Analysis on BPJS Kesehatan From Various Disciplines

BPJS Kesehatan shall be the Social Security Agency (Badan Penyelenggara Jaminan Sosial) established by the government to provide a Health Security for the people. It constitutes an institution specifically established to organize the social security program in Indonesia according to Law No. 40 of 2004 and Law No. 24 of 2011. Pursuant to Law No. 40 of 2004 concerning National Social Security System, BPJS shall constitute a non-profit legal entity. The BPJS Kesehatan Program began on 1 January 2014. The National Health Security Program (Jaminan Kesehatan Nasional / JKN) initiated by BPJS aims at providing health protection for each participant to obtain healthcare benefits. JKN constitutes a healthcare program to serve the people with medical necessities, Insha Allah, Amiin.


BPJS Kesehatan and Social Justice
As is clearly mandated in the Preamble of Constitution paragraph 3 ³«WR EXLOG DQ Indonesian government that protects the entire nation and country and to promote public welfare, intellectual capacity of the nation, and to participate in the establishment of world RUGHU«´ and the Constitution in Article 28H paragraph: 1) Every person shall be entitled to live, physically and spiritually, in prosperity, to reside, and to earn a good and healthy environment as well as to obtain health care. 2) Every person shall be entitled to comfort and special care to obtain the same opportunities and benefits in order to achieve equality and justice. 3) Every person shall be entitled to social security that allows development of oneself as a dignified being.
Subsequently, in Article 34 paragraph: 2) Empowering the weak and incapable people to conform with human dignity.
3) The State shall be responsible for the provision of decent health care facilities and public service facilities.
Article 28 H of the Constitution explicitly specifies the rights of Indonesian citizens in terms of social justice, while Article 34 specifies that it is the obligations of the government to fulfill such rights.
Programs such as BPJS Kesehatan and BPJS Ketenagakerjaan constitute a form of government action in providing social welfare for the citizens. With good and professional management, such programs may provide social protection and welfare to the citizens without exception as ideally-DLPHG LQ WKH ILIWK SULQFLSOH RI 3DQFDVLOD ³6RFLDO MXVWLFH IRU DOO ,QGRQHVLDQ SHRSOH´

History of BPJS Kesehatan
Application of Health Social Security in Indonesia had been started since the era of Old Order, namely in 1960 by Decree of the Minister of Health No. 865 of 1960 concerning health FDUH SURJUDP FDOOHG WKH ³-DNDUWD 3LORW 3URMHFW´ 6XEVHTXHQWO\ LQ WKH JRYHUQPHQW E\ Presidential Decree No. 230 of 1968 issued a policy governing health care for state employees and retired, i.e. Civil Servants and Armed Forces. The Minister of Health at such time, namely Prof. Dr. G.A. Siwabessy established a Special Agency in the Ministry of Health, Healthcare Fund Organizer (BPDPK), which was the forerunner of the National Health Insurance (Askes).
In 1984, by Government Regulation Number 22 and 23 of 1984, in order to provide more professional service, the status of an organizer was changed into the Perusahaan Umum ( a. Simultaneous implementation throughout Indonesia in the principle of mutual cooperation / cross-subsidies. b. Building on the social health insurance. c. Non-profit program of the government. d. Professional and structured health services. e. The principle of equality in the provision of services. f. Transparency and accountability in the administration of the program. In accordance with Law No. 24 of 2011, as of 1 January 2014, PT ASKES (Persero) changed its name to BPJS Kesehatan. The Health Social Security Agency, hereinafter referred to as BPJS Kesehatan, shall be a legal entity established to organize the social security program (Law No. 24 of 2011). BPJS Kesehatan is established to organize the Health Security program. Health Security shall be a security in the form of health protection for the citizens to obtain benefits of health care and protection, in order to meet the basic needs of health provided to every person who has paid dues and the Beneficiary (PBI) category.

Benefits of BPJS Kesehatan
Based on Presidential Regulation No. 12 of 2013 Article 20 concerning Health Security Benefits, the benefits of Health Security comprise of 2 (two) categories, namely healthcare and non-medical benefits. Non-medical benefits shall include accommodation and ambulance services. Accommodation services shall be provided according to the category the dues paid by the participant or PBI, while ambulance service shall be provided only to referral patients from a primary health facility under particular conditions set out by BPJS Kesehatan.
Healthcare shall include four issues: Promotive, Preventive, Curative and Rehabilitative services, including drugs and any other medical consumables according to each medical requirement. Promotive -Preventive services shall include: a. Individual health counseling, namely counseling regarding the management of disease risk factors and clean and healthy lifestyle. b. Primary immunization; including Baccile Calmett Guerin (BCG), Diphtheria Pertussis Tetanus and Hepatitis B (DPTHB), Polio and Measles. c. Family planning; including counseling, basic contraception, vasectomy and tubal ligation.
The program works in cooperation with BKKBN and private institutions in charge of family planning programs. The vaccines for primary immunization and basic contraceptives shall be provided by the Government and / or regional governments. d. Health screening. This program shall be executed selectively with the aim at detecting the risk of disease and preventing the impact of the risk of certain diseases.
Although JKN services can be said to be quite comprehensive, but some basic essential services are excluded from the benefits provided, among other, spectacles, hearing aids and mobility aids (crutches, wheelchairs and corsets).
Following is the procedural chart of BPJS Kesehatan participants:

Sharia Economic Principles
Economic principles shall be human efforts to meet their needs with a certain sacrifice to obtain maximum results. In Islam, economic principles aim at achieving a prosperous society both now and in the afterlife, achieving optimal satisfaction of various physical and spiritual needs in a balanced way, of both individuals and society. Additionally, the relatively individual property rights are recognized as lawful business and for lawful interests. Within the property there is a right to others in need, therefore, it should be provided for distribution of fortune. Islam also asserts in its economic principle that to a certain extent, the relative property rights subject to donation, therefore commerce is allowed in Islam, but usury is strictly forbidden.
Islamic economics is defined as a science that studies human behavior both in terms of individual, family, group of people who organize either in a legal entity or otherwise, a community of nation and state, or citizens who transact / relate between countries in order to meet their physical and spiritual needs or to maintain the self-existence in a unitary group / neighborhood to obtain the happiness now and in the afterlife based upon instructions of the Koran and the Commendable Deed (Prof. DR. H. Suroso Imam Zadjuli, 2010).
Values on which the Islamic economic system stand are, among others, the obligation of donation, the prohibition of usury, economic cooperation, social security and the role of the state. They shall not be separated from the foundation of faith, moral, Al-4XU ¶DQXO .DULP and Ijtihad (5D ¶\X).
The motive of Islamic economics is to seek their fortune now and in the afterlife as the caliph of Allah by worship in the broadest sense. Discussion on Islamic economic system and capitalist economic system cannot be separated from the differences of opinion regarding the illicit nature of the proper or prohibited interest which, by some scholars, is regarded as usury forbidden by the Koran. Money is recognized in various functions as a means of exchange, storage of wealth and support of transition from a barter system to the economic system of money, but usury is agreed as a concept that should be avoided in the economy.
Interest system in banking (rente stelsel) begins to be considered by some experts as a factor that lead to the worsening economic condition and the interest system as a factor driving the investments and savings in Indonesian economy has been proven not the only way to overcome the weak economy. Prohibition of usury in Islam is aimed at building an economic structure which provides that: 1. capital cannot work by itself; 2. there is no profit to a capital without working; 3. there is no gain without any risk.
Therefore, Islam expressly refuses usury and Muslims shall leave it (QS 2:278), but Islam justifies the search for profits through commerce.
In the treasures of Islamic thought, particularly with respect to Islamic economic policy (al-siyasah al-iqtishadi), it can easily be understood that the concept of social security in Islam is a guarantee from the state and the government to its people to meet the basic needs of each individual as well as to set forth the regulation for achieving the welfare of its citizens.
The purpose of implementing Islamic law is to realize the welfare and peace of mind, joy of life and preservation of human affairs in Islam.
Allah SWT said, And We send from the Koran a matter that becomes the solution and mercy for those who believe.  In Islam, the affairs of the people governed by a system of rules and procedures that would bring them into a quiet life, happy, and prosperous. Some of these systems are the laws pertaining to guarantee fulfillment of basic needs of each citizen, such as food, clothing, shelter, education, health, security and employment opportunities. This is because, basically, human beings live to meet their basic and complementary needs according to their capacity.
Based on the above, the economic policy to be made shall be, first, the state shall fulfill the basic needs (hajat asasiyah), namely clothing, food and shelter, for all people. There should be no person suffer from hunger, naked and homeless (owned or rented). In this case, the state shall provide the widest possible employment opportunities and support those who are weak and poor. Secondly, the state shall provide the widest opportunity for all citizens without exception in order to obtain the fulfillment of complementary needs (hajat kamaliyah). In this case, the state shall provide the widest possible facilities. Thirdly, the state shall provide guidance and limits to the public that in order to enjoy their wealth, they shall follow the typical pattern of life, which is not forbidden.
Economic politic of Islam is a guarantee of achieving the fulfillment of basic needs of each individual with full enjoyment, together with the possibilities for everyone to enjoy complementary needs (both secondary and tertiary) according to their capacity (Al-Nabhani, 2004:60). Therefore, the economic politic of Islam is not only aimed at improving the standard of living in a country, but rather pay attention to whether or not each person is guaranteed to enjoy the life.
Islam also ordered the state to ensure the collective needs of the community (without differentiating rich and poor). Society maintained by the state to become a society of intelligent, healthy, strong and safe. Education in general is realized to form individuals who submit to the commands and prohibitions of Allah SWT, have the intelligence and ability to solve all problems with the foundation of Islamic thinking, and have the ability, skills and expertise for the provision of life in society.
Through free education, people have equal opportunities in education and access to proper educational facilities either schools, universities, mosques, public library, or public laboratory. The Prophet accepted services to teach reading and writing for the Moslem children in Medina in exchange of prisoners of Badr war. He also received a doctor as a gift from King Najasyi and the doctor was made as a general practitioners who serve the public for free (al-Badri, 1408 H:30).
At the level of current in Islam, health service is included in basic needs of society that shall be provided by the state free of charge. Health facilities constitute public facilities needed by the people. They are all the benefits and public facilities (al-mashalih wa al-marafiq) to be provided by the state, as it is included in the requirement for UL ¶D\DK (maintenance) of a state in accordance with the words of the Prophet. ª ö êö -I óöË ô-øåôË ò Ýí õ… ø³ô ã ôí ôíõ ë ôí ó É• ôõ áŽô ãö ù• © Imam is the preserver and he is responsible for his people (HR. al-Bukhari) In medical practice, the provision of free health services had been practiced and exemplified by the Prophet as the head of state, and the .KXODID ¶ DO-Rasyidin. It has became the Commendable Deed of the Prophet and LMPD ¶ of his companions that the state is required to provide free health services to all people. Some security practices in Islam can be seen in the fragments of the story of the Prophet and the generation thereafter. Following is one among them,

The Prophet has sent a doctor to Ubay ibn Ka ¶Db (who was ill). The doctor cut one vein of Ubay ibn Ka ¶Db then kay (with a hot iron) the vein. (HR. Muslim).
In another story, In the past, in the history of Islamic civilization golden era, so many care houses were established. In fact, the state fully promoted research on medicines and new treatment techniques. The Prophet once built a healing center for the sick and financed it with the treasures of Bait al-Maal. In the book of Tarikh al-Islam al-siyasi, it is narrated that µ2mar ra. has provided from Bait al-Maal to aid those afflicted by leprosy in the road to Shams, when he was passing through the area. The same thing was also done by the caliphs and saints. Even Caliph Walid ibn Abdul Malik provided particular aid to those affected by leprosy. (Al-Badri, 1408 H:30).

Islamic View on BPJS Kesehatan
As the country with the largest Muslim population in the world, the implementation of the BPJS Kesehatan cannot be separated from the desire of the people for well-targeted and clean Health Security. Clean in the sense that its management practices are free from the elements that are forbidden in Sharia that can affect the blessing of the facilities enjoyed by the people.
Based on the above, the Indonesian Council of Ulama (MUI) by the results of Fatwa Commission ¶V ijtima in June 2015 provides recommendations to the government that BPJS is not in accordance with the Sharia. The bases of these recommendations include: a. The element of maisir and gharar in the fund management of BPJS Kesehatan. Maisir is gained without working, where there are elements of wagering or speculation that may be categorized as gambling. While the terminology of gharar means deception. Deception means the absence of agreement between the two parties regarding the management of collected funds, in which no element of willingness of on the part of the participants, which is something that is forbidden in Islamic law. b. The element of usury, namely the imposition of interest as a form of penalty for late payment of dues.
Gharar element induces vagueness of the managed funds. BPJS Kesehatan funds are reinvested in the form of shares, bonds, time deposits, foreign exchange and any other securities. Such management is aimed at keeping the funds unaffected by the inflation that are relatively high while the currency remains collapsed. However, the management is not specified in the contract agreement between the participants and BPJS Kesehatan, so that it can be said that BPJS manages the funds without consent or willingness of participants.
Fund management in the form of investment in securities and currency may result in profits, which can be categorized as gambling and usury according to the Sharia.
Due to these three elements (gambling, gharar and usury), MUI provides recommendations to the government to implement BPJS Kesehatan products based on Sharia and free from such elements in the fund management.

Opportunities and Obstacles in Its Implementation
Application of BPJS Kesehatan opens a great opportunity to the Government to fulfill the mandate of Pancasila and the Constitution in order to protect the welfare and safety of all citizens. Through the program, then the basic rights of citizens, among others, health and a decent life, can be fulfilled.
Health security that was managed separatedly, such as PT Askes for civil servants, PT Jamosostek for private employees, and so on, is now consolidated under BPJS Kesehatan. Meanwhile, the employment accident security, retirement security, pension and mortality security that used to be managed by PT Jamsostek, PT Taspen and PT Asabri, is now centralized under BPJS Ketenagakerjan.
In addition to centralize the management of social insurance programs, BPJS Law also expands the coverage of social insurance program. At first, the coverage of social insurance program was limited, such as the Employment Social Security program was meant only for private employees, Taspen and Askes programs was for civil servants, as well as Asabri program was for police, military and civil servants of the Department of Defense. Now, Article 14-18 of BPJS Law requires that all residents having met the requirements of social security program shall enroll themselves and their families to BPJS. It includes foreign workers who have worked at least 6 months in Indonesia. Those who are eligible, but not enroll themselves, may be imposed with administrative sanctions.
With centralized and consolidated system and administrative sanctions for individuals / entities refraining from participating, it should be a great opportunity and momentum for the state. In fact, the implementation of BPJS Kesehatan encounters a number of obstacles and malpractices with respect to the administration of services and the management of funds.
In terms of service, problems are found during the operation of BPJS Kesehatan, particularly in respect of poor residents being the Beneficiary (PBI). The most highlighted issue is the poor quality of healthcare received by BPJS Kesehatan patients, such as inadequate health facilities at the first level, patients building-up, unavailable medicine, and accessibility of the first-level health facilities (FKTP) to the advanced health facilities (FKTL).
The reasons for such poor service may be in connection with the prospective payment of claims, namely the amount of payment predetermined BPJS Kesehatan prior to the provision of healthcare. The payment of claim is based upon capitation system for the first-level health facilities and INA-CBG (Indonesia-Case Based Groups) for advanced-level health facilities.
Prospective tariff system is aimed at benefiting BPJS Kesehatan because such system gives BPJS Kesehatan with the capacity to control and reduce the cost of claims. On the other hand, the application of such system put the pressure on profit-oriented health facilities. As a result, some private hospitals is willing to cooperate with BPJS Kesehatan only for certain services. In addition to provide health protection, BPJS Kesehatan also is aimed at assisting the state finance in terms of control of claim amount. These two opposite sides has a counterproductive effect, namely poor healthcare facilities.
Another problem is the frequent denial of PBI patients by hospitals due to administrative reasons and any other reasons such as lack of rooms for class III inpatient. In the Presidential Regulation No. 111 of 2013 concerning Amendment to Presidential Regulation No. 12 of 2013 concerning Health Security, the rooms for PBI patients shall be Class III rooms. In many cases, there are even refusals of emergency patients due to incomplete identity of the prospective patients that makes them late to receive treatment and eventually died.
Problem also occurs in terms of fund management. In 2014, the total premiums received by BPJS was IDR 41.06 trillion, while the cost of claims incurred was IDR 42.6 trillion. In other words, there is a mismatched claim ratio up to 103.9%. Instead of supporting the state finance, the management of funds undermines. Broadly speaking, such deficit may be caused by several factors, among others, miscalculations in determining the amount of claims, human error due to risky and imprudent investment management, and macroeconomic factors: the decline of Rupiah value, decrease of oil prices and global economic recession that have significant influence on the value of Return on Assets (ROA) managed by BPJS Kesehatan.

BPJS Kesehatan is a Social Security Agency established by the government to provide
Health Security to the public. Healthcare shall include four issues: promotive, preventive, curative and rehabilitative services including medicines and any other medical consumables for medical requirements. Non-medical benefits comprise of advanced health facilities accommodation and ambulance services. 4. In terms of administration and management, MUI considers that there are some elements in BPJS Kesehatan that are forbidden in the Sharia. They include: gambling or speculation, gharar or deception / vagueness of business and investment agreements, and usury. Regarding such elements, MUI recommends to the government to provide BPJS Kesehatan that based on sharia principles. 5. The application of BPJS Kesehatan and BPJS Ketenagakerjaan based upon Sharia principles cannot be made in the near future as it takes time. The design should go through a series of process, namely draft submission to the National Legislation Program (Prolegnas), academic studies, drafting of law with the House of Representatives and the development of integrated information systems infrastructure. The whole process takes one or two years (Asman Abnur, republika.co.id, 4 August 2015). 6. Considering the unavailability of Health Security program based upon sharia, MUI does not issue a prohibition decree at once, but first issues recommendation to give the government the time to establish Sharia-based BPJS Kesehatan.
7. On the other hand, the service of BPJS Kesehatan has not been implemented to the fullest extent. Poor services received by PBI patients are frequently found. The principle of providing adequate health services for the people while supporting the state finance through control of claims is like a double-edged sword that is detrimental to the health service. Eventually, the poor who should be the primary target of JKN becomes the victim. 8. In addition to the service, the management of fund remains less optimal. Mismatch between the ratio of total dues to the amount of the claim indicates that the claims management that the aim of supporting the state finance actually becomes a burden. 9. BPJS Kesehatan manages the dues from participants through investments in various instruments (shares, government and private bonds, mutual funds, direct investments and property), both short term and long term. The management of fund in a conventional financial system has potential elements of gambling (speculation) and usury, which is forbidden in Islam. Management by speculation has potential losses that cannot be accounted for. Even if it gains profit, it is considered as usury.

Recommendation
In its implementation, BPJS Kesehatan encounters many obstacles and disadvantages, but the government should remain developing and improving the quality of service. Following are some recommendations for improving the performance of BPJS Kesehatan: 1. Improvement to the quality of service in the first-level and advanced-level health facilities. Health centers and IHC should be empowered to be able to reach people in remote areas / hinterland. The available health facilities shall be more adequate with a better view: arrangement of the slick and aesthetic front yard of the health centers / IHC, friendly and professional service, optimal medical personnel and comprehensive and ITbased administrative governance. Thus, it is expected that the health centers and integrated health centers can perform their role as a mini hospital and become a symbol and hope of a better life and health for the surrounding community. 2. Optimization of medical personnel through increased prosperity, especially those who served in the area that is lack of modern health facilities. Debriefing of medical and nonmedical expertise is necessary for the medical personnel to interact properly with the communities in which they are sent. Non-medical debriefing shall include the training on leadership, management, communication and understanding of local cultures. 3. In addition to the public health service, BPJS Kesehatan should also be more intensive in performing its preventive-promotive programs. Thus, healthcare will be more optimal for using a more integrated approach. 4. Fund management by conventional investment has some portions that are contrary to the principles of Islam because it contains forbidden elements. Islam teaches that a living from forbidden matters will reduce or even eliminate the blessings received in life (QS 2:168, 65:3 and 74:6). Some people believe that the economic difficulties dealt by the Indonesian people in general resulting from the application of the economic system that is not based on the blessing of Allah SWT. Capitalistic monetary economic system is believed not only by the majority of Muslims but also by many economists all around the world as the cause of the fragility of the current global economic system. Considering the above and in order to meet the aspirations of some people who dream of the safe, clean and blessing welfare, the government needs to implement Sharia-based BPJS Kesehatan as an option for the community.