The welfare of its people is commonly considered as an indicator of a nation’s success in its development programs. The welfare is commonly measured in terms of income level, education level and health condition of the people. Indonesia sets its MDGs target to reduce maternal mortality rate to 102 per 100,000 live births by 2015 as one of its development indicators. The 2012 Demographic and Health Survey shows that the rate was still 359 per 100.000 live births for Indonesia.

One of the Indonesian government’s efforts to reduce the high rate of maternal mortality is through providing health service for women during their pregnancy, childbirth, and puerperium through the National Health Insurance (JKN). JKN is provided for the public based on Law No. 40/2004 on National Social Security System (SJSN) and Law No.24/2011 on the National Social Security Agency (BPJS) starting from 1 January 2014.

With the aim of understanding the impact of JKN for the public and health workers, in 2014 Women Research Institute (WRI) conducts a research which focuses on the effectiveness of the implementation of JKN based on the experience of midwives and women in accessing health service provided by midwives in East Jakarta and City of Bandung, the two cities with a high rate of maternal mortality.

During WRI’s research at the end of 2014, we found that female BPJS participants still face several problems such as:

• Access to Information about the National Health Insurance: the access to information about the referencing system, diseases that are considered as requiring emergency treatments and costs that have to be borne by the patient is still lacking. We expect that the BPJS Health will provide comprehensive information by opening up accessible JKN information centers.
• Access to the National Health Insurance membership: there is a risk that women from poor families with lack of access to information will not be provided with the optimal healthcare due to the unclear procedure on how to become BPJS participants.
• The utilization of the National Health Insurance for midwifery service: it is important to clarify the coverage of midwifery service, such as contraception, and whether or not it includes the purchase of contraception. It is expected that the BPJS Health can ensure the availability and distribution of free contraception.
• Inadequate health facilities: the lack of prepared health facilities to accommodate the surging number of JKN participants leads to long queues of prenatal checkup and delivery patients. This increases the delivery risk, as many patients have to wait before they can access the service for delivery operation.
• Health workers (Midwives): it is essential to prioritize increasing the number of midwives in order to meet the needs of midwifery service. There is also a need to automatically appoint midwives as a basic-level health facility in providing checkup and delivery services for pregnant women.
• The referral system of the National Health Insurance: the complicated and bureaucratic referral system as well as the limited information of JKN motivates a lot of women to go to private healthcare providers such as private midwives which results in them paying the cost, which is supposed to be borne by the JKN, themselves. This is because private midwives do not automatically work in cooperation with BPJS Health.
• The National Health Insurance Payment Procedure: there is a need for succinct information on costs that are not covered in JKN program as the rights of JKN participants to avoid the risk of fraud.

Based on our research findings, we firmly believe that monitoring of JKN program is imperative to improve the quality of service.

Based on WRI’s research findings, there are several recommendations for policy changes, namely:

• To add a point that regulates the active role of BPJS Health in facilitating the cooperation between private midwives and basic-level health facilities in the Regulation of the Minister of Health No.71/2003 on Health Service in the National Health Insurance Article 8 Paragraph (3) Point C.
• To add detailed description of adequate equipment and other tools as a requirement for each health facility to be able to work with BPJS Health in the Regulation of the Health Minister No. 71/2013 on Health Service in the National Health Insurance Article 9 to Article 12.  
• To explicitly state that the requirement for the registration and selection of basic-level health facility does not have to conform to the domicile of residence listed in the identity card (Identity Card or Family Card) in the Regulation of the Minister of Health No.71/2013 on Health Service in the National Health Insurance and the Regulation of the Minister of Health No.28/2014 on the Implementation Guidelines for the National Health Insurance Program.
• To provide a more elaborative explanation on patients with special circumstances that are allowed to be excluded from the tiered referral procedure which includes an explanation of: medical emergency condition (Article 13 Paragraph 3 and Article 15 Paragraph 4), geographic consideration (Article 15 Paragraph 4) and the specificity of patients’ health problems (Article 15 Paragraph 4) in the Regulation of the Minister of Health No.71/2003 on Health Service in the National Health Insurance.

Jakarta, 25 March 2015
Women Research Institute

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Press Release_Seminar 25 March 2015-The Effectiveness of the National Health Insurance (JKN) in Reducing Maternal Mortality Rate.pdf