Stakeholder Analysis Approach: Who Is Authorized to Regulate the National Health Insurance Benefits?

BPJS Kesehatan (Badan Penyelenggara Jaminan Sosial Kesehatan) is an agency that liable to organize the nationalhealth security system in Indonesia. The health services director of BPJS Kesehatan has issued three regulations as an effort to control deficits which currently hit since 2014. The issuance of the regulations reaped controversy over its contents governing the limitation of health benefits that assured by BPJS Kesehatan. Besides that, BPJS Kesehatan has assumed not an authorized institution to issue that policy. This study aims to analyze the issuance of the regulations as a public policy. Data collection is obtained by in-depth interviews with top-level management, literature review and observation. Stakeholder analysis used to find out where the position of BPJS Kesehatan in the national health security system environment is. It will help in carrying out its functions and roles to succeed that program. Through stakeholder analysis is known that the government and the participants are the primary stakeholders of the national health security system. While BPJS Kesehatan is an agent representing the government providing health benefits to the participants. BPJS Kesehatan is not the primary stakeholder but secondary stakeholder, then the determination of any health benefits provided to the participants is an authority of the government rather than BPJS Kesehatan. Inaccuracy in the reading relationship between stakeholders could be at risk for BPJS Kesehatan in making a strategic decision. BPJS Health's lack of understanding of its authority, lead to ineffective decision-making and policies. The ineffectiveness of policies or decisions makes the goals of BPJS Health as providers of national health security programs difficult to achieve. By understanding the limits of its authority, BPJS Kesehatan able to take strategic steps according to the


A. Background
To fulfill the basic needs of healthy and towards the realization of a prosperous society, the Indonesia Government develops a Jaminan Kesehatan Nasional/JKN (national health security system). JKN is a guarantee of health protection, given to participants who have paid premium or paid by the government. JKN is held by Badan Penyelenggara Jaminan Sosial/BPJS Kesehatan.
The principles of JKN are social insurance and equity. Social insurance means that JKN has not based on profit. It has collaboration between the rich and the poor, the healthy and ill, the young and the old, and the high and low risk. JKN aims to ease the burden of each participant to provide maximum protection in health. Equity means that there is a similarity in obtaining services according to their medical needs that are not tied to the amount that has been paid.
Due to the non-profit nature of JKN, BPJS Kesehatan is required to be able to manage fund paid by participants and the government, called Dana Jaminan Sosial/DJS(social security fund), and subsequently develop optimally by considering aspects of liquidity, solvency, prudence, security of funds and adequate results, which in the end can be used as a payment for the benefits of participant and also operating cost of BPJS Kesehatan. But it is not easy.
It has become a serious problem for BPJS Kesehatan. The financial performance of BPJS Kesehatan continues to experience a deficit since 2014, where the cost is greater than the revenue. In 2014 the deficit was Rp.3.3 trillion and continues to grow. The deficit swelled at the end of 2017 to IDR 23 trillion.
To overcome the problem of deficits, BPJS Health has made efforts to control it. On July 25, 2018, the Health Services Director of BPJS Kesehatan has issued 3 regulations which contain the mechanism of health claims based on medical indication.

B. Research Question
The issuance of the Perdirjampelkes No. 2, 3, and 5 Year of 2018 has led to contra response from some elements of society, such as patients, doctors, hospitals, and so on. They consider that the deficit should not affect the quality of health services to the community. There are also those who argue that the Health BPJS should not be authorized to issue the regulation This research has identified two problems which will be discussed further: (1) who is authorized to issue a policy of the Director of Health Services Insurance Number 2, 3 and 5 Year of 2018. (2) how it could have an impact on strategic decision making?

II. LITERATURE REVIEW
A. Public Policy Definition [1] cites several books on the definition of public policy, among others: who interpret public policy as a number of government activities, both directly and through their representatives, which affect the lives of their citizens; Charles L. Cochran and Eloise F. Malone (2010), who define public policy as political decisions to implement programs with the aim of achieving community goals; Thomas Dye (2013) explained more concisely, that public policy is anything that the government chooses to do or not do.
Birkland saw similarities in these definitions, all of which referred to the term "public", which the public itself showed something bigger, both in terms of number of people and interests, compared to private decisions. That is why public policy or the government as the maker, sometimes causes controversy, is frustrating but on the other hand is also important. Because there are so many people and interests that must be accommodated in making these policies.

B. Public Policy Process
The term of policy process refers to the division of a system, from policy ideas to implementation of the policy, and has a positive impact (Birkland, 2018). Generally, the process of making public policy is divided into several stages, or often called "stage models", which consist of: (a) issue emergence, (b) agenda settings, (c) alternative selection, (d) enactment, (e) implementation, (f) evaluation, the results of the evaluation are input for the next stage of the process (back to the beginning).
Many opinions criticize the stage models. The first reason is that the stages are carried out step by step so that the policy ideas do not seem to touch all levels, only focusing on the agenda setting section. The second reason is that the implementation and evaluation stages are separate, even though in fact the evaluation phase will continue to exist throughout the implementation of a running policy. Despite criticism, Birkland still uses the process stages in public policy making, with the aim of facilitating the thinking system so that it helps gain understanding regarding the process.
Birkland simplifies by dividing it into 3 parts, namely: (1) policy design, is a process in which a policy is designed to achieve certain goals. Policy design consists of 3 major themes, namely: problems, goals and efficiency. (2) policy tools, namely a policy instrument made to achieve the objectives. There are elements in determining policy tools, namely political feasibility, availability of resources, behavior assumptions of the target population. (2) implementation.
There is main note in this policy process, that basically the policy design process and its implementation are interrelated and inseparable. This is different from the opinion in general that the implementation process is separate from the initial process. Design and implementation are interrelated because the choices made in the design process will greatly influence how the policy is implemented. Another reason is that the design process will continue to exist as long as the design and implementation of the policy takes place.

C. Stakeholder Analysis
As mentioned earlier, that the process of making public policy is political, there are many interests related to public policy products that will later be produced. Many actors play a role in these public policies, both those that influence and are influenced.
Stakeholders are people affected by an activity or people who can influence the impact of an activity. Stakeholders could be individuals, groups, communities or an institution. The government as a stakeholder cannot be seen as a group of stakeholders. A list of ministries within the government must be made as different groups. Similarly, the central government and local governments are different or separate stakeholder groups.
Stakeholders could be divided into 2 (two) types: (a) primary stakeholders, who receive benefits or are negatively affected by the activity. This term describes people who might depend on the resources, services or areas that are being handled. They often have little choice when facing change, their position is vulnerable. They are the reason why an activity is carried out, in this case the end user. (b) secondary stakeholder, includes all people and institutions that have an interest in resources. They are not goals, but have a main role as tools to implement program.

D. Benefits
Stakeholder analysis is a useful for identifying stakeholder and describing the nature of their stake, roles and interest. Stakeholder analysis helps to: (1) improve the understanding of the needs of those affected problem, (2) reveal how little we know as outsiders, which encourages those who do know to participate (3) identify potential winners and losers (4) reduce, or hopefully remove, potential negative impact (5) identify those who have the right, interest, resources, skills and abilities to take part in (6) identify who should be encourage to take part in the planning process and implementation (7) identify useful alliances which can be built on (8) identify and reduce risk which might involve identifying possible conflicts of interest and explanation among stakeholders so that conflict is avoided.

A. Definition
A case study is one of the methods used in qualitative research. John W. Creswell mentions 5 qualitative research traditions, namely: biography, phenomenology, grounded theory study, case study, and ethnography. The five have similarities which are research carried out in a natural, holistic and deep setting. What is meant by natural is that data is obtained through activities carried out in real-life events, and there is no need for special treatment for both research subjects and research sites. Holistic means that researchers must be able to use all information comprehensively without any information left because the data will get facts or reality.
The difference in a case study with other qualitative methods is that if the biography focuses on individual life, phenomenology focuses on understanding a concept or phenomenon, a grounded theory study focusing on developing a theory, and ethnography focuses on a cultural portrait of an individual or cultural group. The case focuses on the specification of the case in an event whether it covers individuals, cultural groups or a portrait of life.
Case studies to answer the need to understand a complex social phenomenon [2]. To get this understanding, the case study method allows researchers to maintain holistic and meaningful characteristics of real events.
As quoted by Robert Yin (2009), the essence of case studies is to try to illuminate a series of decisions, why the decision was taken, how the decision was implemented, and how the decision was made.
Some characteristics of case studies are: (1) Identification of cases aimed at study; (2) Cases are bound by time and place; (3) Collecting data using various sources of information, so that it can provide a detailed and in-depth description of an event; (4) The researcher will devote time to describing the context of a case.
So that it can be concluded, that case studies are an exploration of a case, which is bound to a time and place, through in-depth data collection involving various sources of information.

B. Data Collection
Data collection in case studies can be collected from various information sources. A lot of data is needed in a case study because researchers try to build a deep picture of a case.
According to [3], case studies are powerful research methods because they combine individual interviews with analysis of records and observations. Researchers will look for preliminary information from financial reports, company data, newspapers, and magazine articles. Then followed by direct observation, generally done with a natural approach, and then combined with interviewing data from the participants of the research object.
After the data obtained is considered complete and perfect, then the researcher will analyze the data. According to Creswell, the analysis in the case study consisted of a detailed description of the case. If a case shows the chronology of an event, then analyzing it requires many data sources as evidence in each phase of the development of the case.
Basically, data analysis is an activity of organizing, sorting, grouping, marking and categorizing by group, so that a finding is obtained to answer the formulation of the problem posed.
Case study analysis requires a good strategy because researchers will intersect with a lot of data. According to Yin, the type of analysis of the data can be a holistic analysis and intertwined analysis. A holistic analysis is an analysis of the whole case, while intertwined analysis is an analysis for specific, unique and extreme cases.
The data analysis phase is the most important stage in each study because in this stage important information in the form of research findings will be obtained.

A. Stakeholder Analysis
Regarding who is authorized to issue a policy on limiting benefits, it is first important to determine who are the stakeholders in the implementation of the JKN program. Next, the analysis is related to the roles and interests of these stakeholders, then it would be known who has the authority to regulate health benefits which are the substance of the Perdirjampelkes policy.
There are 4 (four) stages need to be done to get stakeholder mapping, namely: a. Identifying by listing groups, organizations and people relevant to the implementation of the JKN program. b. Analyzing stakeholders based on their perspectives, roles, interests, and attachments to the implementation of the JKN program. c. Mapping by visualizing relationships between stakeholders, objectives and other stakeholders. d. Prioritize by making stakeholder ratings and identifying problems posed.

1) Identifying Stakeholder
The identification of JKN program stakeholders is carried out by referring to the legislation that regulates JKN programs in Indonesia. The results of the identification are presented in Table 1.
There were 25 stakeholders has been identified by researchers. The government as the party that guarantees the health needs of the Indonesian people in the first place. The second place is the party affected by the implementation of JKN program, the participants. In this case, the participants are the entire Indonesian community. Government and participants as the primary stakeholders are the main objectives of implementing a program or work.
While 23 other stakeholders are secondary stakeholders. They act as a tool to implement the program or activity. Although the majority of stakeholders are secondary types, it does not mean that they do not have a main role and influence on determining JKN's fruitfulness. This is what will be analyzed further in the stages of stakeholder analysis.

2) Stakeholder Analysis
Regarding the level of role, there are 3 (three) categories. Stakeholders with high, medium and low levels of role. First, researchers categorize the parties included in the 4 main elements of administering JKN as high-level stakeholders. That includes regulators, participants, organizers and implementers such as health facilities.
Second, stakeholders with moderate levels of role. The researcher categorizes it with considerations of the following causes: a. Part of organizing JKN excludes the 4 main elements (regulators, participants, organizers, health facilities). b. Has substitution (doctors, medical personnel, pharmaceutical companies, medical devices companies). c. Under the higher authority, such as an employer.
Finally, the categorization of stakeholders at a low level of role, such as professional associations, media and non-governmental organizations (NGOs).
In the stakeholder analysis, the researcher also analyzed how much influence the stakeholders had in the JKN program. It would be used to measure the importance and strong position of stakeholders in the program, making it easier to prioritize stakeholders.
The researcher adapted from the criteria in BSR (2018) which was used to analyze the level of influence of stakeholders, namely: a. Contribution (value), do stakeholders have information, advice or expertise about problems that can benefit the company? b. Legitimacy, how legitimate are stakeholder claims to be involved? c. Willingness to be involved, how much do stakeholders want to be involved? d. Influence, how much influence do stakeholders have? e. The need for involvement, if this stakeholder is not involved can fail the program? Regarding the media, in normal conditions the media has a low influence, but in this situation the media has a big influence in bringing opinion to public. So, researchers put the media at a moderate level of influence. BPJS Kesehatan could use the media's support in providing good publication to the public. Related to the JKN program, the performance, and as a clarification of the issues that are detrimental to the implementation of JKN.
The involvement of DJSN and DPR is also very important. The DJSN provide recommendations to the President and Parliament to support BPJS Kesehatan in terms of the budget.

3) Stakeholder Mapping
Next is a stakeholder mapping. The results of the mapping are illustrated in Figure 1.

4) Stakeholder Prioritization
After knowing where the stakeholders are in mapping, BPJS Kesehatan should treat the stakeholders based on priority as follows: • High importance high influence Manage closely. BPJS Kesehatan have to fully engage these people, and make the greatest efforts to satisfy them. • High importance low influence Keep satisfied. Work sufficiently for these stakeholders, to maintain their satisfaction. If too much interaction would lead to saturation. • Low importance high influence Keep informed. Provide adequate information to these stakeholders, talk to them to ensure that no major problems arise. • Low importance low influence Monitor. Monitoring the movements of these stakeholders, does not saturate excessive information.
Priority in managing stakeholders is needed because it is not practical if the company must be involved with all stakeholder groups with the same level of intensity at all times. Companies need to act strategically and clearly with whom they involved and why they should be involved. This have to be done at the beginning of the program, because it can help the next stages of work run effectively and efficiently, including assisting in the right decision making and solution.

B. Stakeholder Relationship in JKN Program
It could be seen that basically in the implementation of JKN there are 2 (two) main parties: the Government and Participants. The Government and JKN Participants act as subjects in this JKN program, where the Government is the party that gives "promises" to guarantee and provide health protection to every citizen who is a JKN participant, and the Participant is the party that receives "promises" for the protection of health.
In the implementation, the Government then appointed BPJS Kesehatan to organize and ensure the JKN program went well. BPJS Kesehatan here acts as an agent of the Government, which is basically have obligation to the Government. The relationship that arises here is between the Government and the Health BPJS.
Related to the tasks that must be carried out by BPJS Health, it is listed in the BPJS Law articles 10 and 11, namely: registering participants, receiving non-PBI contributions and paying contributions from the Government, managing the DJS, managing data, paying health benefits and providing information JKN. Then the authority of BPJS Kesehatan in the JKN program is more administrative, not strategic.