During the past few years, there is a growing momentum toward the Universal Health Coverage (UHC) at the global level. UHC, or sometimes called universal coverage, is defined by the World Health Organization as ensuring that all people obtain the health services they need of sufficient quality to be effective, without suffering financial hardship when paying for them .
According to the report of the Sustainable Development Solutions Network (SDSN), by 2030, every country should be well positioned to ensure universal health coverage for all citizens at every stage of life, with particular emphasis on the provision of comprehensive and affordable primary health services delivered through a well-resourced health system .
—Since the 2005 resolution, universal health coverage has been increasingly seen as a central plank in the articulation of new health-sector strategies in countries. While middle-income countries, including Thailand and many in Latin America, have paved the way, countries such as China, India, Indonesia, and Vietnam are quickly gaining steam — politically and technically — to achieve universal health coverage .
The Universal Health Coverage embodies three related objectives, the first is equity in access to health services, the second is good quality of health services and last but least, financial-risk protection. Universal Coverage is firmly based on the WHO constitution of 1948 declaring health as a fundamental human right. In Indonesia, Universal Health Coverage is relevant to the 1945 constitution or Undang-Undang Dasar 1945 (UUD 45), article 28. Health is a basic right of every individual and all citizens are entitled to health services including the poor. The passing of laws (Undang – Undang No. 40 tahun 20014) about SJSN (Sistem Jaminan Sosial Nasional) is a strong evidence that government and relevant stakeholders has a major commitment to realize social welfare for all people [4,5].
Indonesia has reformed its national health insurance scheme. The new national health insurance scheme started on January 1st, 2014. In the new system, there is only one insurer institution, National Social Security Agency (Badan Penyelenggara Jaminan Sosial/BPJS), a public agency established to implement the social security program. Based on Undang - Undang No. 24/2011 BPJS will replace a number of institutions of social security such as health insurance agency Perseroan Terbatas Asuransi Kesehatan Indonesia changed to BPJS Kesehatan (National Health Security Agency) and social security institutions on employment social security, Perseroan Terbatas Jaminan Sosial Tenaga Kerja also converted into BPJS Ketenagakerjaan (National Employment Security Agency). The government hopes eventually the entire Indonesia citizen can become a participant of social security system.
The new national health insurance scheme pays all claims based on package system called Indonesia Case-Based Groups (INA-CBGs). Hospitals will receive payments based on INA CBGs rate which is the average amount spent by the group for a diagnosis. The amount of the bill for the diagnosis had been organized and endorsed by the Minister of Health Regulation No. 64 Year 2016 on the Amendment Regulation of the Minister of Health No. 52 Year 2016 on Standard Rates in the Implementation of Health Care Insurance Program.
INA CBGs is a continuation of application INA DRG whose licenses expire at the end of 2010 and continues to be improved. The application system adopts a more refined DRGs, which is a type of prospective payment, system of payments to health service facility, either a hospital or a doctor in the amount set before a service is provided without regard to the action taken or the duration of treatment. It is expected the hospital should be able to manage costs effectively in every provision of health care to patients.
From some research journals that are used as reference, the implementation of the INA CBGs system with the prospective payment can provide a positive impact on the financial performance at public hospital, when the hospital could reduce the cost of treatment is not effective.
—Implementation of INA CBGs payment system cannot escape the impact of the Financial hospital. The results showed that it had a positive impact on the financial aspects, namely the income hospitals can already covered all needs and operational expenditure with income derived from the implementation of the INA-CBGs, including from purchasing the drug has begun to be resolved, the food inpatients, maintenance is already entered. 
In order to analyse whether hospital under PPS (Prospective Payment System) combined with DRG Systems are more cost-efficient than hospitals under RPS (Retrospective Payment System). 
However, there was one article saying that the public hospital in Indonesia only has about 5% of accounting and finance personnel who are competent so that they have the wrong perception about the hospital's surplus in this era JKN .
Based on some of the issues that use for this systematic review, the aim of this article is to describe the implementation of the INA CBGs system and its effect on public hospitals' financial performance. It is expected to help public hospitals in identifying and anticipating problems in the INA CBGs system implementation.
This systematic review is using PRISMA-P protocols. There are two steps of searching strategies in this review.
First, articles were searched by keywords Public Hospital Finance Performance, —Universal Health Coverage Indonesia in online database Proquest. For articles in Indonesia, keywords—INA CBGs and — kinerja keuangan rumah sakit umum were used in Portal Garuda and Google Scholar. Second, reference list Regulation of Indonesia Health Minister about INA CBGs policy then assessed based on title. If those hand-searched articles were suitable, they were included for review. Searching process is done within time frame 1 January 2010 – 16 November 2016, with English and Indonesian language restriction.
There were 24.975 articles found from all search engines and 3 articles hand searched. The first restriction is filtered by year, period of 2010 – 2016, and by choosing academic journal articles, dissertation or thesis because most of Indonesian researchers are in the form of the latter. The remaining 2422 articles were screened by adding second keyword—DRG Systems for Public Hospital Finance Performance and—Universal Health Coverage Indonesia. After that 337 articles were screened by title and next 51 articles were screened by abstract. Fifteen (15) articles deemed relevant were then searched for full-text and assessed for its eligibility. Articles excluded about UHC but not offensive about DRGs/INA CBGs, then included have aims or conclusions in accordance with the aims of this systematic review. Final 9 articles were included for qualitative synthesis. The selection process could be seen in Figure 1.
3. Results and Discussion
Universal health coverage in Indonesia
Universal Health Coverage in Indonesia is called National Health Insurance or Jaminan Kesehatan Nasional (JKN) which is a form of government commitment to the implementation of the health security of the Indonesian people. JKN which developed in Indonesia is part of the Social Security System National (Sistem Jaminan Sosial Nasional/SJSN) which organized through the mechanism of the Mandatory Social Health Insurance based on Law No. 40 of 2004 about Sistem Jaminan Sosial Nasional. The goal is for all Indonesia's population is protected in the insurance system, so that they can meet the basic needs of public health.
According to JKN socialization handbook in the national social security system, the National Health Insurance is managed by the principle:
• Mutual cooperation. With all participants the obligation to pay contributions, there will be the principle of mutual cooperation where the healthy help the sick, the rich help the poor
• Non-Profit. Social Security Agency is not allowed to make a profit. The funds collected from the public is a trust fund, so that the development should be utilized for the benefit of participants.
• Openness, cautions, accountability, efficiency, and effectiveness. This management principle underlies the whole management of funds derived from contributions of participants and the results of development
• Portability. This principle ensures that even the participants settle in a new place or a new job, as long as the territory of the Republic of Indonesia will still be able to use their rights as participants JKN
• Participation is mandatory. All people become participants so that they can be protected. Application remains adjusted to the economic capacity of the people and government as well as the feasibility of the implementation of the program.
• Funds Mandate. Funds collected from participants' contributions are funds deposited by administering body to be managed as well for the sake of the interests of the participants.
• The results of the management of social security funds are used entirely for program development and for the great interests of participants.
Evaluation of JKN in public hospitals can be seen from the aspect of membership, aspects of health care services and tariffs, several problems are found in this transition period, including the discovery of restriction of services to any type of health insurance, third ward who often have queuing and type of drugs given only contained in the National Formulary only. However the internal policies set by the hospital management that still refer to the principles of mutual aid of JKN, is a solution that remain underserved patient without causing any damages to the hospital's financial and avoid up coding and fraud .
The prospective payment
There are two methods of payment used for hospital that is retrospective and prospective payment method. Retrospective payment recompenses healthcare providers based on their actual charges. With a retrospective payment, a provider will treat a patient and submit an itemized bill to an insurance company detailing the services rendered. The primary benefit of retrospective payment is that they may allow patients to receive more attentive because there is no limitation of approved treatment plans for providers, they can adjust their services to meet patients' needs individually .
On the other hand, prospective payment works by assigning a fixed payment rate to specific treatments. While these rates might change over time because of factors such as inflation, they are not adjusted to accommodate patients individually. Under prospective payment, a healthcare provider will always receive the same payment for providing the same specific type of treatment.
The previous researches obtained that Prospective Payment System intends to motivate providers to deliver patient's health care effectively and efficiently. This approach assumes that the degree of care required (case intensity) is a function of the patient's diagnosis and the payment to the provider should be based on the intensity of care .
As it was shown in article —Does prospective payment increase hospital (in)efficiency? Evidence from the Swiss hospital, the effectiveness of prospective payment in reducing hospital cost inefficiency are found, particularly with payment per patient case. Prospective payment is more effective in terms of cost reduction than the retrospective alternative .
One of the prospective payment approach is the case-mix group system. A case mix group (CMG) is used for inpatient classification system to group patients with similar characteristics together. This provides a basis for describing the types of patients or other health care provider treatments (its case mix). The development of case-mix system is diagnosis-related group system.
The INA-CBGs system
The Diagnosis-Related Groups (DRG) were developed in 1982 by Robert Fetter from Yale School of Management and John D. Thomson from Yale School of Public Health. The system is used to help a hospital manager controlling the physician's behaviour.
A Diagnosis-Related Group (DRG) is a statistical system of classifying any inpatient stay into groups for payment purpose. The DRG classification system divides possible diagnoses into more than 20 major body systems and subdivides them into almost 500 groups for the purpose of Medicare reimbursement. Although DRG-based payment systems are now mainly understood as a reimbursement mechanism, the original purpose was to enable performance comparisons across hospitals . DRG classification system is grouped according to principal diagnosis, type of treatment, age, surgery, and discharge status .
Diagnosis Related Groups (DRGs) are one of the most striking prospective payment systems around the world in recent years, since implementation of universal health coverage, which booming in the world, uses a system of claims based on DRG systems . This system allows hospital managers to determine more accurately the type of resources to treat a particular group and to predict the cost of the treatment. Similar to the case mix group, this system is applied as an insurance payment system. In this system, patients are classified based on the groups of diagnosis, then that groups are coded by using a DRG software. Next, the diagnosis codes are translated into the payment that must be compensated by insurers.
In Indonesia, Diagnosis-Related Group system was implemented in 2010, called the INA-DRG's. In this system, hospitals were paid a set fee for treating patients in a single INA-DRG category, regardless of the actual cost of care for the individual. The INA-DRGs represented groupings diagnosis of the ICD-9-CM codes into a more manageable number of particular patient categories. ICD-9-CM is the International Classification of Diseases. In 2011, Indonesia changed the name of the system into the INA-CBG's system. However, the principle of the system is very similar to the old INA-DRG's.
According to health ministry regulation, Peraturan Menteri Kesehatan No 64 tahun 2016 tentang Perubahan Peraturan Menteri Kesehatan No 52 tahun 2016 tentang Standard Tarif Pelayanan Kesehatan dalam Penyelenggaraan Program Jaminan Kesehatan, hospitals' health services rate includes INA-CBGs rate and Non-INA-CBGs rate.
INA-CBGs rate is package rates that include all the components of hospital resources used in the service of both medical and non-medical, the rates will not be affected by the days of treatment. On the other hand, Non-INA-CBGs rate is rates for some specific services such as health equipment, chemotherapy drugs, chronic disease drugs, Continuous Ambulatory Peritoneal Dialysis (CAPD) and Positron Emission Tomography (PET) scans. The method of determining cost using the INA-CBG's system implemented by the hospital and the payer (government represented by BPJS) no longer specify the charges based on the details of the services provided but based on several important data, namely:
Hospital finance performance
Hospital must provide good quality health care to make sure the goals of universal health coverage could be achieved efficiently and effectively. In order to be able to give good quality services, hospitals need to be financially healthy. Financing capability represent a vital element of competitive advantage . The hospitals' revenue is collected from services given to their patients. To serve their patients, hospitals spent money for materials, human resources and equipment. In order to be able to survive and make some development, hospitals need to cover all costs they spend. Some surplus is also expected to improve the services. A Surplus is the differences between revenues and costs in a same accounting period. A surplus is one way to figure out a hospital financial performance .
Public hospital is an institution under the supervision of local governments engaged in the public sector by giving health services. Health services provided by hospitals common areas are social and economic with more priority health care for the community. Public hospital as one government agency should be able to provide accountable both financially and non-financially local government and the community as service users.
In this type of organization, public hospitals can be managed as a business organization with flexibility in financial management based on productivity and effectiveness . The key points of accrual accounting include the following:
• Income (revenue) is earned when services are provided.
• Expenses are the costs of providing material and service to the parties that receive the service, when the service is being provided.
• The timing of when an organization gets paid for the services they renders, or when they pay for the materials and services they purchase, it is irrelevant to the accrual accounting method. Cash flow is a separate issue for consideration. (building, equipment and other fixed assets) are
• Costs of fixed assets (building, equipment and other fixed assets) are recognized by allocating their costs over their estimated useful life.
• The accurate measurement of profits or losses depends upon the correct matching of services provided and the costs of providing these services.
Most of journals that are used as references say that there is a significant difference of INA-CBGs rates in each hospital. Some journals state that an increase in the financial performance of the hospital when using INA CBGs system, as in —Hospital Financial Performance in the Indonesian National Health Insurance Era. The research compares average claim in hospitals under hospital rate and INA-CBG's rate for the period of January-April 2014 and found in each severity level of cases and classes, INA-CBGs claims is higher than hospital rate claims. In both outpatient cases and inpatient cases, the claims under the JKN are higher than under the hospitals' rate.
Another article, Perbandingan Biaya Riil Dengan Tarif Paket INA CBGs dan Analisis Faktor Yang Mempengaruhi Biaya Riil Pada Pasien Diabetes Melitus Rawat Inap Jamkesmas di RSUP Dr. Sardjito Yogyakarta, shows that the average value of hospital charges for treatment patients with the severity level I are much lower compared with rates of INA package CBG's. In contrast, patients with severity level II and III has the average value of the hospitals charges that are larger than INA rates CBG's. Because of diversity of comorbid types experienced by patients with diabetes mellitus, the cost of needed drugs tend to give greater impact on total costs of treatment. One way to overcome the difference in costs is making a clinical-pathway which contain detailed essential steps to handle the patients, it consists of protocol therapy and the standard care ranging from admission to hospital discharge .
This new payment system can increase hospital efficiency so it will improve the financial performance as written in —Does prospective payment increase hospital (in)efficiency? Evidence from the Swiss hospital sector journal. If combined with DRG classification, it is found to have maximum efficiency-enhancing effect .
There are still many challenges faced by public hospitals in this transitional period, such as a decrease in average length of stay and no increase in hospital admissions if they could not control the treatment cost, patient could not choose the type of service, the drug given must be listed on national formularium (Formularium Nasional/Fornas), human resources which are not capable in participating in this application system changes. However, the manager of the hospital should be able to address these challenges by conducting innovation using information system and technology, increasing hospital facilities to meet public demand, enhancing of hospital physical development, adding new types of services and confirming that the medical record is complete, timely and accurate.
In the National Health Insurance (JKN) system, there is only one method of payment. It is a package system and based on the INA-CBG's rate. The system change influences the hospitals' financial performance. The prospective payment (INA-CBGs systems) generates more financially surplus generally, more effective in terms of cost reduction through the elimination of non-value adding activities.
Each public hospital management must have a strategy and innovation to improve the quality of service so they can compete with other hospitals and financial performance can be improved in universal health coverage era.