Seeking a Way Out of Poverty in East Java, North Maluku, and West Timor

The study explores the community's understanding of the condition of their welfare and the experiences associated with the ups and downs of welfare. This report was written based on various reports generated in the two studies of Moving Out of Poverty carried out by SMERU. The main focus of the study is on the movers group, the group of people who managed to improve their welfare, both those who managed to move out of poverty and those who have not yet been able to do so. This report compares movers in three regions, namely East Java, North Maluku, and West Timor, to investigate the characteristics of movers and how the process of welfare improvement takes place.Five research communities were selected for each region, including those located in rural areas and those located in (semi) urban areas. Data collection was conducted by combining the quantitative (household surveys) and qualitative (focus group discussions, life history interviews of men and women, interviews with community leaders/figures, and observation) methods.The study found several patterns of processes of improving welfare and moving out of poverty, namely retaining the same work/livelihood but obtaining better returns; shifting to another occupation or livelihood that is larger or more stable in its returns; developing several sources of income; and having a fixed salary (by becoming a civil servant or an employee). Welfare improvement is affected by the capacity of the individual or household, the capacity of the community, and the local and regional contexts. Therefore, these three elements must be used as entry points in the making of policies and development programs to increase community welfare

Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms in Kabupaten Tabanan, Bali : A Case Study

Based on the notion that good health is one of the basic right of all citizens, the Government of Indonesia (GoI) has promoted programs on health care financing for the poor. One of these programs is the Jaminan Pemeliharaan Kesehatan (JPK). In 2003, the pilot project on JPK for the poor (JPK-Gakin) started in 15 districts and two provinces, and was expanded to additional regions the following year. Since April 1 2004, PT Askes, a profit oriented private insurance company, was assigned as the insurer of the nonprofit health insurance scheme for the poor (the JPK-Gakin) in district Tabanan. With respect to PT Askes it is important to see in what ways does the prominent role of PT Askes influence the dynamics of health service delivery and how different is PT Askes from other insurers (the non-profit - public institutions) in managing the JPK-Gakin scheme. The Tabanan case demonstrated that the supervision and monitoring by the Dinas Kesehatan (DinKes) of an insurer like Askes runs the risks of being less effective because PT Askes is a relatively well-established institution that is totally independent of the DinKes. Moreover, there is a difference in the level of expertise and experience between PT Askes and the Dinkes regarding the management of insurance schemes. Therefore, the supervision and monitoring of PT Askes by the DinKes tends to be formal instead of actual. This difference in the level of expertise and experience can also be a barrier for the DinKes to negotiate the cost and coverage of the scheme with PT Askes. PT Askes as the insurer is also barely involved in the promotion and socialization of the program and the identification of the poor as their potential clients. Obviously, the JPK-Gakin scheme can secure primary health care for the poor (the gakin) at the puskesmas, but this does not necessarily mean that the poor will receive good quality care. In general, the health care at the puskesmas is quite limited both in term of quality and variety. The implementation of the JPK-Gakin scheme including adequate capitation for the puskesmas from this scheme would certainly not change this condition easily as it relates to more complex factors such as the availability of good medical staffs, instruments and facilities. The most positive effect of the JPK-Gakin scheme on the provision of health care for the poor is the possibility to get secondary and tertiary health care that is usually unaffordable for the poor. Nevertheless, for a range of different reasons, the majority of Gakin patients are not referred to the hospital. There are cases where the poor refused to be referred to the hospital although it was necessary because they were insecure about the additional costs that were not covered by PT Askes. Thus, although the JPK-Gakin scheme does secure the right of the poor to get medical treatment at the hospital, it cannot secure the actualization of it.health care program, financing mechanism, insurance scheme, stakeholders, health services

Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms (JPK-Gakin) Scheme in Kabupaten Purbalingga, East Sumba, and Tabanan

The government of Indonesia has started the implementation of locally based healthfinancing schemes based on health insurance principles. This scheme is commonly known as JPK-GAKIN, which is a health-financing scheme through which the poor can access health care in public facilities, including primary and secondary health care. Due to the perceived success of JPK-GAKIN pilots, the government has decided to provide JPK-GAKIN in all districts in Indonesia from January 1, 2005. This study looks at the effects of different characteristics of JPK-GAKIN program on healthcare service provision, utilization of health care services, quality of healthcare provision, and how insurance characteristics can influence the relationships between stakeholders. Three districts were selected for the case studies : Purbalingga (Central Java), Tabanan (Bali) and East Sumba (Nusa Tenggara Timur). We found that compared with previous health financing schemes, JPK-GAKIN scheme has achieved better results in providing access to adequate health care coverage to members of the population, especially the poor. However, we found several problems associated with the scheme, such as : there is a need to improve its targeting and efficiency, it needs stricter financial monitoring and auditing, and it needs to increase stakeholders involvement in the governance of the scheme. We will elaborate on these concerns and recommend possible policy options to resolve them in this paper.local health financing, JPK-GAKIN, public health, poverty, Indonesia

Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms in Kabupaten Tabanan, Bali : A Case Study

Based on the notion that good health is one of the basic right of all citizens, the Government of Indonesia (GoI) has promoted programs on health care financing for the poor. One of these programs is the Jaminan Pemeliharaan Kesehatan (JPK). In 2003, the pilot project on JPK for the poor (JPK-Gakin) started in 15 districts and two provinces, and was expanded to additional regions the following year. Since April 1 2004, PT Askes, a profit oriented private insurance company, was assigned as the insurer of the nonprofit health insurance scheme for the poor (the JPK-Gakin) in district Tabanan. With respect to PT Askes it is important to see in what ways does the prominent role of PT Askes influence the dynamics of health service delivery and how different is PT Askes from other insurers (the non-profit - public institutions) in managing the JPK-Gakin scheme. The Tabanan case demonstrated that the supervision and monitoring by the Dinas Kesehatan (DinKes) of an insurer like Askes runs the risks of being less effective because PT Askes is a relatively well-established institution that is totally independent of the DinKes. Moreover, there is a difference in the level of expertise and experience between PT Askes and the Dinkes regarding the management of insurance schemes. Therefore, the supervision and monitoring of PT Askes by the DinKes tends to be formal instead of actual. This difference in the level of expertise and experience can also be a barrier for the DinKes to negotiate the cost and coverage of the scheme with PT Askes. PT Askes as the insurer is also barely involved in the promotion and socialization of the program and the identification of the poor as their potential clients. Obviously, the JPK-Gakin scheme can secure primary health care for the poor (the gakin) at the puskesmas, but this does not necessarily mean that the poor will receive good quality care. In general, the health care at the puskesmas is quite limited both in term of quality and variety. The implementation of the JPK-Gakin scheme including adequate capitation for the puskesmas from this scheme would certainly not change this condition easily as it relates to more complex factors such as the availability of good medical staffs, instruments and facilities. The most positive effect of the JPK-Gakin scheme on the provision of health care for the poor is the possibility to get secondary and tertiary health care that is usually unaffordable for the poor. Nevertheless, for a range of different reasons, the majority of Gakin patients are not referred to the hospital. There are cases where the poor refused to be referred to the hospital although it was necessary because they were insecure about the additional costs that were not covered by PT Askes. Thus, although the JPK-Gakin scheme does secure the right of the poor to get medical treatment at the hospital, it cannot secure the actualization of it.health care program, financing mechanism, insurance scheme, stakeholders, health services

Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms in Kabupaten East Sumba, East Nusa Tenggara : A Case Study

Kabupaten Sumba Timur is one of 29 kabupaten/kota that were included in the test piloting of the JPK-Gakin program. Since 2003, the local health agency (Bapel) has been quite successful in managing this program. The program that is funded by the government from fuel subsidy allocations has already touched the poor whose numbers are quite significant (75% of the population are poor families) in Sumba Timur. Since 2005, the government has appointed PT Askes as the only implementing body for the JPKGakin program, while Bapel still operates this program. The involvement of two managers as JPKGakin implementers made the government issue a policy on the division of the puskesmas service area.. This transition period provided an opportunity for the local government to undertake an evaluation of the implementation of the program. There are several differences in the type and extent of health services offered by the two of them. The outcome of the findings shows that puskesmas and hospitals have responsibility for the patient costs of all poor families. However, the number of referrals of the poor to hospitals is small although Bapel provides transport allowances for patients who are referred to the hospital. There are quite a lot of limitations that are faced by the poor who live in a wide area across Sumba Timur. These limitations are the communitys very poor socio-economic conditions, endemic malaria, minimal numbers of health workers in rural areas and the long distances of peoples homes from health services. The manager of JPK-Gakin needs to give proper attention to the handling of health in Sumba Timur, the majority of whose people are poor.JPK-GAKIN, Sumba Timur, health, poverty program

Making Services Work for the Poor in Indonesia : A Report on Health Financing Mechanisms in Kabupaten Purbalingga, Central Java : A Case Study

Purbalingga is the first kabupaten in Indonesia to start implementing its health insurance scheme for the poor, as a replacement for the JPS-BK scheme (Social Safety Net Program Health Sector). Poor families (Gakin) receive a range of health insurance services that are subsidized by the government free-of-charge, while better-off families pay a premium of only 50% or 100%. They are categorized as participants in Gakin Levels I, II and III. The aim is to achieve universal coverage for all citizens in Kabupaten Purbalingga, those who are poor as well as those who are not. Kabupaten Purbalingga is considered unique in the scope of its health services, because it not only includes poor families in its scheme, but also non-poor families. The local government of Kabupaten Purbalingga considers the health insurance scheme to be one of the main pillars of the poverty reduction effort in the region. They want the management of this scheme to become more independent and less dependent on DinKes (the local government health agency) so the program can be managed more efficiently and with more accountability. What is rather interesting is that DinKes plans to arrange a health insurance scheme that will be autonomous and sustainable for all better-off members in the future. They intend to slowly increase the premium until it reaches the real cost of the assistance package. According to DinKes, the cost should be approximately Rp92,000 per family per month. From the perspective of Bapel, an autonomous scheme with that level of premium definitely has potential, however they will always depend on the premiums to be paid by the government. It needs to be noted that the Community Health Insurance Scheme (JPKM) initiative in Kabupaten Purbalingga is almost entirely the initiative of the government as its moving force. The main protagonists are government (Regent, DinKes and Bapel), public service providers (public hospitals and puskesmas), the local parliament (DPRD) and other government agencies.JPK- Gakin, Purbalingga, health, poverty program

A framework for understanding old-age vulnerabilities

Understanding vulnerability matters because being vulnerable represents a profoundly undesirable state. People who experience vulnerability in old age are of obvious humanitarian concern, as their insecurity and heightened exposure to certain threats is likely to be compounded by reduced capacities for coping independently. Comprehension of the causes and consequences of vulnerability is important for the development of social policies as it indicates ways of avoiding and alleviating bad outcomes. Policies which have the concept of vulnerability at their heart encourage the development of preventive and targeted measures, which is crucial in conditions of financial constraints and competing demands. By studying vulnerability we investigate processes of relative disadvantage or exclusion and, for purposes of comparison, absolute differences in socio-economic or policy context can be set aside. This makes the study of vulnerability particularly germane to cross-cultural and cross-national research on old-age and elderly support