With the e-prescription in the Austrian Federation of Social Insurances (Dachverband der Österreichischen Sozialversicherungsträger – DSV), health insurance prescriptions for all insured persons are issued, filled and billed electronically. Because all the necessary information is available electronically in the pharmacy, paper is no longer necessary. This reduces the administrative workload for everyone involved.

One of the biggest challenges in managing social healthcare in Indonesia is low awareness and willingness of informal members to pay their premium contribution regularly. This condition was further worsened by the fact that in 2020, 91.3 million people were unbanked (have no bank accounts. Data source: Central Bank of Indonesia).

As mandated by the constitution, the Social Security Administering Body for Health Sector of Indonesia (BPJS Kesehatan) of Indonesia has the authority to examine the compliance of employers to the social security for health programme. Some of their responsibilities include registering all workers in the programme, updating workers’ data including wages as the basis for deducting contributions, and paying monthly contributions for their workers.

Employers are obliged to submit monthly reports to BPJS Kesehatan as the basis for inspecting compliance.

Since the beginning of the COVID-19 pandemic in March 2020 in Indonesia, a number of health-related problems have arisen, including the uncontrolled increase of cases in hospitals, the lack of pre-existing facilities for handling COVID-19, the availability of budgets for handling those cases, and the increasing number of health workers infected.

Village is the smallest governmental unit in Indonesia managed by village officials known as KP Desa. Recruitment of KP Desa is challenging since they are scattered in 74,957 villages across Indonesia. Thus, it is hard to inform them about enrolment to the national health insurance (JKN) considering the limited resources owned by the Social Security Administering Body for the Health Sector (BPJS Kesehatan), 127 branch offices and 389 district offices.

The national social security system in Indonesia can be divided into two social security administering bodies (BPJS), namely Social Security Administering Body for the Health Sector (BPJS Kesehatan) and National Social Security Administering Body for Employment (BPJS Ketenagakerjaan). BPJS Kesehatan organizes health insurance programmes and BPJS Ketenagakerjaan provides work accident insurance, old-age savings, pension benefits, and death benefits.

Until 2024, the Social Security Administering Body for the Health Sector (BPJS Kesehatan) of Indonesia has a target of 82 million formal workers. To achieve this target, it is necessary to carry out a certain strategy, namely empowering Relationship Officers (RO) to recruit formal workers. The recruitment process requires adequate knowledge and communication skills. To support this, platforms are provided, namely ALIANRO and PAPERORO.

In 2020, Indonesia was hit by the COVID-19 pandemic just like many other countries in the world. It affected all aspects of life in Indonesia including public services such as those provided by the Social Security Administering Body for the Health Sector (BPJS Kesehatan).

Contribution collection is a vital aspect in the implementation of the social security for health programme in Indonesia. Since it was implemented in 2014 until the end of 2018, contribution collections from the informal sector have continued to decline, with the collecting ratio in the range of 60 per cent.

The Social Security Administering Body for the Health Sector (BPJS Kesehatan) is a public legal entity that reports directly to the President and is assigned to administer national health insurance for all Indonesian citizens. Its organizational structure consists of 24 Departments, 13 Regional Departments, 127 Branch Offices and 365 Regency/City Offices.

Compliance of formal sector to register and pay for the contribution of workers is an on-going problem for Indonesia’s National Health Insurance Programme. To ensure optimal supervision and compliance check in the midst of the pandemic, Indonesia’s Social Security Administering Body for the Health Sector issued a technical guideline on compliance supervision and inspection of non-government employers in the new normal. The new Compliance Express for Companies (CoEx) is an innovation that does not change the business process but shortens the time required for compliance checks.

Before July 2018, the drug billing system of Social Security Administering Body for the Health Sector (BPJS Kesehatan) of Indonesia was an offline system, which made it possible for members to be prescribed with the same drugs at different health facilities. This fraudulent behaviour cost BPJS Kesehatan around 382 million Indonesian rupiahs (IDR) from August 2017 to July 2018. The system made it possible for the health facilities to reimburse non-covered drugs of around IDR 10.8 billion.

Organisations may face conditions that create uncertainty in attempts to achieve their goals. Risk management is one of the best ways to obtain certainty from an existing phenomenon. An organisation prepares a measurable risk strategy to be implemented by all units in accordance with the principles of good governance. The strategy is to use an operational framework as a reference for work units in managing risk.

Healthcare and medical insurance are vulnerable areas for health care fraud. Traditional fraud detection efforts were unable to cope with the rapidly increasing health care utilisation and costs. A machine-learning tool is needed to detect potential fraud more effectively and efficiently.

One of the extra packages covered by the Social Security Administering Body for the Health Sector (BPJS Kesehatan) is spectacle services. Participants receive spectacles after a referral from the primary healthcare (PHC) and an ophthalmologist at the hospital. The optics and hospitals are all located in the sub-urban/urban areas, which cost the participants access to receive the benefits.

As one of the biggest social security institutions in the world, the Social Security Administering Body for the Health Sector (BPJS Kesehatan) of Indonesia is part of a large ecosystem that involves many institutions. Most of the inter-institutional correspondence used to be carried out through the exchange of formal letters.

Due to the enormous interactions, organizing correspondence documents constitutes a great challenge. Documents that are carried everywhere will have an impact on data security and confidentiality.

Indonesia is among the countries with very high number of traffic accidents. Benefit service for traffic accidents was slow because of overlapping benefits between two insurers, namely, the Traffic Accident Insurance Agency (Jasa Raharja) and the Social Security Administering Body for the Health Sector (BPJS Kesehatan). The process is still manual and is not coordinated.

Around 5 million Austrians are insured with the General Institute for Insurance against Employment Accidents and Occupational Diseases (Allgemeine Unfallversicherungsanstalt – AUVA). According to the occupational disease (BK) list Section 177 of the Austrian General Social Security Act (ASVG) Annex 1, BK No. 19 – skin diseases (BK 19) – have been the second most commonly recognized occupational disease in Austria for decades.

In order to achieve universal coverage for the Employment Social Security Programme, the central government continues to encourage local governments and businessmen to protect all workers through it.

Fraud incidence in healthcare is not easy to find. As a country that started its National Health Insurance program (Jaminan Kesehatan Nasional – JKN) in 2014, there are not many parties that provide fraud detection tools for the Indonesia-Case Based Group (INA-CBG) case-mix system. In addition, the law that establishes an investigation for potentially fraudulent incidents is still being drafted. On the other hand, there is a significant increase in the number of JKN participants and in the number of claims. By the end of 2017, the number of claims submissions was 80,641,271.

The Family Virtual Account (FVA) is a system which combines enrolee bills in a family. This system has great benefits for the enrolee such as more efficient payment, prevention of adverse selection for the Social Security Administering Body for the Health Sector (BPJS Kesehatan) and improved collection of contributions from informal sector workers. In the implementation of this system, BPJS Kesehatan must coordinate well with the Ministry of Internal Affairs which manages the population data and must also improve the promotion of the FVA system to the public.

The increasing number of participants in Indonesia’s Health Insurance Program has greatly increased the utilization of the services of and the number of claim reimbursements received by the Social Security Administering Body for the Health Sector (BPJS Kesehatan). This required a large number of additional resources and staff for claim administration processing. BPJS Kesehatan thus launched an initiative to simplify claims processing and management so that less resources would be needed.

Kader JKN is a partnership programme that encourages the general public to care about social health care programme. Every social health care provider has its limitations and challenges. We must be smart to optimize resources around us. By creating Kader JKN Programme, the Social Security Administering Body for the Health Sector (BPJS Kesehatan) can manage and go beyond the limitation of its resources to collect contributions from individual or informal sector members and turn the challenges into opportunities.

According to the Government Regulation of the Republic of Indonesia, in order to improve the quality of the implementation of the social security programme, the Social Security Administering Body for the Health Sector (BPJS Kesehatan) can cooperate with government and non-government institutions. There are so many institutions both at the national and international levels that have to be managed by BPJS Kesehatan. Cooperation is needed to expand the membership coverage and improve health service quality, which are the most important factors of social security programme sustainability.

After a year of implementing the National Health Insurance program (Jaminan Kesehatan Nasional – JKN), the Social Security Administering Body for the Health Sector (BPJS Kesehatan) instituted in 2015 a Pay for Performance (P4P) scheme in the capitation system for primary care providers. P4P or Kapitasi Berbasis Komitmen Pelayanan (KBK) is commitment-based capitation that aims to measure the commitment of primary care providers to deliver primary care services comprehensively. Unfortunately, resistance from primary care providers hindered its full execution.

Since the transformation of the Health Insurance for Government Employees (PT ASKES) into the Social Security Administering Body for the Health Sector (BPJS Kesehatan) in 2014, the interest of the people to participate in the National Health Insurance program (Jaminan Kesehatan Nasional – JKN) Indonesian health cards (KIS) has grown. The service in branch offices is far from perfect because of the long queues and the lack of uniformity in the service counters.

From the establishment of the Social Security Administering Body for the Health Sector (BPJS Kesehatan) on 1 January 2014 up to 1 May 2018, the coverage of participants was at 197 million, leading to a high number of visits to the branch offices. For the participant registration process, the national daily average of visits to all branch offices in Indonesia is 70,000 to 100,000 or a daily average of 700 to 1,000 visits per branch office.

The National Social Security Administering Body for Employment (BPJS Ketenagakerjaan), as one of the biggest public institutions in Indonesia, is managing social security funds of more than 30 billion US dollars (USD) and has more than 50 million members nationwide.

With its large funds and many stakeholders, BPJS Ketenagakerjaan must be able to maintain the trust with an integrated fraud control system to prevent fraud and corruption inside the institution.

The Health Facilities Information System (HFIS) is a platform developed by the Social Security Administering Body for the Health Sector of Indonesia (BPJS Kesehatan) to improve contracting accountability and referral system efficiency. Before the HFIS, the contracting mechanism was done and monitored manually which was not only time consuming but also sparked dissatisfaction from providers. Referral from one health facility to another was also not based on sufficient information about the availability of medical specialists or facilities at the referral hospitals.

The vision of the Social Security Administering Body for the Health Sector (BPJS Kesehatan) is to achieve universal coverage within five years (2014–2019). Because of this, BPJS Kesehatan needs to prepare itself in minimizing all risks, which comes in many forms, that could delay the achievement of the target. Risk management in BPJS Kesehatan is based on the Director’s Regulation No. 46 of 2017 on the BPJS Kesehatan Integrated Risk Management Guidelines to comply with the international risk management standard ISO 31000.

The National Health Insurance program (Jaminan Kesehatan Nasional – JKN) is one of the national strategic programs mandated by Indonesian Law aimed to provide health insurance for all Indonesian citizens. It is managed by the Social Security Administering Body for the Health Sector (BPJS Kesehatan). The number of JKN participants as of 1 May 2018 has reached 196.62 million. The primary issue faced by this program is the high number of visiting participants to branch offices for administrative matters.

BPJS Kesehatan (Badan Penyelenggara Jaminan Sosial Kesehatan) is a public agency established to implement the social security programme. The ultimate vision of BPJS Kesehatan is "Universal Health Coverage"; to provide all participants with health care benefits and protection to meet the basic needs of health care. As Indonesia is fourth most populous country in the world there are a large number of participants, so BPJS Kesehatan is facing constraints in the participants' registration process.

In the implementation of the Indonesian Social Health Insurance (called JKN), that had been started on 1^st of January 2014 based on the Health Ministry Regulation No. 69/2013 about health care payment standard that increased the capitation cost from Rp. 2.000 to Rp. 6.000,-. ( Rp 400 million to Rp 1.2 billion per month - USD 31 thousands to USD 93 thousands).

In an archipelago country like Indonesia, the financial barrier is not the only barrier to healthcare access, but also the socio-geographical barrier. Health facilities are distributed unevenly throughout the nation, where hospitals are only available at the district level. The lack of infrastructure to reach the hospitals is another challenge for rural patients to receive treatment. On the other hand, there are sufficient numbers of primary healthcare facilities in the rural areas, which are not utilized optimally.

One form of quality management is cost-efficiency. In term of cost-efficiency,  BPJS Kesehatan is developing a referral system. Fasilitas Kesehatan Tingkat Pertama (FKTP) acts as a gate keeper for the selection of cases that can treated at the first or second level of health care. Of course this is very important for the aspect of financing, because the cases handled by the second level of health care cost more. The fact is that 144 diagnoses that should be completed in FKTP were still referred to second level health care facilities.

For more than 20 years, the Employment Injury Insurance scheme for workers has provided cash benefits/compensation. In 2014, BPJS Ketenagakerjaan was mandated to reform its social security system. In order to fulfill that mandate, we proposed the Return to Work Programme to the Indonesian Government as a part of social security reform that provides a holistic approach.

Primary Care Providers (PCPs) have many business processes ranging from referral systems, service quality to claims management. All business processes data must be recorded for utilisation evaluation.

Regarding the referral system, unnecessary referrals to hospitals made the cost of outpatient visits reach 3.6 million US dollars (USD) in 2018. This reduced primary care service quality. However, service quality needed a more patient-centred instrument for evaluation.

As part of the social security reform processes in Indonesia as mandated by the 2004 Law concerning the National Social Security System, BPJS Ketenagakerjaan must cover all workers in Indonesia, in both formal and informal sectors, totalling 120 million workers distributed in 17,000 islands.

The social security administrator, as mandated in the Law, must provide a single identity number to its members. As part of the social security reform processes in Indonesia, BPJS Ketenagakerjaan initiated a project to integrate its whole administration system with the National ID administered by the Home Affairs Ministry (which was recently reformed in the agenda of national public administration).

Indonesia is a rapidly growing middle-income country with a 271 million population and the largest archipelagic country in the world with 17,491 islands. The main challenge facing by the Social Security Administering Body for Health (BPJS Kesehatan) in Indonesia is to manage a single payer national health social security with the geographical barriers and large population.

In order to achieve service excellence, BPJS Ketenagakerjaan developed a new service blue print putting prime concern on three aspects: People, Process, Physical Evidence.

The institutional reform in 2014 had transformed BPJS Ketenagakerjaan into a new non-profit public entity which is directly responsible to the President of Republic of Indonesia. The creation of this new entity has had an enormous impact on its supervisory system, both external and internal, to ensure its transparency and accountability.

As a result of the new governance landscape, BPJS Ketenagakerjaan has been reconstructing its value and governance system toward the vision of good citizenship governance in 2018.

Issues such as the increase in health-care costs arising from demographic changes, inequities in health, innovation of medical technology and drugs, and epidemiological developments need to be addressed. Increased efforts are required to make better use of limited resources to increase the efficiency of the health-care system and improve value for money in terms of health outcomes, quality and consumer satisfaction.

The investment philosophy of BPJS Ketenagakerjaan is to manage and develop the fund optimally by considering aspects of liquidity, solvency, prudence, security of the fund and adequate return. The investment philosophy is implemented by the following principles:
 

Since its implementation in 1992, the membership of JAMSOSTEK's healthcare program has shown an impressive growth until the late nineties due to its mandatory attribute. In 1999, the growth was ceaselessly declining until JAMSOSTEK was experiencing negative growth of its membership during the period of 2002 - 2004.

The main concept is to establish an administrative services counter (ASKES CENTRE) in hospitals. At the counter, the assigned officer verifies members' referral letters from primary care providers as well as provides the guarantee letters required for members to begin receiving medical services at hospitals. While members are receiving medical services, the officer will also provide them with any necessary information and approvals that may be required by members receiving several catastrophic services.

DPHO has been the hallmark of Indonesia's drugs policy for twenty five years (since 1987). The basic principles of DPHO are to ensure that patients receive drugs that meet the criteria stated above. In practice, DPHO is the main reference for providers to prescribe drugs.