Functional and Regulatory Review of Strategic Health Purchasing Under JKN POLICY NOTE July 15, 2018 Purchasing of Primary Health Care Under JKN Introduction Indonesia’s national health insurance scheme -- of PHC should create a foundation that allows Jaminan Kesehatan Nasional, or JKN –Indonesia adequate resources to flow to the primary care level aims to guarantee every Indonesian citizen stays to make priority interventions accessible to the entire healthy rather than to simply insure those who are population. Strategic purchasing of PHC should also sick. Therefore, the national health insurance system create incentives across the health system to manage is built on a foundation of primary health care (PHC)- population health and avoid unnecessary services and -health promotion, prevention, and rehabilitation. expenditures at the secondary and tertiary levels. The The primary care system is the first point of contact elements of strategic health purchasing are described for the population and potentially has the greatest in Box 1. impact on the population’s health. Strategic purchasing BOX 1. FOUNDATIONS OF STRATEGIC HEALTH PURCHASING Strategic purchasing requires an institutional home where most purchasing functions will be carried out, although other institutions will likely be responsible for some purchasing functions. being clear and deliberate about what is being purchased, which starts with a well-defined benefits or essential services package. Once the service package is defined, the purchaser pays health providers specifically to deliver these services, which is referred to as output-based payment. Output-based payment typically goes hand-in- hand with some form of contracting to clarify the obligations of the provider and also the purchaser. It also requires that providers have some autonomy to make decisions to respond to incentives—they can decide to shift their staff around or other inputs. All of this requires new accountability measures and better use of information. PURCHASING OF PRIMARY HEALTH CARE UNDER JKN Strategic purchasing of PHC under JKN is carried out PHC SERVICE PACKAGE AND SERVICE DELIVERY by Badan Penyelenggara Jaminan Sosial-Kesehatan STANDARDS (BPJS-K), with some purchasing functions distributed The JKN entitles participants access to a comprehensive across other institutions, including the Ministry of package of necessary health services, including Health (MOH) and local government. The Social Security comprehensive PHC (Presidential Regulation Number Council (Dewan Jaminan Sosial Nasional--DJSN) is 12 of 2013 Chapter IV on Health Care Benefits). The responsible for overseeing the implementation of JKN PHC package include: promotive and preventive and as part of that mandate commissioned a review services; medical examination, treatment and medical of strategic purchasing under JKN in partnership with consultation; non-specialty medical treatment either USAID, the World Bank, Abt Associates and Results for surgical or non-surgical; medicine and medical Development (R4D). This policy note summarizes the consumables; blood transfusion according to medical results of the strategic purchasing review focused on need; first-level laboratory examinations; first-level the current status, results, and challenges of strategic inpatient care. Promotive services and preventive purchasing of PHC under JKN. services cover individual health counseling, basic immunization, family planning, and health screening. Strategic purchasing for PHC means deliberately The PHC service package is further defined by the MOH prioritizing PHC in resource allocation and service in terms of minimum service standards for health care delivery, and creating incentives throughout the in “first level health facilities” (FKTPs). These minimum system to strengthen access to and quality of PHC service standards include 144 competencies (services) service. This is done be strategically deciding what that puskesmas must provide [Minister of Health to purchase (which PHC services and interventions, Regulation No.5/2014 Clinical Practice Guidelines for according to which service delivery and quality Primary Care Physicians]. standards, delivered at which level of care), from 2 whom to purchase PHC (ensuring there are adequate A new MOH program makes local governments PHC providers to meet demand for the service package, accountable for 12 new minimum service standards and contracting providers based on criteria such for promotion and prevention programs related to as access and quality) and how to purchase PHC conditions such as mental health, hypertension, services (leveraging contracts, provider payment diabetes, tuberculosis and HIV [Minister of Health systems, and provider performance monitoring to drive Regulation No. 43/2016]. These services are intended to service delivery and other objectives). be complementary to JKN and help reduce the need for curative services. What to Purchase GATEKEEPING There is a gatekeeping policy in place in Indonesia that regulates how patients can be referred to different levels of the health system. Initially BPJS-K registers Strategically deciding what to purchase for PHC means: each JKN participant to one FKTP based on the recommendation of the District or Municipal Health a. A PHC service package is clearly specified Office. After the first three months the participant has b. Quality or service delivery standards are defined the right to select their own first level health facility. that are used for purchasing decisions The participant is required to obtain services at first c. Mechanisms are used by the purchasing agency level health facility where he or she is registered unless to allocate funds efficiently between primary, a referral is made [Presidential Regulation No. 12 of secondary and tertiary care (e.g. ring-fencing 2013 article 29 clauses 1 and 2]. BPJS-K has developed funds for PHC, gate-keeping policies, etc.) a computer application (Aplicare) to help JKN participants find the nearest health facilities according The laws and regulations related to JKN to their location, provide brief profiling information implementation make provisions for all three of these on health facilities, and support FKTPs in referring strategic purchasing mechanisms, although some patients according to the competencies of referral challenges have arisen in implementation. facilities. POLICY NOTE The MOH also has recently enacted a stricter referral are not medically necessary. A study by BPJS-K found policy, which limits payment for hospital cases that that up to 50% of referrals are at the request of the were not referred by the appropriate class of health patient. Some stakeholders noted that inadequate FKTP facility. There is also a referral back system from infrastructure and supply of essential medicines at the hospital to primary care. BPJS-K has begun refusing FKTP level can also drive referrals. to pay claims for inappropriate referrals, but this has been challenged by specialists. Furthermore, the lack of From Whom to availability of certain medicines in puskesmas makes it difficult to enforce the referral system consistently IMPLEMENTATION CHALLENGES Purchase In spite of strong policies in support of PHC in the MOH and JKN, challenges continue with unequal access to PHC that meet service delivery standards Strategically deciding from whom to purchase PHC means: and low priority for PHC in total BPJS-K spending. In spite of the emphasis on PHC by the MOH and in JKN, a. Ensuring there are sufficient providers with BPJS-K data show that less than 20% of expenditures by adequate capacity to deliver the PHC service BPJS-K in 2016 went toward PHC, with the remaining package to all JKN participants (“supply-side spent on hospital-based services. Utilization of PHC readiness”). has increased under JKN, but outpatient specialty b. Standards are established for PHC providers to be utilization has increased at a faster rate. Based on the contracted by the purchaser to deliver services to 2016 BPJS-K non-audited report, the total number of JKN participants (credentialing), and public and JKN participants who utilized primary cares in FKTPs providers can be contracted equally if they meet reached 134.9 million, a 102% increase over utilization credentialing criteria. 3 in 2014. But outpatient specialty utilization increased 137% over the same period from 21.3 million to 50.4 SUPPLY-SIDE READINESS million visits (Figure 1). As FKTP utilization has The MOH has broad responsibility to strengthen increased, the gate-keeping policy has been difficult the foundation of preventive and promotive care to enforce, which keeps the share of total expenditure to reduce the burden of chronic disease [Minister on referral services high. One reason is FKTPs continue of Health Regulation No. 75/2004]. This promotive- to meet patient requests for referrals even when they preventive program is considered the foundation of Figure 1 Trends in JKN Service Utilization % 160 140 102% 2014 120 2015 100 2016 80 60 137% 40 20 81% 0 PHC Outpatient specialty Impatient Source BPJS-K 2016 unaudited report PURCHASING OF PRIMARY HEALTH CARE UNDER JKN health development, community empowerment and Although many stakeholders agree that private engagement in health promotion across sectors. This providers need to be better engaged in JKN and BPJS-K program also aims to reduce high-cost catastrophic contracting to help close supply-side gaps, private illness events in JKN. The MOH is also responsible providers argue that they are not included actively for strengthening capacity at the primary care level, in the credentialing process to ensure that private optimizing the referral system, and improving quality. FKTPs and individual doctors have the opportunity District Health Offices supervise Puskesmas and also to contract with BPJS-K. Some stakeholders noted that have some role in operational arrangement. According the role of private providers is not address in the laws to the Indonesian Law on Regional Autonomy, local and regulations governing JKN and BPJS-K, which governments have the responsibility to ensure the may at least partially explain the lack a formal role infrastructure is adequate to deliver guaranteed PHC for private professional associations and FKTPs in the services. credentialing process. CREDENTIALING AND SELECTIVE CONTRACTING How to Purchase BPJS-K contracts with health providers that meet the criteria for credentialing specified by the MOH (Regulation of Minister of Health Number 71 of 2013 Chapter III Cooperation of Health Facilities wiith BPJS Healthcare Section Two Article 9). The Strategically deciding from whom to purchase means: purpose of credentialing is to improve the availability and accessibility of health facilities as well as the a. Contracting procedures are in place that are standardization effort of health facilities quality. As leveraged to specify and create incentives to part of their role in ensuring the quality of primary care adhere to service delivery and quality standards, 4 services, District Health Offices collaborate with BPJS specify reporting requirements for providers, Health to do the credentialing for public PHC providers. and include other provisions that specify the The BPJS-K credentialing process is as follow: responsibilities of providers and the purchaser. b. Provider payment systems are selected, designed → → needs analysis mapping of providers → profiling  and implemented to create the right incentives → credentialing → tariff agreement → contract to drive provider behavior and service delivery toward quality, efficiency, and other objectives. When selecting health facilities for contracting, BPJS-K c. Monitoring of PHC provider performance not only considers the extent to which facilities meet and quality assurance systems are carried out regulatory standards, but also whether they have routinely by the purchaser and used to provide a quality commitment that will be continuously feedback to improve provider performance. monitored. For a health facility to renew its contract with BPJS-K it must continuously meet quality CONTRACTING AND PROVIDER PAYMENT FOR PHC standards. BPJS-K contracts with selected FKTPs and pays them to provide the PHC package of services using capitation IMPLEMENTATION CHALLENGES payment (a fixed payment each month for each person Some challenges to credentialing and selective registered with the PHC). The JKN capitated rate for contracting by BPJS-K have emerged in practice, PHC is set out in Minister of Health Regulation No. including uneven distribution of health personnel 52 of 2016, which states that “The tariff for capitation and health facilities, particularly in remote and very received by FKTP is determined through a selection remote areas. In more remote areas, the facilities and process and credentialing carried out by BPJS involving infrastructure of FKTPs facilities and infrastructure is the District Health Office / City and / or the Association often insufficient, and there is wide variability in the of Health Facilities considering human resources, the capability of FKTPs capability to thoroughly manage completeness of facilities and infrastructure, scope of non-specialist cases. For example, according to data services, and commitment to service”. Obstetric and presented by BPJS-K, there are 740 public FKTPs in 27 neonatal services, such as antenatal care, normal provinces that have no general practitioners, including delivery and services for family planning programs are West Java Province. not paid by capitation but by fee-for-service. POLICY NOTE The current capitated rate is 3,000 - 6,000. The capitated other previous programs and have not been updated to rate is considered to be low and based only on reflect the new distribution of population under JKN. the cost of staff without relation to service needs, particularly for private clinics. There are currently no Ratios of registered patients to physicians that are adjustments for age/sex or other indicators of health either too high or too low are both problematic for need, only supply side variable such as availability capitation payment. If the ratio is too high, registered of medical doctor and dentist and 24-hour services. participants may not have timely access to necessary MoH Regulation No. 52 of 2016 article 5 set the special PHC services. If the ratio is too low, the capitation capitation tariff for remote areas, but the amount revenue for the facility may be insufficient to stock is considered too small as the compensation for necessary medicines, supplies and other inputs, or even the physician practices in remote areas. The lack of to remain financially viable. adequate adjustment for geographic differences in the cost of delivering primary care was raised as a concern A more general concern with all of the payment systems by many stakeholders. used to purchase services under JKN is that they are fragmented across different levels of care with no The capitated rate also disadvantages private providers, linkages between capitation for PHC and the INA-CBG as BPJS-K pays the same capitated rate to both public payment system for secondary and tertiary services. and private providers, although public providers are highly subsidized by the government, which MONITORING PROVIDER PERFORMANCE AND QUALITY covers health worker salaries and investment costs. In 2016 the MOH and BPJS-K agreed to add a Furthermore, private providers complain that their performance-based element to capitation payment, cost structures are also different because unlike public Capitation Based Service Competence (KBKP). providers, they cannot access medicines at favorable KBKP is governed by a joint regulation between prices through the government procurement system the MOH and BPJS, which was updated in 2017 [No 5 and they do not have tax exempt status. HK.08.08/111/980/2017 TAHUN 2017 NOMOR 2 TAHUN 2017 on Technical Guidelines for Performance-Based Capitation payments are distributed to FKTPs based on Payment to FKTP]. the population that selects that provider through BPJS enrollment. Private primary care clinics BPJS maintains KBKP was started in 33 provincial capital cities as part enrollment lists on the P-Care site, and in principle of phased implementation. Under KBKP, the final providers can access the lists at any time, but they are capitation payment to a FKTP is based on performance not notified when an individual is added to or removed against 4 indicators that are self-reported through P-Care: from that facility’s list. Some FKTPs have complained that data related to the number of participants registered at a. Contact rate (target=15/1,000 members per month) the FKTP are not provided, which is information needed b. Referral rate to perform education and preventive promotive efforts. c. Chronic Disease Management Program (Prolanis): Some stakeholders noted several problems with P-Care prevention for NCDs following protocol and whether this data source can be used effectively as a management tool. The performance of participating FKTPs is assessed every three months, and payment would be adjusted There are concerns that the distribution of registered downward if the targets are not achieved, although participants across FKTPs is highly imbalanced. BPJS-K has not yet begun implementing the financial Although the average ratio of registered JKN penalties only the assessment. BPJS-K has decided the participants per doctor in FKTPs is 5,000:1, which is maximum adjustment is 10% so, if not all of the targets the target, the ratio exceeds 8,500:1 for puskesmas in are achieved, the final capitation payment will be 90% 7 provinces (Figure 2). On the other hand, FKTPs that of the original amount. are not puskesmas have much lower ratios, typically below 1:2,500. Private providers in particular appear to In 2017 the implementation of KBKP is being expanded be at a disadvantage in the distribution of participants. in health centers outside the capital of the province, Some of this imbalance may reflect registration an indicator related to home visits will be added, patterns that were inherited from Jamkesmas and and private FKTPs will be included although private PURCHASING OF PRIMARY HEALTH CARE UNDER JKN provider associations complain that they have not and utilized according to local policy. Puskesmas been involved in any of the process of determining are increasingly given discretion to manage their performance indicators and targets. KBKP has not been own financial affairs, and a number of the facilities properly monitored and evaluated, the results of which have been converted to BLUD Puskesmas, which could be used to improve KBKP. allows them to manage their own financesLocal governments have also been advised not to overly AUTONOMY OF PUSKESMAS AND THE USE OF exploit Puskesmas for revenue purposes. According to CAPITATION FUNDS Presidential Regulation No. 32 even if the Puskesmas The capitation payment is paid directly to private has not been converted to BLUD, the capitation primary care clinics and puskesmas that have bank funds no longer go to the local treasury but directly to accounts in the local treasury system. The use of Puskesmas account but they still need approval for the capitation revenue is restricted, with up to 40% spending money held in local treasury. designated for operational expenditures (e.g. supplies) and 60% or more can be used to pay fees directly to Even in autonomous Puskesmas, the complicated rules health workers. The portion of the capitation revenue on the allocation of capitation revenue have led to low that is distributed to health workers also follows a set of absorption in some cases, with the revenue taken back rules and criteria: by the government treasury if it remains unspent at the end of the year. There is also a heavy administrative • Education burden for the reporting of expenditures. There are • Years of experience different treasury accounts for each funding source (e.g. • Position JKN, MOH budget, local government, Jamkesda) and • Whether a program manager different financial reports for each account. A different • Attendance/absenteeism health facility staff member has to complete the 6 financial report for each account, so clinical staff spend The utilization of capitation funds paid by BPJS-K a significant amount of time on financial reporting. to puskesmas or District Offices is regulated by Presidential Regulation: 32/2014, but some regions IMPLEMENTATION CHALLENGES consider capitation income as regional income There has been good progress on contracting and provider payment for PHC under JKN, but some implementation challenges have limited the impact Figure 2 Ratio of registered JKN participants to doctors in FKTPs by Province 10,500 DPP Klinik 8,500 Puskesmas 6,500 5,000 4,500 2,500 500 NAD SUMATERA UTARA SUMATERA BARAT RIAU KEPULAUAN RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG DKI JAKARTA JAWA BARAT JAWA TENGAH D.I YOGYAKARTA JAWA TIMUR BANTEN BALI NUSA TENGGARA BARAT NUSA TENGGARA TIMUR KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA SULAWESI BARAT GORONTALO MALUKU MALUKU UTARA PAPUA PAPUA BARAT Source BPJS-K analysis POLICY NOTE of these purchasing mechanisms on FKTP service delivery, quality and efficiency. Referral rates remain high, and the imbalance in BPJS spending between PHC and higher levels of care persists. The unequal distribution of JKN participants across FKTPs is a major concern, creating risks at both the high and low ends of participant-to-doctor ratios. The current capitation payment system puts rural FKTPs at a disadvantage since there is no adjustment for the higher fixed costs associated with serving populations in rural and remote areas. This disadvantage will become worse when the performance- based payment withholding is put into practice and rural providers are more likely to be penalized for not meeting contact rate targets. There have also been some challenges with absorption of capitation revenue at the puskesmas level, particularly the 40% for operational expenditures because of concerns about violating the regulation and spending the funds inappropriately. Although progress has been made to generate better PHC-level data through P-Care, stakeholders raise several concerns with the P-Care system. Not all puskesmas have access to the P-Care data, so they are 7 not able to use it for managing the health needs of their registered populations, and performance evaluation is not transparent. Another concern is that Puskesmas, private FKTPs, and DHOs have no mechanism to identify registered JKN participant for each FKTP and P-Care data is not linked to hospital utilization data, the data have limited value for policymaking, planning, and budget allocation at the regional level. BPJS-K is in the process of developing dashboard portal for stakeholders (Ministry of Health, District Health Offices, health provider associations and professional organizations) is under development to allow them better access to the data. PURCHASING OF PRIMARY HEALTH CARE UNDER JKN Options for Improvement in Strategic Purchasing of PHC Under JKN In order to strengthen strategic health purchasing of PHC under the JKN, some regulations simply need to be implemented better (supply-side readiness and credentialing and selective contracting of FKTPs), while other regulations may need to be revised (contracting and provider payment and use of capitation funds). OPTIONS TO IMPROVE STRATEGIC HEALTH PURCHASING UNDER JKN Purchasing Related Regulations Options for Improvement Function Accountability Law no. 40 on the National • Strengthen accountability through improved governance system of JKN with Social Security System clear definition of which institutions are responsible for which outcomes of JKN implementation. Law No. 24 of 2011 Chapter • Clarify the mandate and accountability of BPJS-K as both a health and a VIII Accountability Article 37 finance institution, increasing accountability for access to service by JKN participants, effective and efficient service delivery, quality of care, and cost management. • Establish a routine monitoring system based on a jointly used database of BPJS-K claims data, other MOH service utilization data, and other key 8 indicators and data sources. • Establish a link between central-level financial transfers to sub-national governments and accountability for JKN implementation. What to purchase Service delivery Law No 40/2004 President Gradually shift authority to BPJS-K to select which service delivery and quality standards Regulation number19/2016 standards (e.g. standard clinical practice guidelines set by MOH) will be used for article 43 A purchasing services, even if the agency does not develop them. From whom to purchase Supply-side readiness Law Number 23 year 2014 • Establish regional-level joint service delivery planning team including concerning local government representation of local governments, District Health Offices, professional associations (public and private), and local branches of BPJS-K to discuss Regulation of Minister of service delivery investment needs to meet service delivery standards but in Health No. 71 of 2013 consideration of the budget impact on BPJS. • Increase regional commitment to allocate funds used to build adequate health facilities, particularly in rural and remote areas. • Improve regulations to allow compensation funds as an alternative for source of health expenditure in some rural and remote areas with low fiscal capability. • Increase partnerships with the private sector, particularly for rural and remote areas, with the payer for the health care, BPJS-K, as the guarantor. Selective contracting Regulation of Minister of • Increase the role of BPJS-K in the contracting function by giving greater Health Number 69 on Health authority to establish provider selection criteria, establish the terms of Services Standard Rates At contracts, negotiate contracts with providers, and monitor and enforce First Level Health Facilities contracts. and Advanced Level Health • Implement the BPJS-K credentialing process in a participatory way with Facilities in Health Insurance DHOs, local governments, professional associations (public and private), Program Implementation and other stakeholders to jointly carry out mapping in the regions, analyze population growth, and project future PHC supply needs for JKN. • Create more opportunity for private FKTPs to contract with BPJS-K: • Specify the role of private providers in JKN/BPJS-K regulations • Engage private professional associations in credentialing POLICY NOTE Purchasing Related Regulations Options for Improvement Function How to purchase Contracting and Regulation of Minister of • Increase the role of BPJS-K in the selection and development of provider provider payment Health Number 69 on Health payment systems, and provider rate-setting. policy Services Standard Rates At • Explore options to better harmonize between capitation payment for PHC First Level Health Facilities and INA-CBG payment for secondary and tertiary services. and Advanced Level Health • Provide fair contracting conditions for private providers, including tariff Facilities in Health Insurance adjustments and access to government medicines prices. Program Implementation • Consider establishing an independent provider payment policy analysis unit to gather cost information, conduct analysis to inform provider payment system design and parameter development, and budget impact analysis (possibly built from the MOH Case Mix Unit) Capitation • The capitation rate-setting should be more explicitly linked to the package of services and, include adjustments for geography and other factors related to health need. • The capitation payment system should be refined to include regulations on the upper and lower limits of ratios of registered participants to physicians in a FKTP. • The pay-for-performance component should be evaluated and revised to ensure that incentives are aligned with service delivery objectives and rural and remote FKTPs are not disadvantaged. INA-CBGs • The INA-CBG payment system should be refined to improve alignment between case groups and relative costs. • The hospital costing system should be evaluated and possibly refined • Consider transitioning the INA-CBG payment system to a budget-neutral payment system (either volume caps or adjustable base rate). 9 Provider autonomy Regulation of Minister Test a capitation waiver that allows puskesmas meeting certain criteria to of Health Number 19 of pool revenues from multiple sources (capitation, BOK, local funds, etc.) with 2014 regarding the Use increased autonomy for management and allocation of funds. of Capitation Fund of the • Set up a district-level platform for communication and monitoring among 4 National Health Security entities: DHO, BPJS, puskesmas providers, and local government For Health Care Service And • Monitor effects on service delivery Operational Cost Support on Regional Government-Owned First-Level Health Facilities MOH regulation no 21/2016 Provider performance Regulation of Minister of • Establish an integrated health information system that can be used by monitoring Health Number 71 of 2013 multiple stakeholders for multiple purposes. CHAPTER VI Quality and Cost • Improve the P-Care data system to that it can be used effectively by Control Articles 33, 37 and 38 all stakeholders, especially FKTPs, for planning, management, and performance monitoring and improvement and link it to the BPJS-K Regulation of Minister of claims database. Health Number 71 of 2013 • Establish a routine monitoring system within BPJS-K that analyzes and Chapter VII Reporting And reports on a set of standard indicators related to service delivery and other Utilization Review Article 39 key JKN outcomes. • Build on the BPJS-K cost and quality control team to build Joint provider monitoring and quality assurance commissions at the district level, including representation of the local branch of BPJS, DHO, and local government. • Establish the authority of BPJS-K to act on results of the cost and quality control teams utilization reviews, etc. and possible link to financial or other incentives. • Establish a routine reporting system for BPJS-K to report routine monitoring and evaluation results to MOH and DJSN on a regular basis PURCHASING OF PRIMARY HEALTH CARE UNDER JKN Annex 1. Health Sector Laws and Regulations in Indonesia Related to Purchasing PHC STRATEGIC PURCHASING REGULATIONS IMPLEMENTATION/ ROLE OF STAKEHOLDERS FUNCTIONS QUALITY OF CARE Regulation of Minister of Health BPJS-K performs selection and credentialing of FKTPs Number 71 of 2013 article 9, as amended to establish a contract with BPJS-K using the following To ensure qualified to Permenkes NO. 99 Year 2015. technical criteria: a. Human resources; b. the completeness public and private of facilities and infrastructures; c. scope of services; and d. providers are service commitment. These activities involve district/city empanelled [e.g. health agencies and/or the association of health facilities. The Credential, accreditation, technical criteria are based on the ministerial regulation. using structural quality, clinical quality, patient Utilize a structural quality, clinical • Type of FKTP requirements should be met and the follow-up, to safety, infectious quality (Requirement) be able to form collaboration with BPJS-K. control] • Recredentialing for extension of FKTP contract utilizing agreed Regulation of Minister of Health technical criteria, and involving health agencies in the district/ Number 71 of 2013 article 6-7. city and /or Health Facilities Association and should be made at least 3 months before the cooperation agreement expires. Credential Regulation of Minister of Health Number 71 of 2013 article 10 Patient safety • THE ROLE OF LOCAL GOVERNMENT: The local government 10 Presidential Regulation Number 12 of regulates the utilization of Puskesmas funds to be more 2013 concerning health coverage article effective and efficient and the role of local government in 42-43. subsidizing of Puskesmas is carried out. • The quality control of health assurance services conducted entirely comprising the fulfillment of quality standards of health facilities, ensure health services process carried out based on agreed standards and supervise health outcomes of the members. • Health services for JKN members should consider the quality of services; patient’s safety oriented, action effectiveness, appropriate with the patient’s needs, and cost efficiency. • The implementation of health assurance quality control conducted comprising the fulfillment of quality standards of health facilities, ensure health services process carried out based on agreed standards and supervise health outcomes of the members. • The provision of the implementation of quality control of health assurance services are referred to the article (2) governs with BPJS regulations. (1) In order to ensure the quality control and cost, the ministry of health has a responsibility to: a. Conduct health technology assessment; b. Clinical advisory and advantages of health assurance; c. Tariff standards calculation; and, d. Monitoring and evaluation to the administrator of health services assurance. POLICY NOTE STRATEGIC PURCHASING REGULATIONS IMPLEMENTATION/ ROLE OF STAKEHOLDERS FUNCTIONS HR COMPETENCIES • UU 20 year 2013 on medical education • Medical education profession comprises of primary medical services program, medical specialist/sub specialist, and dentist • The Ministry of Health decree No. 5 specialist/sub specialist. year 2014 on clinic practice guidelines • Reference for a doctor to provide health services in government for a doctor in primary health services health services facilities or private to enhance the quality of facilities. services as well as to decrease the number of referrals patients based on the following criteria: a. the disease that has a high prevalence; b. High-risk disease; and c. High-cost disease. Credentialing and • The government regulation (UU) No. 9 • The role of regions to provide Health Facilities (FKTPs). contracting Year 2009 on health • The infrastructure of Community Health Center (Puskesmas) • UU No. 23 Year 2014 regarding Regional not meet the standard, Government (Pemda). • The national and regional health facilities that meet the • Article 36 verse (2) Presidential credentialing requirements are required to establish a Regulation (Perpres) No. 12 Year 2013, cooperation with the BPJS-K by establishing a written • The Ministry of Health (MoH) decree agreement. (Permenkes) No. 5 Year 2014 concerning • BPJS coordinates with health agencies in the district/city on a guidelines of clinical practice for a contracting doctor in primary health facility services. • The guideline of Clinic practice for a doctor in primary health service facilities with aims to provide a reference for a doctor to support primary health services both owned by the government or private to enhance health quality services as well as to decrease the number of patients referrals, with the following criteria: a. the disease that have a high prevalence; b. High-risk disease; and c. High-cost disease. PAYMENT • Permenkes no. 52 Year 2016 on Tariff ROLE OF MoH: setting up the tariffs (CAPITATION) standard for health services in JKN program. • The utilization of capitation funds of JKN, JKN services, the 11 • Article 24, UU no. 40/2004, The amount operational cost of health services, utilization of the remaining of payment to the Faskes determined capitation funds, guidance and supervision. by the agreement of BPJS with Faskes association in the area. • Capitation tariffs of FKTP equal to the amount of IDR 3,000 • The MoH decree (Permenkes) No. 21 (Three Thousand rupiah) until IDR 6,000 (Six Thousand year 2016 concerning the utilization of Rupiah). capitation assurance National Health Funds for Health services and Operating • Technical guidelines for budgeting, implementation and support funds on the first level of health administration and the accountability of JKN capitation funds facilities owned by the government. on FKTP owned by the regional government that has not • The Ministry of Health decree implement financing pattern of regional Pubic Services (PPK- (Permenkes) no. 69 Year 2013 on health BLUD) services tariff standards on the first level of health facilities to the advance levels in performing health insurance programs. • The regulation of health security agency number 2 Year 2015 on the norm of determination of the amount of capitation and capitation payment based on the commitment to support health facilities for the first level. • Circular letter from the Ministry of Home Affairs (MoHA) Number 900/2280/SJ Year 2014 concerning financing technical guidelines, implementation and administration, and the accountability of the national health assurance capitation funds on the first level of the health facilities owned by the regional government. PURCHASING OF PRIMARY HEALTH CARE UNDER JKN STRATEGIC PURCHASING REGULATIONS IMPLEMENTATION/ ROLE OF STAKEHOLDERS FUNCTIONS • Circular letter from the Ministry of ROLE OF DHO : credentialing Health and BPJS Number HK.03.03/ IV/053/2016 and Number 01 Year 2016 on • Determination of contracting with BPJS-K by utilizing the the implementation and supervision of following technical criteria: a. Human resources; b. the KBK and implementation of FKTP. completeness of facilities and Infrastructure; c. scope of services; • Regulation of Minister of Health and d. services commitment. These activities involved district/ Number 71 of 2013 article 9 as amended city health agencies and/or the association of health facilities to Permenkes No. 99 Year 2015 or determination of the results together with the health agency • Regulation of Minister of Health in the district/city and or association of health facilities. Those Number 71 of 2013 article 6-7. technical technic based on the MoH regulations. • Regulation of Minister of Health Number 71 of 2013 article 10. • The requirements that should be fulfilled by FKTP and in advance to be able to form cooperation with BPJS Kesehatan. • Re-credential to extend cooperation of Faskes with BPJS Kesehatan by utilizing an agreement on technical criteria, and involving health agencies in district/city and/or Health Association Facilities and should be made at least (three) months before the cooperation agreement expiration. Joint regulation of General Secretary ROLE OF LOCAL GOVERNMENT: Infrastructure fulfillment of the Ministry of Health (MoH) and President Director of BPJS kesehatan Number HK.02.05/III/SK/089/2016 and Number 3 Year 2016 on the technical guidelines for KBK payment on FKTP. Permenkes regulation no. 455/2013, ROLE OF BPJS: setting up the criteria/performance 12 on the amount of Faskes payment, determined based on the BPJS agreement with Fakes association in the regions with reference to tarrif standard regulated by the ministry. Presidential Regulation (Perpres) 12/ ROLE OF DHO: negotiation PCP’s performance 2013, article 43A verse (1), UTILIZATION PERPRES 32/2014 on Utilization of ROLE OF BPJS: negotiation with DHO CAPITATION BUDGET capitation fund. MONITORING AND Presidential Regulation Number 12 of Health services should provide a high quality of services EVALUATION 2013 concerning health coverage Chapter to the health assurance members; consider patient’s safety IX Quality Control, cost and the quality oriented, action effectiveness, appropriate with patients needs, of health insurance implementation and cost effectiveness. article 42-43. b. Regulation of Minister of Health ROLE OF MoH: establishment of regulation; Number 71 of 2013 CHAPTER VI The ministry conduct: QUALITY CONTROL AND COST article a. health technology assessment; 33-38. b. Clinical advisory; c. Tariff standard calculation; d. Monitoring and evaluation to the health assurance administrator; ROLE OF DHO: with the BPJS perform a credentialing.