Kanal Pengetahuan | Reportase Kongres InaHEA ke 3 Materi Prof Ghufron
INDONESIA ON ITS PATH TO UNIVERSAL
HEALTH COVERAGE: A SUCCESS STORY
AND ITS CHALLENGES
PRESENTED BY
Prof. dr. Ali Ghufron Mukti, MSc, PhD
Jogjakarta, 30
July 2016
TABLE OF CONTENT
1
SITUATION OF UHC IN INDONESIA A DECADE AGO
2
EVOLUTION OF UHC IN INDONESIA: MAJOR MILESTONES
3
OUTLOOK INTO THE FUTURE
4
FACTORS OF SUCCESS AND IT CHALLENGES (HUMAN
RESOURCES)
5
RECOMMENDATIONS
Financing
Benefit
Package
Membership
Source: WHO, T he World Health Report.
Health System Financing; the Path to Universal
Coverage, WHO, 2010, p.12
3
1. SITUATION OF UHC IN INDONESIA A DECADE AGO
Population Coverage 11% : 22 Million by various
schemes
Financial Protection : heavy out of pocket 70%
Poor and near poor people : Social Safety Net for
36 Million people with high cost sharing and the
rest have to pay (the Poor is Forbidden to get
sick)
4
4
COMPARISON OF UHC ACHIEVEMENT IN ASEAN COUNTRIES AND BANGLADESH
Country
(3)
Pop
cover
age
People
covered
(Mill)
Malaysia
100%
28
28
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%
67
69
Comprehensive benefit package, free at point of
service for all three public insurance schemes
19.2%
Indonesia
68%
163
240
Good policy intention but low per capita
government subsidy for the poor of US$ 6 per year
30.1%
Philippines
76%
70
93
High level of co-payment, 54% of the bill are
reimbursed
54.7%
Vietnam
54.8
%
48
87.8
Benefit package comprehensive but substantial
level of co-payment, 5-20% of medical bills
54.8%
Lao PDR
7.7%
0.5
6
Low level of government funding support to the
poor results in a small service package
61.7%
Cambodia
24%
3
14
The poor covered by the health equity fund but the
scope and quality of care provided at government
health facilities are limited
60.1%
?
(?)
148.7
??? (cannot find the data)
Bangladesh
Pop
(Mill)
(2) Health service coverage
*) WHO
(1)
Financial
protection*
66%
*) WHO 2009
Financial protection * measured by OOP as % of THE, 2007
5
5
2. EVOLUTION OF UHC IN INDONESIA: MAJOR MILESTONES
1969: Civil Servant Benefit Scheme was introduced (ASKES)
Early 1970s: Health Card
Early 1990s, Managed Care System was Introduced (JPKM).
1992: Social Security for Formal Sector Employees (JAMSOSTEK)
After the economic crisis in 1998, a social safety net program for
health was implemented
On October 19, 2004, Indonesia enacted the National Social Security
System Law
2005: The Health Insurance for the Poor (covers 76,4 Million)
Program was introduced
2005: Local government health insurance initiatives grow
2008: Implementing prospective provider payment system (INA DRGs
and Capitation)
In 2010 Jampersal (for delivery) was introduced
2011: Act on Health Insurance Carriers (BPJS -> merging various
schemes into one scheme and be implemented in January 2014)
INDONESIA’S ROLE AND POSITIONING IN
ADVOCATING UHC AT GLOBAL LEVEL
President of RI as co-Chair in developing draft
of Post-MDGs Agenda
I do esia’s role i WHA
Indonesia as a member of Foreign Policy and
Global Health Initiative UN UHC Resolution
draft
Ministerial Level Meeting Organized by WHO
and WORLD BANK in Geneva
Comparison of UHC in ASEAN Countries and
Bangladesh
3. OUTLOOK INTO THE FUTURE
Government
Kendali Biaya & kualitas Yankes
BPJS Kesehatan
Regulator
Health Insurance
Member
Provide Services
Searching services
Refferral system
Non member; who
finally become member
Health
Facility
Regulation of health
system (refferral, dll)
Regulation (stadarization) h
service quality; farmacy,
medical supplies
Regulation of Health Service
Tarriff and Cost-sharing
Public Health & Goods
Program Handling
Handling health services in very
remote area (DTPK), dll
KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
Membership Roadmap towards
Universal Health Coverage
96,4 million subsidy
2,5 subsidy for
people without ID
124,3 million member
be managed by BPJS
Health Program
Citizen has been cover with
several scheme 148,2 million
90,4 million has not yet
being member
2012
50,07 million
managed by non BPJS
Kesehatan
73,8 million has not
yet being member
2013
2014
Setting up
Systenm
Procedure of
Membership
and Premium
Big company
Middle company
Small co
Micro co.
2014
2015
2016
2017
2018
20%
20%
10%
10%
50%
50%
30%
25%
75%
75%
50%
40%
100%
100%
70%
60%
100%
80%
2016
2017
257,5 million
(all citizen) manage
by BPJS Keesehatan
2019
Membership
Satisfaction level 85%
100%
2018
2019
Integration member of Jamkesda/PJKMU Askes comercial to BPJS Kesehatan
Transforming
TNI/POLRI
membership to
BPJS Kesehatan
Membership Extention of big company, midle, smal and micro
Companies
Mapping and
socialization
Sinkronizing Membership Data of
JPK Jamsostek, Jamkesmas and
Askes PNS/Sosial – using citizen ID
11/10/2012
`Company
(Perusahaan)
2015
Transforming JPK Jamsostek, Jamkesmas, PT
Askes to BPJS Kesehatan
President
Regulation of TNI
POLRI Operational
Health Support
Activities :
Transformation, Integration, extention
B
S
K
20%
50%
75%
100%
20%
50%
75%
100%
10%
30%
50%
70%
100%
100%
Membership satisfaction measurement periodically, twice a year
Review of Benefit Package and Health Services Refinement
Vice MoH of Indonesia
10
REFERRAL HEALTH SYSTEM
Tertiary
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,
pediatics, surgery, internist)
Health Centers, Private Clinics,
private doctors
11
4. CRITICAL SUCCESS FACTORS
Leadership
Political committment (Sustainable Budget and
Establishing Laws and Regulations)
Creating and facilitating critical mass of experts and
stakeholders interested in Social Health Insurance (e.g. GIZ
etc)
Technical capacity in system design and implementation
Learning experience in running different schemes of the
past
Preparing and Enhancing Health Infrastructures (HRH)
Education, Advocacy and awareness of various
stakeholders
CHALLENGES OF HUMAN RESOURCES FOR HEALTH
HRH AVAILABILITY VS GDP PER
CAPITA
PRODUCTION CAPACITY OF DOCTORS, NURSES,
AND MIDWIVES, PER 100,000 POPULATION
June 2015
April 2015
GHWA Board:
Synthesis Paper
WHO / WB / USAID:
Measurement
UNGA HighSummit
Level
Meeting:
Post-2015
development
agenda
adopted
UNGA 70th
session.
Global Health
& Foreign
Policy Group
Sep 2015
Feb 2015
Global Strategy HRH: Workforce 2030
WHO Global Strategy HRH:
Development and
consultation
Jun
Jul
Aug
Sep
WHO
Regional
Committee
Meetings:
+
Technical
consultations
Oct
Nov
Dec
GSHRH v1
Mission Briefing
Jan
Feb
Mar
WHO Executive
Board
Apr
May
May 2016
May
Oct 2015
Apr
August- Oct 2015
Mar
May 2015
Feb
Feb- 2015
Jan
2016
Jan 2016
2015
Adoption at 69th
World Health
Assembly
Investing in new health workforce employment opportunities may also add broader
socio-economic
value to the
andwith
contribute toDraft
the &
implementation
for the 2030
Development
andeconomy
consultation
final versions and
Agenda forMember
Sustainable
Development
States
and other stakeholders
accompanying resolution
United Nations General Assembly resolution A/RES/70/183
December 2015
Workforce 2030
Q: What are the health
workforce implications
of the SDGs + UHC?
Q. What evidence can
we draw upon?
Global Strategy HRH: Workforce 2030
1. Optimize the existing workforce in pursuit of the
Sustainable Development Goals and UHC (e.g.
education, employment, retention)
2. Anticipate future workforce requirements by 2030
and plan the necessary changes (e.g. a fit for
purpose, needs-based workforce)
3. Strengthen individual and institutional capacity to
manage HRH policy, planning and implementation
(e.g. migration and regulation)
4. Strengthen the data, evidence and knowledge for
cost-effective policy decisions (e.g. National Health
Workforce Accounts)
Health labour market: Need, supply and demand
+
SDG Index
4.45 (midwives, nurses and
physicians) per 1,000
population
Insufficient
supply to meet
demand
(demand based
shortage)
+
Need
Supply
Demand
+
Needsbased
shortage
+
+
Insufficient demand to
employ workforce to
meet needs
+
Sources 1 World Bank, publication forthcoming; 2 World Health Organization, background paper to
the Global Strategy on HRH (draft)
Health labour market: emerging scenarios
Global economy is
projected to create
around 40 million
new health sector
jobs by 20301
++++++++++++++++++++
+++++
High income
++++++++++
+++++++
++++++++++++++++++++
++++++++++++++++++++
++++++++++++++++++++
+++++++++++++++++
Upper-middle income
+++++++-
++++++++++++++++++++
++++++++++++++++++++
++++++++
Lower-middle income
++++++++++
++++++++++
+++++++
Low income
++++++++++
++++++++++
+++++
Projected shortage of 18 million
health workers to achieve and
sustain the SDGs2
+
1 World Bank, publication forthcoming . 2 Cometto et al, World Health Organization
Decent work, inclusive economic growth, UHC
Health as a cost disease
and a drag on the
economy
Health as a multiplier
for inclusive economic
growth
Baumol (1967)
Growth in health sector
employment without
increase in productivity
could constrain economic
growth (data from USA)
Hartwig (2008 and 2011)
Confirmation of Baumol
hypothesis (data from OECD
countries)
Arcand et al., World Bank (In press, 2016)
– larger dataset; data from low-,
middle- and high-income countries
– establishes positive and
significant growth inducing effect
of health sector employment;
multiplier effect on other
economic sectors
– magnitude of effect greater than
in other recognized growth sectors
Workforce 0 0: Source of e ploy e t…. USA
Workforce 2030: Source of future employment (USA)
U.S Bureau of Labour Statistics:
http://www.bls.gov/emp/ep_table_103.htm
Workforce 0 0: Source of future e ploy e t…..
Source:
Human Development Report 2015: Work for Human Development
5. RECOMMENDATIONS FOR COUNTRY’S STRATEGY
STRONG LEADERSHIP AND POLITICAL COMMITMENT
FACILITATING COMPARATIVE STUDY FOR POLICY
MAKERS
CREATING CRITICAL MASS
EDUCATION, ADVOCACY AND PUBLIC DEBATE
LAWS AND REGULATIONS
START TO COVER CIVIL SERVANT, THE POOR AND
FORMAL SECTOR
BENEFIT PACKAGE
Publikasi Internasional
Posisi Indonesia dalam kancah publikasi internasional (general)
Indonesia
26
Publikasi Terindeks Scopus s/d 2014
Seminar Professorship
27
28
HEALTH COVERAGE: A SUCCESS STORY
AND ITS CHALLENGES
PRESENTED BY
Prof. dr. Ali Ghufron Mukti, MSc, PhD
Jogjakarta, 30
July 2016
TABLE OF CONTENT
1
SITUATION OF UHC IN INDONESIA A DECADE AGO
2
EVOLUTION OF UHC IN INDONESIA: MAJOR MILESTONES
3
OUTLOOK INTO THE FUTURE
4
FACTORS OF SUCCESS AND IT CHALLENGES (HUMAN
RESOURCES)
5
RECOMMENDATIONS
Financing
Benefit
Package
Membership
Source: WHO, T he World Health Report.
Health System Financing; the Path to Universal
Coverage, WHO, 2010, p.12
3
1. SITUATION OF UHC IN INDONESIA A DECADE AGO
Population Coverage 11% : 22 Million by various
schemes
Financial Protection : heavy out of pocket 70%
Poor and near poor people : Social Safety Net for
36 Million people with high cost sharing and the
rest have to pay (the Poor is Forbidden to get
sick)
4
4
COMPARISON OF UHC ACHIEVEMENT IN ASEAN COUNTRIES AND BANGLADESH
Country
(3)
Pop
cover
age
People
covered
(Mill)
Malaysia
100%
28
28
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%
67
69
Comprehensive benefit package, free at point of
service for all three public insurance schemes
19.2%
Indonesia
68%
163
240
Good policy intention but low per capita
government subsidy for the poor of US$ 6 per year
30.1%
Philippines
76%
70
93
High level of co-payment, 54% of the bill are
reimbursed
54.7%
Vietnam
54.8
%
48
87.8
Benefit package comprehensive but substantial
level of co-payment, 5-20% of medical bills
54.8%
Lao PDR
7.7%
0.5
6
Low level of government funding support to the
poor results in a small service package
61.7%
Cambodia
24%
3
14
The poor covered by the health equity fund but the
scope and quality of care provided at government
health facilities are limited
60.1%
?
(?)
148.7
??? (cannot find the data)
Bangladesh
Pop
(Mill)
(2) Health service coverage
*) WHO
(1)
Financial
protection*
66%
*) WHO 2009
Financial protection * measured by OOP as % of THE, 2007
5
5
2. EVOLUTION OF UHC IN INDONESIA: MAJOR MILESTONES
1969: Civil Servant Benefit Scheme was introduced (ASKES)
Early 1970s: Health Card
Early 1990s, Managed Care System was Introduced (JPKM).
1992: Social Security for Formal Sector Employees (JAMSOSTEK)
After the economic crisis in 1998, a social safety net program for
health was implemented
On October 19, 2004, Indonesia enacted the National Social Security
System Law
2005: The Health Insurance for the Poor (covers 76,4 Million)
Program was introduced
2005: Local government health insurance initiatives grow
2008: Implementing prospective provider payment system (INA DRGs
and Capitation)
In 2010 Jampersal (for delivery) was introduced
2011: Act on Health Insurance Carriers (BPJS -> merging various
schemes into one scheme and be implemented in January 2014)
INDONESIA’S ROLE AND POSITIONING IN
ADVOCATING UHC AT GLOBAL LEVEL
President of RI as co-Chair in developing draft
of Post-MDGs Agenda
I do esia’s role i WHA
Indonesia as a member of Foreign Policy and
Global Health Initiative UN UHC Resolution
draft
Ministerial Level Meeting Organized by WHO
and WORLD BANK in Geneva
Comparison of UHC in ASEAN Countries and
Bangladesh
3. OUTLOOK INTO THE FUTURE
Government
Kendali Biaya & kualitas Yankes
BPJS Kesehatan
Regulator
Health Insurance
Member
Provide Services
Searching services
Refferral system
Non member; who
finally become member
Health
Facility
Regulation of health
system (refferral, dll)
Regulation (stadarization) h
service quality; farmacy,
medical supplies
Regulation of Health Service
Tarriff and Cost-sharing
Public Health & Goods
Program Handling
Handling health services in very
remote area (DTPK), dll
KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
Membership Roadmap towards
Universal Health Coverage
96,4 million subsidy
2,5 subsidy for
people without ID
124,3 million member
be managed by BPJS
Health Program
Citizen has been cover with
several scheme 148,2 million
90,4 million has not yet
being member
2012
50,07 million
managed by non BPJS
Kesehatan
73,8 million has not
yet being member
2013
2014
Setting up
Systenm
Procedure of
Membership
and Premium
Big company
Middle company
Small co
Micro co.
2014
2015
2016
2017
2018
20%
20%
10%
10%
50%
50%
30%
25%
75%
75%
50%
40%
100%
100%
70%
60%
100%
80%
2016
2017
257,5 million
(all citizen) manage
by BPJS Keesehatan
2019
Membership
Satisfaction level 85%
100%
2018
2019
Integration member of Jamkesda/PJKMU Askes comercial to BPJS Kesehatan
Transforming
TNI/POLRI
membership to
BPJS Kesehatan
Membership Extention of big company, midle, smal and micro
Companies
Mapping and
socialization
Sinkronizing Membership Data of
JPK Jamsostek, Jamkesmas and
Askes PNS/Sosial – using citizen ID
11/10/2012
`Company
(Perusahaan)
2015
Transforming JPK Jamsostek, Jamkesmas, PT
Askes to BPJS Kesehatan
President
Regulation of TNI
POLRI Operational
Health Support
Activities :
Transformation, Integration, extention
B
S
K
20%
50%
75%
100%
20%
50%
75%
100%
10%
30%
50%
70%
100%
100%
Membership satisfaction measurement periodically, twice a year
Review of Benefit Package and Health Services Refinement
Vice MoH of Indonesia
10
REFERRAL HEALTH SYSTEM
Tertiary
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,
pediatics, surgery, internist)
Health Centers, Private Clinics,
private doctors
11
4. CRITICAL SUCCESS FACTORS
Leadership
Political committment (Sustainable Budget and
Establishing Laws and Regulations)
Creating and facilitating critical mass of experts and
stakeholders interested in Social Health Insurance (e.g. GIZ
etc)
Technical capacity in system design and implementation
Learning experience in running different schemes of the
past
Preparing and Enhancing Health Infrastructures (HRH)
Education, Advocacy and awareness of various
stakeholders
CHALLENGES OF HUMAN RESOURCES FOR HEALTH
HRH AVAILABILITY VS GDP PER
CAPITA
PRODUCTION CAPACITY OF DOCTORS, NURSES,
AND MIDWIVES, PER 100,000 POPULATION
June 2015
April 2015
GHWA Board:
Synthesis Paper
WHO / WB / USAID:
Measurement
UNGA HighSummit
Level
Meeting:
Post-2015
development
agenda
adopted
UNGA 70th
session.
Global Health
& Foreign
Policy Group
Sep 2015
Feb 2015
Global Strategy HRH: Workforce 2030
WHO Global Strategy HRH:
Development and
consultation
Jun
Jul
Aug
Sep
WHO
Regional
Committee
Meetings:
+
Technical
consultations
Oct
Nov
Dec
GSHRH v1
Mission Briefing
Jan
Feb
Mar
WHO Executive
Board
Apr
May
May 2016
May
Oct 2015
Apr
August- Oct 2015
Mar
May 2015
Feb
Feb- 2015
Jan
2016
Jan 2016
2015
Adoption at 69th
World Health
Assembly
Investing in new health workforce employment opportunities may also add broader
socio-economic
value to the
andwith
contribute toDraft
the &
implementation
for the 2030
Development
andeconomy
consultation
final versions and
Agenda forMember
Sustainable
Development
States
and other stakeholders
accompanying resolution
United Nations General Assembly resolution A/RES/70/183
December 2015
Workforce 2030
Q: What are the health
workforce implications
of the SDGs + UHC?
Q. What evidence can
we draw upon?
Global Strategy HRH: Workforce 2030
1. Optimize the existing workforce in pursuit of the
Sustainable Development Goals and UHC (e.g.
education, employment, retention)
2. Anticipate future workforce requirements by 2030
and plan the necessary changes (e.g. a fit for
purpose, needs-based workforce)
3. Strengthen individual and institutional capacity to
manage HRH policy, planning and implementation
(e.g. migration and regulation)
4. Strengthen the data, evidence and knowledge for
cost-effective policy decisions (e.g. National Health
Workforce Accounts)
Health labour market: Need, supply and demand
+
SDG Index
4.45 (midwives, nurses and
physicians) per 1,000
population
Insufficient
supply to meet
demand
(demand based
shortage)
+
Need
Supply
Demand
+
Needsbased
shortage
+
+
Insufficient demand to
employ workforce to
meet needs
+
Sources 1 World Bank, publication forthcoming; 2 World Health Organization, background paper to
the Global Strategy on HRH (draft)
Health labour market: emerging scenarios
Global economy is
projected to create
around 40 million
new health sector
jobs by 20301
++++++++++++++++++++
+++++
High income
++++++++++
+++++++
++++++++++++++++++++
++++++++++++++++++++
++++++++++++++++++++
+++++++++++++++++
Upper-middle income
+++++++-
++++++++++++++++++++
++++++++++++++++++++
++++++++
Lower-middle income
++++++++++
++++++++++
+++++++
Low income
++++++++++
++++++++++
+++++
Projected shortage of 18 million
health workers to achieve and
sustain the SDGs2
+
1 World Bank, publication forthcoming . 2 Cometto et al, World Health Organization
Decent work, inclusive economic growth, UHC
Health as a cost disease
and a drag on the
economy
Health as a multiplier
for inclusive economic
growth
Baumol (1967)
Growth in health sector
employment without
increase in productivity
could constrain economic
growth (data from USA)
Hartwig (2008 and 2011)
Confirmation of Baumol
hypothesis (data from OECD
countries)
Arcand et al., World Bank (In press, 2016)
– larger dataset; data from low-,
middle- and high-income countries
– establishes positive and
significant growth inducing effect
of health sector employment;
multiplier effect on other
economic sectors
– magnitude of effect greater than
in other recognized growth sectors
Workforce 0 0: Source of e ploy e t…. USA
Workforce 2030: Source of future employment (USA)
U.S Bureau of Labour Statistics:
http://www.bls.gov/emp/ep_table_103.htm
Workforce 0 0: Source of future e ploy e t…..
Source:
Human Development Report 2015: Work for Human Development
5. RECOMMENDATIONS FOR COUNTRY’S STRATEGY
STRONG LEADERSHIP AND POLITICAL COMMITMENT
FACILITATING COMPARATIVE STUDY FOR POLICY
MAKERS
CREATING CRITICAL MASS
EDUCATION, ADVOCACY AND PUBLIC DEBATE
LAWS AND REGULATIONS
START TO COVER CIVIL SERVANT, THE POOR AND
FORMAL SECTOR
BENEFIT PACKAGE
Publikasi Internasional
Posisi Indonesia dalam kancah publikasi internasional (general)
Indonesia
26
Publikasi Terindeks Scopus s/d 2014
Seminar Professorship
27
28