Special Health Insurance as an Inclusive Social Protection Program for People with Disabilities

The article illustrated the intervention of government within poverty alleviation through inclusive social protection for People With Disabilities (PWDs). By studying Special Health Insurance (SHI) program in the Special Region of Yogyakarta, it assumes that the existence of the program has occurred from a rights-based perspective in inclusive health configuration. It is based on the case study approach that aimed to explain the SHI program implementation to extend coverage to all PWDs. The main result provided the SHI-integrated scheme program can be more inclusively and accessible for PWDs than former social protection programs in Indonesia. It has finally provided the best practice for the social protection program as a social policy tool focusing on disability.


A. Introduction
Poverty is a multidimensional issue. It can be relied on structural failure or created by the individual itself, or as a part of both of them.
Moreover, "disability is also both as a cause and a consequence of poverty" (Pinilla-Roncancio, 2015: 1005. "Disability is the umbrella term for impairments, activity limitations, and participation restrictions, referring to the negative aspects of the interaction between an individual (with a health condition) and that individual's contextual factors They also face social exclusion, stigma, and often find lack the social support, education, and legal right to access functions of the community or national level (DFID, 2000). Consequently, the government must implement strategies to face these problems.
Also, it has been ordered by the United Nations through the result of the Convention on the Right of Persons with Disabilities (CRPD). On the CRPD's report, some declarations specifically address the urgency of poverty reduction and establish the equal inclusion of disabled people in all development and global health efforts as a right (UN, 2006). Furthermore, a multi-sectoral and integral policy should be implemented to reduce the risk of disability and to prevent disabled people and their families from becoming multidimensional poor (Pinilla-Roncancio, 2015).
Over the last decade, a variety of literature to examine links between disability and social protection has begun progressively, especially in Europe and America, but it is not equal to Africa and Asia (Walsham, Kuper, Banks, & Blanchet, 2018). Nevertheless, various social protection has also emerged as "an important tool of social policy to overcome vulnerability, poverty, and social exclusion in developing countries" (Palmer, 2013: 139). As a part of developing countries, Indonesia's government has also implemented a social protection program into one of the national poverty reduction strategies which are However, the implementation of BPJS-Kesehatan is still covered only a small minority of disabled people living in poverty. It is caused by "the lack of systematic identification and minimization of physical and social barriers for PWDs and also for support or access to the corresponding services" (Mleinek & Davis, 2012: 41-42). "Disability inclusion has not been included in the design or implementation of these programs and little is known about whether they meet the needs of PWDs" (Rohwarder, 2014, p. 7 (Kim, 2015;Halimatusa'diyah, 2015;Walsham, Kuper, Banks, & Blanchet, 2018). Almost the majority unaddressed in development studies and disability and social policy literature (Barrientos & Hulme, 2009).
Moreover, Indonesia's case within SHI in DIYtoo lack to be discussed in the national academic agenda and literature, even in International scope.
It is still mostly unexplored; then this article will be intended to cover the unsolved problem.

Research design
This article discusses the intervention of government within poverty alleviation through inclusive social protection for PWDs in Indonesia. By taking the empirical study on the SHI program implemented in DIY, this illustrates increasingly the urgent of disability issues until the government has to implement social protection program specifically for PWDs. The linkage studies between disability and social protection are employed as a conceptual boundary of this study. This article applied a qualitative case study method. Also, it is appropriate with the aims of this article to see the dynamics process of SHI implementation which is "to shape the activity, as well as the experiencing and the interpretation of the activity" within this case (Stake, 2006: 2).

Data collection method
This article is also a result of research based on a field in February 2018. Primary data obtained through two phases. First, directly observed on the location which SHI implemented. It is intended "to highlight the unique use of empirical information as a basis for drawing causal inferences in qualitative research" (Blatter & Haverland, 2012: 20). Second, in-depth interviewed of 28 key informants who have involvement within provide the case study investigator with insights into a matter and also can initiate access to corroboratory or contrary sources of evidence" (Yin, 2009: 107). To enrich the discussion of this study, the secondary data also used by collecting and reviewing some literature that relates to disability and social protection issues, such as previous research articles, newspapers, and reports.

Data analysis technique
To interpret and process the data, then this article also used the explanation building technique. According to Yin (2009), this technique aims to analyze the case study data by building an explanation about the case. It is in line with the aims of this article to reflect critical insights into the public policy process especially on social protection programs for PWDs. By using this technique, these critical insights that resulted "can lead to recommendations for future policy actions" (Yin, 2009: 141 Social-Health Insurance (Jaminan Kesehatan Sosial); and Regional Health Insurance (Jaminan Kesehatan Daerah), has still many problems.
According to SIGAB's report (2013), there are four main problems with those social protection programs: (1) Only a minority of the total of PWDs in DIY who covered by social protection programs. It has caused difficulties in ensuring the participation of PWDs in the insurance scheme.
(2) The existing insurance scheme does not cover transportation services for as appropriate assistive devices, long-term therapy, and medicines that need to be consumed in the long term without limitation in funding.
In sum, what is needed is a health insurance program that is "able to see the problems and overcome them with policy and scheme insurance that are accessible, tangible, and flexible" to ensure the fulfillment of the need for health services for PWDs in DIY (SIGAB, 2013: 1).To respond to these problems, the DIY government has ratified Governor Regulation No. 51, 2013, which has concerned with the system of SHI Implementation. This regulation is the guidance of all matters relating to the implementation of SHI. This program provides benefits for PWDs through the provision of tools for health, essential health services, advanced health services, and social, economic, and educational rehabilitation. Officially, the implementation of SHI began in 2014.

b. Special Health Insurance scheme and its mechanism
SHI program is one of the Universal Health Insurance (Jaminan

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Whereas curative health services refer to the provision of benefits for PWDs in the form of treatment or healing measures, consisting of (1) Outpatient care, including examinations, treatments, health consultations, supporting diagnostic laboratories, blood transfusions, and forensics; (2) Hospitalization, including examinations, treatments, health consultations, pre-hospital inpatient cares, emergency rooms, diagnostic support laboratories, intensive and non-intensive hospitalization, blood transfusions, and forensics. Finally, rehabilitative health services refer to the provision of benefits to help the recovery of PWDs with post-treatment in hospitals, such as home care for PWDs with severe illness.
To be able to access the benefit claims from the SHI program, the participants only have to show their membership card to the health service institutions that on a partnership with Bapel Jamkesos. There are Community Health Center (Pusat Kesehatan Masyarakat), family doctors, clinics, and referral hospitals as a service provider of SHI. However, if anyone of the PWDs is still not yet covered and has no membership card, they can still access buffer health insurance services through the Community Health Center.

Discussion a. The link between social protection and disability
Social protection is an umbrella term that covers schemes to address risk, alleviate poverty, and enhance living conditions (Barrientos, 2011). It encompasses social assistance, social insurance, social and health care, and labor market interventions (Barrientos & Hulme, 2009

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Over the past decades, literature that discussed specifically social protection and disability issues had been developing increasingly. It occurred not only in high-income countries, yet also in developing countries or low-and middle-income countries. In those countries, there is a stronger focus on "poverty alleviation and social and economic development using risk management, also often through a combination of income transfers and interventions to support access to basic services" (Walsham, Kuper, Banks, & Blanchet, 2018: 2). Besides, social protection which specifically takes in PWDs insurance is "an increasingly important component of strategies for alleviating poverty in many low-and middleincome countries" (Banks, et al., 2016;Walsham, Kuper, Banks, & Blanchet, 2018).
Indonesia, as a middle-income country in the Asia region, has also been conducting inclusive social protection for PWDs through BPJS-Kesehatan as one of the national poverty alleviation strategies. However, BPJS-Kesehatan implementation still has many problems to cover PWDs, such as "limited and overlapping coverage and mixed objectives" (Mleinek & Davis, 2012: 4). On the other hand, the discussion of PWDs in Indonesia has been blowing up not only in the academic area but also at the grassroots level. By the time, disability issues in Indonesia are inclined to the right-based approach. Thus, circumstance implicates to suggest terminology change from disability to diffability. The term of diffability (different ability) or diffabel (people who differently able) has emerged in DIY and is considered more appropriate for respecting differences and recognizing the abilities of people with impairments (Suharto, Kuipers, & Dorsett, 2016).
Indonesia, especially in DIY, has recognized diffability terminology almost in all public services, such as on traffic lanes and various facilities of public space. In this region, the term disability "related to second-class citizens, gives rise to discrimination and stigma, and demeaning to people with impairments" (Amundson, 2000;Purwanta, 2004). Whereas the corresponding term of diffability may "enable people with impairments and direct service providers to better express the uniqueness of each person" (Fakih, 2004;Suharto, Kuipers, & Dorsett, 2016).
For those reasons, the weaknesses of BPJS-Kesehatan within cover PWDs and the implication of the term diffability, then SHI program become a form into the effort of the DIY government to arrange inclusive social protection for PWDs specifically. Also, as a strategy to alleviate poverty in DIY through health improvement for PWDs as a significant vulnerable group.

b. National health insurance critiqued
BPJS-Kesehatan is one of Indonesia's national health insurance which authorized in 2014. There is also BPJS-Ketenagakerjaan (focuses on employment) arranged by the government simultaneously. While the BPJS-Kesehatan covers the entire of the inhabitant, especially for civil servants; pension recipients of civil servants and army and police; veterans; independence pioneers and their families; and other business entities or ordinary people, whereas the BPJS-Ketenagakerjaan covers labors and other people who related to employment (Wisnu, 2012;Yuda, 2018). Based on two BPJS's social protection programs aim to poverty alleviation based on universal coverage method.
In the context of disability, BPJS-Kesehatan is more related to PWDs. It considers to PWDs as the poorest and most socially and economically marginalized, so they cannot pay for the cost of contribution. Therefore, the government believes that inclusive social protection policies will contribute significantly to poverty alleviation (Mleinek & Davis, 2012). Moreover, social protection in term of the BPJS-Kesehatan has also "promoted the right of PWDs and ensured equal opportunities about education at all levels, skills development, work, equality of treatment, rehabilitation, social assistance, and social welfare" (Mleinek & Davis, 2012: 18).
Not getting loose from all of these, there is an important study that has carried out a detailed evaluation of disability inclusion in Indonesia's social protection programs. This evaluation study was conducted by Mleinek and Davis in 2012 as a form of collaboration with the Indonesian National Planning Development Agency, and the results have become important literature in looking at the conditions of social protection programs in Indonesia. On these programs, only one social assistance program is specifically targeted at PWDs. It is the "social protection for a severe-class disability which provides a monthly grant of IDR. 300,000 (USD 21.34)" (Mleinek & Davis, 2012: 22). It provides that only severeclass disability who linked to full dependency on others. It has meant that social protection programs in Indonesia only reach a small proportion of the PWDs who have a right to this assistance (Mleinek & Davis, 2012).
Grounded on problems, Mleinek and Davis (2012) suggested some common challenges for operating social protection programs for PWDs in Indonesia. First, the lack of data and understanding of the need lead to expensive and unreliable targeting. Second, a proper targeting system requires to follow up assessment and monitoring, which are also costly. Third, the benefit is sometimes worth less than the cost of traveling to receive it. Fourth, many poor PWDs who lived in remote areas are unaware of social protection schemes or cannot access them. According to this, the article provides and discusses how SHI as an inclusive social protection program has overcome those challenges.

c. Integrated Special Health Insurance: A scheme to overcome the obstacles
To respond to the result of the Mleinek  year. This scheme was also conducted in a sub-district in each of its districts in turn. Therefore this scheme may enable the SHI program to obtain PWDs data in detail and certainly can understand the needs. It can also alleviate the cost of traveling to receive the services, even provide more opportunities for PWDs in remote areas to access services, and also enable affordable assessment and monitoring system properly. Finally, it can alleviate the cost of SHI implementation and avoid unreliable targeting.
The success of this scheme is also evidenced by a large number of PWDs covered by SHI, which from the last report states that in 2017 has covered 26,825 PWDs from all PWDs in DIY totaling 28,758 PWDs (Jamkesos, 2017a). It was reaffirmed by the results of a study in 2017 regarding the claim verification service index that received a perfect score (Jamkesos, 2017b), and a guarantee service index that achieved perfect scores as well (Jamkesos, 2017c). Therefore, these data provide that the SHI program through integrated schemes can more inclusively and accessible for people with disabilities than former social protection programs in Indonesia.

D. Conclusion
This article discusses disability and social protection issues by taking focus on the SHI program in the Special Region of Yogyakarta, Indonesia. Also, it is a form of intervention of government within the poverty alleviation strategy by increasing the health-quality of PWDs as a significant vulnerable group.
The result of this study shows that inclusive social protection for PWDs has been increasingly implemented in Indonesia, even though belonging to developing countries. This statement is demonstrated by the emergence of the SHI program built by two main things. First, there are an increasing number of PWDs and the variety of their problems after the earthquake disaster. Second, the weaknesses of former social protection programs within coverage PWDs and the implication of the term diffability. Those circumstances eventually deliver to establish social protection more inclusively and specifically for PWDs.