!Universal!Health!Coverage!in!ASEAN!Countries! and!Its ... 8! UHC!IN!ASEAN!Countries! 8! Country Pop coverag e Health service coverage Financial protection* Malaysia 100% PHC services

The Ministry of Health Republic of Indonesia

Keynote speech:

Universal Health Coverage in ASEAN Countries and Its Road Map for Indonesia

Vice Ministry of Health

Prof dr Ali Ghufron MukB Msc, Phd, “InternaBonal Conference: on Health Equity in Asia: ReproducBve Health /

Disaster and Health Management to Achieve MDGs”

University of Indonesia, 12 December 2012

PresentaCon Outline 1.  Equity and Health Financing System 2.  UHC In ASEAN Countries 5.  NaConal Priority Agenda : Towards UHC 6.  PreparaCon of Social Security Law

implementaCon and challenges a)  Roadmap of membership and Premium

EsCmaCon b)  Roadmap benefit package, health services &

subsidy Scheme 5. Health Human Resources Conclussion

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

12/12/2012 Indonesia Vice MoH: UHC & Challenges 2

1. EQUITY AND HEALTH FINANCING SYSTEM

Indonesia Vice MoH: UHC & Challenges 3


12/12/2012


Resources (Man, Facility,

Equipment, Farmacy)

Health Services

Health Status

Stewardship

WHO World Health Report, 2000

Responsiveness

Financing Fairness/ Equity

Equity in Health Financing System As part of National Health System

Health System Performance

Goal Performance

FuncCons the system Perform ObjecCve of the system

Policy on Health Financing


HEALTH REFORM

HEALTH FINANCING REFORM

• EQUITY (Egalitarian,/Libertarian?) • EFECTIVE & EFFICIENT • TRANSPARANT & ACCOUNTABLE

Sick Health

Universal Health Coverage

Promotive.Preventive Maternal and Child Health, Nutrition , NCD, CD, Disaster


KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Health Service System &

Finance

Public Health& Goods Private Goods

Health Insurance (Individual Health)

Community Health

Healthy Individu and DTPK Sick Individu

Reffe

rral sy

stem

6 Indonesia Vice MoH: UHC & Challenges 12/12/2012

Clinics; Laboratory, inpaCent care

Integrated health post;PHN, sanitaCion;, health promoCon; school health, school dental health; comm dental health

Premium BPJS

Key HCF indicator in ASEAN Countries 2007

THE, %

GDP

GGHE, % THE

Priv. HE, % of THE

GGHE, %

government

expenditure

External, % of THE

SHI, %

THE

OOP, % THE

THE per capita US$

THE Per capita

PPP int. $

Malaysia 4.4 44.4 55.6 6.9 0.0 0.4 40.7 307.2 604.4 Thailand 3.7 73.2 26.8 13.1 0.3 7.1 19.2 136.5 285.7 Indonesia 2.2 54.5 45.5 6.2 1.7 8.7 30.1 41.8 81.0 Philippines 3.9 34.7 65.3 6.7 1.3 7.7 54.7 62.6 130.2 Viet Nam 7.1 39.3 60.7 8.7 1.6 12.7 54.8 58.3 182.7 Lao DPR 4.0 18.9 81.1 3.7 14.5 2.3 61.7 26.9 83.9 Cambodia 5.9 29.0 71.0 11.2 16.4 0.0 60.1 36.8 108.1 Low income 5.3 41.9 58.1 8.7 17.5 4.6 48.3 26.8 67.0 Lower middle Income 4.3 42.4 57.6 7.9 1.0 15.8 52.1 80.2 181.0 Upper middle Income 6.4 55.2 44.8 9.4 0.2 21.0 30.9 487.9 757.0 High Income 11.2 61.3 38.7 17.2 0.0 25.6 14.0 4,405.2 4,145.0 GLOBAL 9.7 59.6 40.4 15.4 0.2 24.6 17.7 802.3 862.5

8

UHC IN ASEAN Countries

8

Country Pop coverage

Health service coverage Financial protection*

Malaysia 100% PHC services focus on MNCH. But long waiting time, and limited number of family physicians; Survey reports 62% of ambulatory care was provided by private clinics

40.7%

Thailand 98% Comprehensive benefit package, free at point of service for all three public insurance schemes

19.2%

Indonesia 48% Good policy intention but low per capita government subsidy for the poor of US$ 6 per year

30.1%

Philippines 76% High level of co-payment, 54% of the bill are reimbursed 54.7%

Vietnam 54.8% Benefit package comprehensive but substantial level of co-payment, 5-20% of medical bills

54.8%

Lao PDR 7.7% Low level of government funding support to the poor results in a small service package

61.7%

Cambodia 24% The poor covered by the health equity fund but the scope and quality of care provided at government health facilities are limited

60.1%

Financial protecCon * measured by OOP as % of THE, 2007

9

Fiscal Space and the Government Health Exp and UHC

9

Figure 2 Fiscal space in the context of insurance coverage and general government expenditure Note: The size of the spheres indicate the size of the fiscal space as measured by tax revenues as percentage of gross domestic product. GGHE=general government expenditure. THE=total health expenditure.

HRH Availability vs GDP per capita

DensiCes of doctors, nurses, and midwives, per 1,000 populaCon

ProducCon capacity of doctors, nurses, and midwives, per 100,000 populaCon

13

ProducCon capacity of doctors, nurses, and midwives

Community Health Status

National Goals

NaBonal Health System

NaBonal Long-‐Term Plan

Development

Current conditions

Community health status not optimally yet

Basic problem on health development:

STRATEGIC ENVIRONMENT: (IdeologiY PolitiC, EConomiY, Soscal Culture and

national security)

GLOBAL, REGIONAL, NATIONAL, LOCAL

Opportunity and Barrier

NATIONAL PARADIGM:

(PANCASILA, UUD 1945,WASANTARA,TANNAS,)

(Law no 36/2009 Health, Law No 17/2007 RPJPN)

Develpment Based on Health

Healthy & Productive People

-‐ Law is needed to be sincronized

-‐ Comm behaviour not optimal

-‐ Environment issue

-‐ Food & Nutrition need protection

-‐ Access to public service not o[timal yet

-‐ HRD need improvement

NATIONAL HEALTH SYSTEM AND SOCIAL SECURITY IN INDONESIA HEALTH DEVELOPMENT PLAN

Sumber: Rancangan Perpres R.I ttg Sistem Kesehatan Nasional 2012 (12-‐4-‐2012) Modifikasi dari Presentasi Hapsoro



Private Goods (SJSN) Law no

40/2004

Public Goods

Indonesia MoH Vission: 8 NaConal Focus & 7 Priority ReformaCon

8 NATIONAL FOCUS PRIORITY FOR HEALTH

1.  Improving maternal health and fam planning

2.  Comm nutrition improvement 3.  CD and NCD control,

environmental health 4.  Fulfiling Health HR

5.  Improving Availbility, affordability, safety, quality, food and farmacys

6.  Jamkesmas (health insurance for the poor)

7.  Community development, disaster and crisis management

8.  Improving primary, secondary and tertiary health care

7 PRIORITY HEALTH REFORMATION 1. HEALTH INSURANCE 2. Health services in very

remote area (DTPK) 3. Availability of farmacy,

health equipment in every health facility

4. Birocration Reform 5. Bantuan Operasional

Kesehatan (BOK) 6. Overcoming districts

Health problem (PDBK) 7. Indonesia World class

Hospital

RPJMN 2010 – 2014 (National Middle Development Plan)

MDGS 2015

VISSION : Self Reliant Healthy People within a just health care system


Universal Coverage 2014


Social Security Law & The ImplementaBon

12/12/2012 Indonesia Vice MoH: UHC & Challenges

Law No 40 Year 2004: NaBonal Social Security

System (SJSN):

Universal Health Coverage

Law No 24 Year 2011: Secial Security Carrier

(BPJS) -‐ 5 Program à the 1st program implementaBon is HEALTH -‐  Execute based on humanity, benefit, & social fairness

To provide basic life need nesessarily for

all member

16

Law No 17 Year 2010 : NaBonal Development Middle Plan (RPJMN)

MoH Indonesia was planned to achieve UHC

in the 2014


ImplementaCon NaConal Social Security System (SJSN) for Health Program KEMENTERIAN KESEHATAN

REPUBLIK INDONESIA

Regulator

BPJS Kesehatan

Health Insurance Member

Health Facility Searching services

Provide Services

RegulaCon of health system (refferral, dll)

RegulaCon (stadarizaCon) h service quality; farmacy,

medical supplies

RegulaCon of Health Service Tarriff and Cost-‐

sharing

Public Health & Goods Program Handling

Handling health services in very remote area (DTPK), dll

Kend

ali Biaya & kualitas Yankes

Government

17 Indonesia Vice MoH: UHC & Challenges

Refferral system Non member; who

finally become member

12/12/2012

2. PREPARATION OF SOCIAL SECURITY LAW IMPLEMENTATION AND CHALLENGES



12/12/2012

ROADMAP: a.   MEMBERSHIP & PREMIUM,

b.   HEALTH SERVICES, BENEFIT PACKAGE,

Financing

Membership

Benefit Package

Sumber: WHO, The World Health Report. Health System Financing; the Path to Universal Coverage, WHO, 2010, p.12



2A. ROADMAP MEMBERSHIP AND PREMIUM ESTIMATION



12/12/2012

Health insurance

Compulsory Population

Non poor

Poor

JK Free

choice

Government

Iuran/premi

Iuran/premiuj

Premium Subsidy Receiver (PBI ):

Membership of Social Health Insurance : Towards UHC



Membership Roadmap towards Universal Health Coverage

20% 50% 75% 100%

20% 50% 75% 100%

10% 30% 50% 70% 100% 100%

`Company (Perusahaan) 2014 2015 2016 2017 2018 2019

Big company 20% 50% 75% 100% Middle company 20% 50% 75% 100% Small co 10% 30% 50% 70% 100% Micro co. 10% 25% 40% 60% 80% 100%

2012 2013 2014 2015 2016 2017 2018 2019

Transforming JPK Jamsostek, Jamkesmas, PJKMU to BPJS Kesehatan

Membership ExtenCon of big company, midle, smal and micro Sejng up Systen

Procedure of Membership and Premium

Companies Mapping and socializaBon

Membership saBsfacBon measurement periodically, twice a year

IntegraCon member of Jamkesda/PJKMU Askes comercial to BPJS Kesehatan

Transforming TNI/POLRI membership to BPJS Kesehatan

Review of Benefit Package and Health Services Refinement

Sinkronizing Membership Data of JPK Jamsostek, Jamkesmas and

Askes PNS/Sosial – using ciBzen ID

CiCzen has been cover with several scheme 148,2 million

124,3 million member be managed by BPJS Health Program

50,07 million managed by non BPJS

Kesehatan

257,5 million (all ciCzen) manage by BPJS Keesehatan

Membership SaCsfacCon level 85%

AcCviCes : TransformaCon, IntegraCon, extenCon

B S K

73,8 million has not yet being member

90,4 million has not yet being member

President RegulaCon of TNI POLRI OperaConal Health Support

96,4 million subsidy 2,5 subsidy for

people without ID KEMENTERIAN KESEHATAN REPUBLIK INDONESIA


Health Insurance Coverage, Year 2011


Jamkesmas, 76,400,000 ,

32%

Govt employ & Fam,

19,564,265 , 8% Jamostek &

Fam, 5,183,479 , 2%

Jamkesda, 31,866,892 ,

13%

Private Insurance,

2,856,539 , 1%

Company , 15,351,532 , 7%

No Insurance, 87,055,320 ,

37%


2014 Membership PredicCon BPJS Health Program, 2014 membership % Premium subsidy receiver w/ complete ID 96.400.000 39,34% Premium subsidy receiver w/o ID 2.500.000 1,02% Govt emply & Fam 19.363.208 7,90% Jamsostek & Fam 6.075.200 2,48% sub-‐ Total 124.338.408 50,75%

Non BPJS Health Program 0,00% Jamkesda 31.866.390 45,13% Company provide insurance 15.351.532 21,74% Private insurance 2.856.539 4,05% Sub-‐Total 50.074.461 70,92% PopulaCon with health insurance 174.412.869 121,66% PopulaCon without health insurance 70.608.831 100,00% PopulaCon 245.021.700 221,66% 12/12/2012 Indonesia Vice MoH: UHC & Challenges 24


Membership (arCcle 20, SJSN)

•  Member: is every single ciCzen who has paid premium or been paid by Government

•  Family member have right to receive benefit package of health services

•  Every member can registered all other family member with addiConal premium


Will be differenBated b/w subsidy receiver and non subsidy

Premium


2B. ROADMAP: BENEFIT PACKAGE, HEALTH SERVICES



12/12/2012


Medical Benefit Package

Based on Medical Need :

1.  Health Service covered 2.  Health Service limited

3.  H Service with cost-‐sharing 4.  Health Service NOT covered

NON Medical Benefit Package

•  It was agreed: At least similar to current benefit

Benefit Package in UHC


Benefit Package and Premium

2012 2013 2014 2015 2016 2017 2018 2019

Consensus Benefit package;

stated on President

RegulaCon, by Nov 2011

Jamkes President RegulaCon adjusted

Various Benefit of various scheme, not yet based on medical needs

-‐ Benefit Package standart is

comprehensive as medical need

-‐ Differ in hospitality

Premium : DifferenBate between

PBI from Non PBI

Similar Benefit package

Premium RelaCvely equal to economic

level for all populaCon

AcCviCes

Various premium

Review periodically on sallry, premium, benefit package effecCveness, payment among region

UClizaCon Review to ensure eficiency, reduce moral hazard, improve saCsfacCon of membership, human resources and health facility

Jamkes President RegulaCon adjusted

Premium agreed for PBI : Rp. 22.201) Premium for Non PBI sCll on going discussion : 5% of sallary 3% -‐ 2%;



Health Service Aspect

2012 2013 2014 2015 2016 2017 2018 2019 AcCon plan of health facility, HHR, referral

health system and infrastructure

Periodically Review of health facility eligibility, credensialing, Quality of care, and payment and tarrif economically adjusted

ImplementaCon, monitoring and referral health refinement and uClizaCon review

•  Health facility distribusCon not opCmum; various quality of services, referral helth system not opCmum yet; payment system not opCmum yet

-‐  health facility extenCon and

development incl human health resources

-‐  EvaluasCon and determined payment

• Jumlah mencukupi •  Distribusi merata •  Sistem rujukan berfungsi opCmal

•  Pembayaran dengan cara

prospekCf dan harga keekonomian untuk semua penduduk

AcBviBes

Implementasi roadmap: facilty development, HR, referral system, and other infrastructure.

Designing Standart and payment

procedure, and health facility

ImplementaCon payment mechanism : KapitaCon, INA-‐CBGs; including serta penyesuaian payment and tarrif economically adjusted every 2 years



Referral Health System

•  The referral health system has been renewd à Ministry of Health RegulaCon No 1 year 2012

•  The social health insurance will use the referral health system based on the severity of disease

•  General disease can be served by primary health services and should not be serve at upper health services facilty



Referral Health System

TerCary Care

Secondary Care

Primary Care


Hospital type A/ B Hospital with sub-‐spesialist doctor

Hospital type D/C Hospital type D: Hospital with GP & 4 basicc specialist (Obgyn, pediaCcs, surgery, internist)

Health Centers, Private Clinics, private doctors


Water & Electricity Health Center without Water 852 Health Center with no 24 hours electricity 4.160 Source: PODES, 2010

Source: RIFASKES, 2011


5385, 64%

2026, 24%

828, 10% 198, 2%

Health Center condiBon

Good

slight damage

mild damage

severe damage


The DistribuCon of Hospital &Health Center (Puskesmas)

Beds per Provinsi KEMENTERIAN KESEHATAN

REPUBLIK INDONESIA

(20,000)

(15,000)

(10,000)

(5,000)

-‐

5,000

10,000

DKI JAK

ARTA

SUMUT

DIY

SULU

T

NTT

SULSEL

NAD

KALTIM

MAL

UKU

SUMBA

R

B A L I

KEPR

I

SULTEN

G

PAPU

A

IRJABA

R

MAL

UT

GORO

NTA

LO

BABE

L

BENGK

ULU

KALBAR

SULBAR

J A M

B I

R I A

U

JATENG

KALTEN

G

SULTRA

NTB

KALSEL

SUMSEL

LAMPU

NG

JATIM

BANTEN

JABA

R

Beds Disparity

CondiCon Per-‐April 2012


Primary Care Policy adjustment (1)


Type Urban Type Standart (Rural)

Type DTPK (very remote)

Adjustment of Main funcBon of Primary Care: •  How is the Level of services at Primary Care Urban/Rural-‐Standart /DTPK

HR Standart adjustment: How is HR for Primary care Urban type different to Standart /DTPK type

Adjustment of Input – Proces – Output of Primary Care : How is Input – Proces -‐ Output of Primary care Urban type different to Standart /DTPK

InformaBon Technology : How is the ervices system, referral among Primary Care, Standart tarrif, etc


Secondary – TerCery Care Policy


Hospital Type A,B

Hospital TypeC,D

RS Pratama?

Main FuncBon : How is main funcBon of every Type hos[ital? Govenment hosp? Private hosp?

Standart HR & equipment: How is Standart of HR & equipment in every refferral services ??

Adjustment Input – Proses -‐ Output: How is Input – Proses -‐ Output Secondary/TerBery Care?

How is System Informasi Technologi:

Private hospital type

Clinic SpesialisBc?

GP / Spesialis individual PracBce?


RSD MAJALENGKA

RS Pertamina Klayan

RSUD ARJAWINANGUN

RS TANGKIL

RS MITRA PLUMBON

RSUD WALED

RS GUNUNG DJATI

RST CIREMAI

RS PELABUHAN

PINTU TOL YANG ADA

Industri Rotan

Penghasil MIGAS Pertamina

Anjung MIGAS Lepas pantai

Industri kue

RS PUTRA BAHAGIA

RS SUMBER WARAS

RS MEDIMAS

RSIA SUMBER KASIH

Industri BaCk Trusmi

RSD INDRAMAYU

RSD KUNINGAN

RSD MAJALENGKA

Mapping model Regionalization referral system using GIS approach:

At Ciayumajakuning Jabar

36 Indonesia Vice MoH: UHC & Challenges


12/12/2012

3. HEALTH HUMAN RESOURCES



Development & Empowerment of HHR in relaBon with Health Development & HHR Stndard

HHR Health Resourc

es

Comm Empowement

Health Effort

Comm Health Status

1.  AdvocaCon, coord, strengthening plan

2.  Need Pllanning 3.  Establishing Prof Std &

competencies 4.  EsCmaCng types,

amoubt,

1.  Educ based on HS standard 2.  Determine std of educ &

competences 3.  Educ InsCtuConal

regulaCon 4.  Inst educ AccrediataCon

Social , Religion & Culture

Resources & HRR Quality Monitor

HHR Planning

Deploying DiistribuBon HRR

Health Development Blue

Print IT

1.  SelecCon, recruitment, deploy

2.  CompensaCon 3.  Carrier dev 4.  Training 5.  External HRR

Health Environment



Deploying DiistribuBon HHR

HRR Development & Empowerment

4.Prof ethic

3.Educ Standard

2.Prof Standard 1.Service

Standard

Economic Environment

R & D

Health Management

Culture Changes Phisical & Biological Envi

PoliCcs & Law Envi

Health Facility

Fundamen of Moral Humanity

Science & Technology

1.  DirecCon, strengthening RegulaCon support,

1.  serCficaCon, registraCon, 2.  Compentency exam 3.  IT support 4.  Resources support

Fufilling the HR Gap Strategy

1.  Medical Doctor SpesialiCes Program (PPDS) 2.  Program Doctor Plus 3.  Non Permanent Employer (PTT) 4.  Individual special assigment (Residen & D-‐3

Nakes) 5.  Team special assigment (team based)-‐à

contracCng & contracCng out 6.  Revising recruitment and posing regulaCon

including carrier path



4. CONCLUSSION



Conclusion (1)

•  Ensuring access to health preven2on and health care services -‐ especially for some par2cular groups like newborn baby, under-‐5 children, and pregnant mother will be fostering the achievements of MDGs.

•  Empowering the community in improving health and sanita2on which will result to the improvement of health status of the society



Conclussion (2) KEMENTERIAN KESEHATAN

REPUBLIK INDONESIA

Indonesia is going to achieve UHC •  The Indonesia Law No (40/2004; 17/2010; 24/2011) à support to achieve Universal Health Coverage

•  End of 2011 has already reached 63% of populaCon or 142 million people have health insurance with different type of insurance and benefit package



REPUBLIK INDONESIA

•  Propose benefit package has been agreed: – Will be divided into Medical benefit package and Non Medical benefit package

– Medical benefit package will be based on the Medical NEED

– Medical benefit package no less than on-‐going current benefit package

•  There are 4 category of Medical Benefit Package has been agreed: 1) Health Service covered; 2) Health Service limited; 3) H Service with cost-‐sharing; 4) Health Service NOT covered



REPUBLIK INDONESIA

•  Agreed that the premium will be differenCated between PBI (subsidy for the poor) and Non PBI (non subsidy for non poor)

•  The amount of Premium is sCll undergoing discussion


THANK YOU TERIMA KASIH MATUR NUWUN



Documents

!Universal!Health!Coverage!in!ASEAN!Countries! and!Its ... 8! UHC!IN!ASEAN!Countries! 8! Country Pop coverag e Health service coverage Financial protection* Malaysia 100% PHC services