators Purpose Share of expenditures accounted for by “strategic” purchasing Characterizing the pool-purchaser relationship Number of purchasers Mean and distribution of total expenditures across purchasers Mean and distribution of the number of providers who are contracted or hired by each purchaser To characterize the structure of interaction between purchasers and providers Share of total funds spent with different payment mechanisms (e.g. salaries, fee-for-service, capitation) To measure the financial incentives embedded in payments to providers

Health Financing Schemes Financing mechanisms Financing sources Tax-based financing 1. General tax or other revenue Natural resource revenue Social health insurance 2.Payroll tax Health care services Household Other prepayment schemes 3.Contribution or premium External resource Out-of-pocket payments 4. Direct payment

Issues in Health Financing What's the nation's ethical foundation for health care? Is equity a priority over efficiency? For whom you allocate resources and for what services/drugs? How much would the program cost? Who pays? Can the nation's transform money into effective and efficient services? Is financing scheme sustainable?