Introduction
Health is a right for all Indonesian citizens. Based on
the Law of the Republic of Indonesia No. 36 of 2009 concerning health that
health is a human right and one of the elements of welfare that must be
realized by health services. This requires the intervention of health services
in order to achieve the degree of public health in accordance with the ideals
of the nation with effective, efficient and targeted services.
A system is needed that regulates the implementation of
efforts to fulfill the rights of citizens to live healthy lives, by
prioritizing health services for the community. The National Health System or
SKN aims as health development is to achieve the ability to live a healthy life
for every resident in order to realize optimal health status. Health services
are one of the factors in achieving the ability to live healthy for the
community.�
Health is part of a basic measure of human well-being.
Based on article 28 H and 34 paragraph 2, the state firmly guarantees that the
people have the right to health services that are fair and dignified. The high
cost of health services and the poverty rate make health services not
accessible to the poor. And there are still many poor people who have to bear
health costs independently. The contributing factors are the high cost of
treatment and the limited cost of health insurance.
The main factor causing health problems is inequality in
the provision of health services.��
Inequality occurs between the middle and upper class
people who easily get access to good health services, while the lower middle
class still cannot get maximum health services. Therefore, the creation of a
health insurance program is an effort by the government to improve health
status and maintain public health.
In 2011 the government enacted Law No. 24 concerning the
Social Security Administering Body (BPJS), which aims to fulfill the rights of
the people in accordance with the constitution and laws. In 2013, BPJS
Kesehatan and the Indonesian government launched the National Health Insurance
(JKN) which is one of the flagship programs of the Indonesian government. After
the JKN program was launched, it was felt that the program was not running
optimally. So that the Indonesian government began to make improvements by
creating an innovative health program, namely the Healthy Indonesia Card (KIS).
In implementing the KIS program, the Indonesian government began to be faced
with problems, causing the implementation of the KIS program to be uneven.
The Central Health Social Security Administration (BPJS)
noted that 201,660,548 Indonesians had become participants in the National
Health Insurance-Healthy Indonesia Card (JKN-KIS) service as of September 1,
2018. This number reached 77% of the total population of Indonesia who reached
261 million people. Of this 77%, the Government and BPJS Health still have the
task of attracting 33% or about 60 million more people to become JKN-KIS
service participants in 2019, in accordance with the National Medium-Term Development
Plan (RPJMN). JKN-KIS is considered capable of preventing people from the risk
of falling into poverty due to paying the cost of health services for
catastrophic diseases due to expensive diseases. Based on the results of
research by the Institute for Economic and Community Research FEB UI in 2017,
in 2016 the JKN-KIS program has saved 1.16 million people from poverty.�
While the limitations of the central government is in providing fair health services to the community. So
that some local governments make local health policies for their people. As of
August 16, 2017, it was recorded that the number of people participating in the
national health insurance program in the Bali region had only reached 67% while
Denpasar only reached 78%.� This indicates
that not all people in Bali have received health insurance services. To
minimize these problems, the Badung Regency
Government provides solutions for people who do not have health insurance to
get access to good health through the innovation of the Krama Badung Sehat Health insurance
program (KBS).
Based on the Badung Regent
Legislation Number 6 of 2018 concerning Amendment to Perbup
Number 73 of 2016 concerning the KBS program, the Badung
Regency government created the Healthy Badung Krama
aimed at self-managing and ensuring the health of the Badung
community independently which synergizes directly with the JKN-KIS (Card Card)
program. Healthy Indonesia). The Badung Regency
Government (Badung Regency Government) seeks to
ensure the health services provided to all Badung
people by creating Healthy Badung Krama (KBS).����
This program is implemented to support the government's
efforts to ensure that all citizens have access to health services according to
their needs and justice ( Universal Health Coverage-UHC
). After the 2017 KBS program was launched, there were several obstacles, one
of which was the distribution of the Badung Sehat Card. There is a comparison of the acceptance of the Badung Sehat Card between South Badung and North Badung which can
be seen from the uneven distribution of the Badung Sehat Card distribution process.�� Therefore, researchers are interested in
analyzing the policy of integration of the Krama Badung
Sehat (KBS) insurance against health services in Badung Regency.
Method
This study aims to analyze the policy of Krama Badung Sehat (KBS) insurance that
has been implemented towards health services in Badung
Regency. Methodologically, this research was conducted using empirical
juridical research which was described descriptively. The type of data used is
qualitative data both obtained from primary data and secondary data. Primary
data obtained from direct interviews and also with field observation
techniques. While secondary data was obtained by studying literature in the
form of reference studies from sources in the form of research journal books
and interviews from informants who were quoted from electronic media (Internet)
Results And Discussion
A.
Legal
Basis For The Integration Of Healthy Badung Krama Policy (KBS)
Health insurance is a constitutional
right of every citizen. Prapti Widyaningsih,
Fulfillment of the Rights of National Health Insurance Participants. By having
health insurance, every citizen has the right to health services. This
guarantee is regulated in Article 28H paragraph (1) of the 1945 Constitution of
the Republic of Indonesia (UUD 1945), which stipulates that everyone has the
right to live in physical and spiritual prosperity, to live, and to obtain
health services. In accordance with Law Number 40 of 2004 concerning the
National Social Security System, the government is obliged to provide
comprehensive social security and develop the implementation of the National
Social Security System (SJSN) for the entire community.�
The cooperative relationship between the
Social Security Administering Body (BPJS) and Health Facilities as mandated in
the Government Regulation of the Republic of Indonesia Number 85 of 2013
Article 6 paragraphs 1 and 2 of the Social Security Administering Body (BPJS)
in carrying out its duties, may cooperate with organizations or other
institutions at home and abroad. This collaboration is carried out in order to
improve the quality of BPJS Health or improve the quality of its services to
participants.� Cooperation with the
central government program can be carried out in order to improve the quality
of BPJS Health or health services to participants. Functionally BPJS as a
guarantor of health services for its participants and health facilities, one of
which is a hospital and health center, which is the implementer of health
services.
Health services are sub-systems of health
services whose main purpose is preventive (prevention) and promotive (health
improvement) services with community targets.��
According to Presidential Regulation Number 19 of 2016 Article 2
Paragraph 1 The benefits of promotive and preventive services include the
provision of services such as individual health counseling, routine
immunization, family planning and health screening. According to Presidential
Regulation Number 19 of 2016 Article 22 paragraph (1) letters a and letter b
explains that guaranteed health services are first-level health services,
including non-specialist health services and advanced level referral health
services.�
The Krama Badung
Sehat (KBS) health insurance program is a health
insurance program created by the Badung Regency
government. The government seeks to ensure the health of all Badung people by creating the Healthy Badung
Krama Program (KBS) as a health service according to need and justice (universal
health coverage -UHC). UHC is a health system that ensures that every citizen
in the population has fair access to quality promotive, preventive, curative
and rehabilitative health services at affordable costs which includes two core
elements, namely access to fair and quality health services for every citizen,
and financial risk protection when citizens use health services where the
country of Indonesia is currently in a transition period towards universal
health service coverage. Efforts to realize UHC in Badung
Regency, in addition to supporting national programs, are also efforts to
realize the vision and mission of regional development in Badung
Regency, namely improving the quality and competitiveness of human resources.
This program was created to be
self-managed and to ensure the health of the Badung
community independently through the Krama Badung Sehat (KBS) program, in accordance with the Badung Regent's Legislation Number 6 of 2018 concerning
Amendments to Perbup Number 73 of 2016 concerning the
KBS program. Badung Regent Regulation Number 6 of
2018 concerning Amendments to Regent's Regulation Number 73 of 2016 concerning
the Badung Healthy Krama Program (KBS) normatively
does not overlap with existing laws and regulations.������������
This is in accordance with the provisions
stipulated in Chapter II of the Regent's Regulation above, concerning the
Purpose, Objectives, Participants and Places of Service. KBS has the intention
of providing health services to all residents of Badung
Regency through KBS which is integrated with JKN, with the aim of improving the
health quality of the residents of Badung Regency,
increasing the benefits of JKN and ensuring health services for residents of Badung Regency who have not become JKN participants. In terms
of participation, it also reflects integration with JKN, without any conflict
with one another.
B.
The
Benefits Of The Healthy Badung
Krama (KBS) Policy For Community Welfare.
1.
Health
Service Guarantee
Krama Badung Sehat (KBS) is a health service guarantee provided to all
residents of Badung Regency with the benefits divided
into: (1) All residents of Badung Regency who have
not become participants of the National Health Insurance (JKN) as Recipients of
Regional Budget Fees (PBI); (2) All residents of Badung
Regency who already have JKN in order to be able to add additional benefits in
addition to the benefits already received from JKN; (3) All residents of Badung Regency who do not have JKN because it has not been
registered, a newborn baby, or because of marriage; last (4) All residents of Badung Regency who are inactive JKN Mandiri
participants. In practice, although card ownership is not an absolute
requirement for receiving KBS benefits, especially for the use of health
services for those who do not have JKN membership or whose JKN is in an
inactive condition or for those who are newly married and newly born children,
card ownership is one of the indicators that can be used to determine the
coverage of KBS membership.
All people of Badung
Regency are required to make a recording beforehand to get access to health in
the form of a card from the Krama Badung Sehat (KBS) program, namely the Badung
Sehat Card. The Krama Badung
Sehat (KBS) health insurance program has 23
additional benefits compared to the JKN-KIS program, meaning that things that
are not covered by JKN-KIS are covered by KBS. One of the advantages of the KBS
program compared to JKN is the efforts of the Badung
Regency Government to protect its people from catastrophic expenditures in the
health sector by providing financial guarantees for those who administratively
do not have an active KIS register number (including newborns and residents
with Badung NIK). just entered), then the financing
of services that are not covered by JKN and the consequences of treatments that
are not borne by any institution, such as the cost of processing a corpse.
Based on the Technical Guidelines for the implementation of KBS set by the Badung Regency Government, all additional benefits provided
by the KBS program must be carried out at the 3rd grade level of care.
2.
Financial
Protection Guarantee
The KBS program provides financial
protection for the burden of medical expenses, especially at advanced hospital
health facilities, including the cost of sending patients during an emergency
to services, protection of catastrophic expenses due to high-cost medical care
and treatment costs, as well as financial protection for families who have
patients treated by guaranteeing costs lost or incurred to take care of
patients in the hospital. The KBS program has sought to prevent a greater
financial impact on the families left by patients who die by replacing the
costs of care and delivery of the bodies. However, a more in-depth study is
needed to see, for example, whether reimbursement for inpatient care is indeed
more widely used by groups at risk of financial risk or by those who belong to
the economy with minimal threat risk.
Based on the list of additional benefits
guaranteed by the KBS and data available at the Badung
Health Office from the recapitulation of health facility bills, it is known
that the costs that must be incurred by the Regency Government to pay for
additional benefits in hospitals are more than 24 billion and at FKTP Puskesmas more than 400 million. Thus, the dominant bill
for additional benefits comes from advanced outpatient and inpatient services.
The average bill per month for hospitals reaches 1.9 billion rupiah, while for Puskesmas it reaches 35 million per month. The trend of
monthly billing varies with an unclear pattern, longer data is needed in the
following years of KBS operation to see if there is a billing pattern according
to the current month. From the results of the evaluation, it was also revealed
that the financing of other additional benefits such as immunization, obtaining
health certificates and also the use of village ambulances became a significant
cost burden that had an effect on KBS financing. Therefore, better monitoring
and evaluation capabilities are needed as well as checking the validity of
claims in addition to a clearer and more transparent technical mechanism.�
3.
Social
Justice Guarantee���
Social justice is a balanced relationship
between individuals and society which is measured by comparing the distribution
of wealth differences from personal freedom to fair privilege opportunities. In
older Western and Asian cultures, the concept of social justice often referred
to the process of ensuring that individuals fulfill their social roles and
receive their rights from society. Guarantees for the realization of a social
justice are needed in order to realize the welfare of society for all
Indonesian people. In order to achieve social justice guarantees, it is
necessary to guarantee public services, especially in the health sector which
can guarantee the welfare of all levels of society.
Public service is a series of activities
to fulfill the service needs of every citizen for goods, services, and/or
administrative services provided by public service providers. Public services
carried out are based on the general interest, legal certainty, equal rights,
balance of rights and obligations, and others. In the implementation of public
services, community participation is needed in the form of cooperation,
fulfillment of rights and obligations as well as playing an active role in the
formulation of public service policies. The community can also form a public
service supervisory agency with the procedures regulated in government
regulations. In its implementation, people who feel aggrieved by the
implementation of public services can sue public service providers through the
state administrative court.[12] With the integration program of Krama Badung Sehat (KBS) in health
services, it will increase the guarantee of health services for community groups
who cannot be fully protected against certain diseases that are not covered by
the national health insurance program.
C.
Weaknesses
of The Healthy Badung Krama Policy (KBS)������
Utilization of the KBS program since it
was implemented in early 2017 until 2021 has gone well when viewed from visits
to health care facilities (faskes) and compared to
the previous year. Although the increase in the number of visits to health
facilities is influenced by various factors, the provision of financing through
KBS is certainly one of the main factors that play an important role. Although
there are many positive impacts that are felt by the community, the KBS program
also still faces various obstacles, one of which is the distribution of the Badung Sehat Card. There is a
comparison of the recipients of the Badung Sehat Card between South Badung
and North Badung, which can be seen from the uneven
distribution of the Badung Sehat
Card distribution process. This is due to the mobilization of the population in
the South Badung area, which makes it difficult to
collect further data. Of course, this is an obstacle faced by the government of
Badung Regency.
From the distribution side, some of the
problems that were identified were the printing of cards for those who had died
or moved to those who had not recorded the data but the cards had been printed.
For this matter, the Health Office has coordinated with the village, where the
village party is obliged to report people who have died and who have changed
their domicile, where the people in question are obliged to return their KBS
card. It's just that until now no one has done that (returned the KBS card).
Strategic planning is needed to develop
more useful KBS card functions to support service delivery if the existence of
this card is still to be maintained. For example, if the card can be developed
as an identity KBS condition or health status (electronic medical record) which
Badung people can know in detail record or records
Krama health and can be delegated to health facilities at various levels of
service to be accessed by health care providers. This will ensure continuity of
information between service providers at various levels.
Based on the 2018 Healthy Badung Krama evaluation study, other inhibiting factors
emerged due to the lack of good socialization carried out to the community.
This has an impact on the implementation of Krama Badung
Sehat (KBS) where many users still do not understand
about the Krama Badung Sehat
(KBS) program. Many people claim that they do not know the process of
distributing cards, who distributes them or where the cards are taken when they
are ready. Meanwhile, from the side of the KBS manager, he revealed that the
issue of transparency and accountability is very vulnerable due to the lack of management
and education personnel who are not in accordance with the authority to manage
a health insurance. So it has the potential to
accumulate workloads and the potential for fraud (fraud) both from the provider
side, consumer side, and internal fraud due to inadequate management
capacity.�������
In implementing the Badung
Sehat program policy, the Badung
District Health Office has carried out activities in accordance with the
applicable SOP. In addition, the Health Department has been monitoring the Badung regency every 1 month or 3 months once, would be but
the do not have any oversight consistent schedule.
Furthermore, the aspects of coaching and training have been carried out by the Badung Regency Health Office once every 1 (one) year to the
implementers, the goal is to be given guidance so that this program runs well.
In this KBS program oversight, there are
internal and external controls which internal controls that include the terms
of the implementation process is done directly by the monitoring team of the
District Health Office Badung while for external
supervision conducted by the Financial and Development Supervisory Agency
(BPK). Furthermore, in the implementation of the Krama Badung
Sehat (KBS) program, the Badung
District Health Office will also conduct an evaluation through reports that are
submitted to the service, while also evaluating complaints from the
public.��������������������
Another weakness of the KBS card is the
procedure for service providers and also the KBS user community where there are
emergency health problems outside the Badung Regency
area. Although it is possible with a cooperation mechanism, the effort to
organize cooperation with health facilities outside Badung
itself presents significant difficulties. Here the use of the KIS card will
ensure that patients are served throughout Indonesia. This aspect of the
portability of the health insurance system is still limited to the area because
not all hospitals throughout Indonesia have collaborated with the Badung Regency Government.
So far, the advantage of the KBS card
over KIS is that the barcode can display facial and fingerprint photo data so
that it does not allow the card to be used by others. Strategic planning is
needed to develop more useful KBS card functions to support service delivery if
the existence of this card is still to be maintained. For example, whether the
KBS card can be developed as an identity for health conditions or status
(electronic medical records) where the Badung
community can find out in detail their health records and can be authorized to
health facilities at various service levels to be accessed by health service
providers. This will ensure continuity of information between service providers
at various levels. In developed countries this card is known as a personal
electronic health record.
Another obstacle experienced in
implementing the Krama Badung Sehat
(KBS) policy was experiencing constraints in the limited budget sector.
Entering 2021 the budget for the KBS program that has been prepared by the Badung Regency Government cannot enter because it collides
with the JKN administration system (SPID) according to the provisions of the
Minister of Home Affairs. Therefore, it is feared that health services for Badung manners for cases of diseases that are not covered
by BPJS Kesehatan cannot be served. The Head of Badung
Health Office, Dr. Nyoman Gunarta, stated that to
resolve this budgetary constraint, namely by approaching the Ministry of Home
Affairs so that the KBS budget can still be implemented, so that public health
services are carried out and are not disrupted.
D.
Integration
Of Healthy Badung Krama Policy In
Facing The Covid-19 Pandemic
The coronavirus that has been endemic in
Indonesia since 2020 has not only had a high death rate but also caused various
other problems, both economic and social. Facing this, governments in various
countries are trying with all their efforts to minimize losses, both by
reducing the number of fatalities and overcoming economic problems in the
community. �
In the midst of the Covid-19 pandemic,
the Badung district government took 6 strategic
policies that became priorities in preventing the spread and accelerating the
response to Covid-19 in Badung. One of them is for
the Badung community who are JKN participants with
the participation segment of wage-earning workers (PPU) whose BPJS insurance
premiums are paid by the company according to their income, because they are
currently being laid off or the company is unable to pay. The Badung KBS party coordinates with BPJS for the activation
of these participants as PBI Badung APBD
participants. Independent JKN participants in class 1, 2, 3 who are no longer
able to pay premiums, will have their membership changed to be Recipients of
the Badung Regency APBD Iuaran
Aid (PBI) so that they are not subject to fines in arrears in BPJS.
The role of KBS in ensuring health
services for residents of Badung Regency who have not
become JKN participants, which is in accordance with Badung
Regent Regulation Number 37 of 2016 concerning the Healthy Badung
Krama Program. Efforts to finance services at the primary to tertiary levels
through the PBI-APBD mechanism and direct financing to health facilities (fee
for service) for those who are not or have not been registered as JKN PBI-APBD
participants have provided adequate financial protection for Badung residents. This is a government effort that must be
appreciated and given sufficient appreciation and supported by all components
of service providers.
Conclusion
In the health sector, the Badung Regency Government
created the Healthy Badung Krama (KBS) as an effort to ensure health services
for the Badung community. The Krama Badung Sehat (KBS) health insurance program
has 23 additional benefits compared to the JKN-KIS program and has strong legal
protection. However, there are still obstacles, one of which is the
distribution of the Badung Sehat Card and the limited budget in the COVID-19
pandemic situation. Another inhibiting factor arises because of the lack of good
socialization carried out to the community. Meanwhile, from the management side
of KBS (Krama Badung Sehat)
revealed that the issue of transparency and accountability is very vulnerable
to occur due to the lack of management and education personnel who are not in
accordance with the authority to manage a health insurance.����
Practically, in implementing the integration of the Krama
Badung Sehat (KBS) health insurance into the National Health Insurance, the
government's actions are not limited to centralizing the entire existing system
into a larger system, but also must be balanced in maintaining the continuity
of the spirit of decentralization and the interests of the local community
under the umbrella National Health Insurance (JKN). The integration of local
government programs, especially health insurance, is very necessary for the
community to perfect national health insurance programs.
References
Assume Pidada, Ida Bagus. "Termination of Employment in the Covid-19
Pandemic Situation According to the Pancasila State Conception." Raad
Kertha Scientific Journal, 2020.
Banai, Ayelet, Miriam Ronzoni, and Christian Schemmel. Social Justice,
Global Dynamics: Theoretical and Empirical Perspectives. Social Justice, Global
Dynamics: Theoretical and Empirical Perspectives, 2011.
In, JKN, Puskesmas Dalam, and Get Services. �Fulfillment Of The Rights Of
National Health Insurance Participants� 3, no. 1 (2020): 580�98.
Suprianto, Arip, and Dyah Mutiarin. "Evaluation of the Implementation
of the National Health Insurance." Journal of Governance and Public Policy
4, no. 1 (2017): 71�107.
Syaifuddin, A. 2018. BPJS Health Participants Reach 77 percent of
Indonesia's population. Tempo Business. 3 September 2018.
Tarini, Ketut Bella, I Dewa Ayu, Putri Wirantari, and I Putu Dharmanu Yudartha.
�Implementation Of Health Insurance Programme Policy In Healthy Badung Regency (KBS)
IN REGENCY OF Nabadung,� 2013, 1�10.
Indonesian Ministry of Health. 2010. Ministry of Health's strategic plan
2010-2014. Jakarta.
Badung Regent Law Number 6 of 2018 concerning Amendments to Perbup Number
73 of 2016 concerning the KBS (Krama Badung Sehat) program.
Law of the Republic of Indonesia Number 36 Year 2009 concerning Health.
Presidential Decree Number 19 of 2016 concerning Health Insurance.
