asco Funding for Public Health InaHEA Jogya 28 07 16

(1)

Sources and adequacy of

public funding for Public Health

Ascobat Gani

CHEPA-University of Indonesia

InaHEA (Indonesia Health Economic Association) Conference,

Jogyakarta, 28 – 30 July 2016

(2)

Topics

• _{Comprehensive Health Financing}

• _{The nature of Public Health}

programs

• _{Financing PH}

a. Sources

b. Adequacy

(3)

Why should move toward

“comprehensive HF” ?

Because the current mode of HF has

been:

• _Partial

_{: investment vs operating &}

maintenance

• _Vertical

_{: Specific disease driven: ATM,}

MCH, etc

• _Bias:

_{toward financing curative}

services: through pricing and/or

health insurance

(4)

Comprehensive HF ?

• Strengthenin g Hlth System Building Blocks • Promotion • Prevention • Surveylance

• Mobilizing government machinery

• Mobilizing social machinery • Mobilizing “beyond health”

• Primary Care • Secondary Care • Tertiary Care

Health

System

Public

Health

Medical

Services

• Central • Provincial • District • Sub-district Insurance • _Collecting • _Pooling • _Purchasin g Tax based: • _Collecting • _Allocating • _Budgeting Risk reductio n Financial protectio n 1. Governance &

regulation 2. HWF 3. Pharm/medical equipment 4. R&D 5. Comm.participa tion & empowermnt 6. Hlth Financing 7. HSD (supply

side) Ta x b a se d UKM UKP

(5)

The nature of PH

Classic definition of PH (Winslow,

1920):

_•

_{Science and art}

• _{Preventing diseases and prolonging life; promoting}

physical health and efficiency

• _{Through organized community effort}

_for:

a. The sanitation of the environment

b. The control of community infections

c. The education of individual in personal in the

principal of

personal hygiene

• _{The organization of medical and nursing services}

for early diagnosis and preventive treatment

• _{The development of social machinery}

• _{To ensure to every individual a standard of living}

adequate for the maintenance of health

Mobilizi

ng socia

l machin

ery

Mobilizi

ng beau

rocratic

machine

(6)

* Art and science

* To prevent disease and disability * To prolong productive life

* Through organized community effort

Health Promotion

Specific

protection _{Prompt Th/}Early D/

Dissability limitation

Rehabilitation PUBLIC

HEALTH _{CLINICAL MEDICINE}

Ascobat Gani 08/03

• Primary

• Secondary

• Tertiary

Mobilizi

ng socia

l machin

ery

Mobilizi

ng beau

rocratic

machine

HEALTH CARE CONTINUUM C O M P R_{E H E N}

S I V E H_LTH C A R E

(7)

PUBLIC HEALTH MEDICAL CARE

Economic

properties Public goods + merit goods Private goods (<< merit goods) Target Population & area as a

whole (Kesehatan wilayah) Individual/family

Indicator Morbidity/mortality,

epidemic Clinical symptoms and pathology Emphasis of

interventions Risk factors reduction, prevention, surveilans, early D/, community participation and

empowerment, inter-sectoral collaboration, strengthening health system

Individual diagnosis, treatment, rehabilitation Curing diseases

Approach Team Work,

multi-disciplines Individual, mono-discipline Impact Medium and long term Short term

Workforce SKM, MPH, Hlth Promotion, Environmental Hlth, PH nutrition, etc

Medical doctor, dentist, nurse, midwife, etc

(8)

Ascobat Gani/FKMUI

3 Core function

10 Essential PH functions

Assessme nt

1 Surveylance of public health problems

2 Assessment/Investigation of risk factors (determinants of public health problems)

3 Evaluation of effectiveness, access and quality of public health interventions

Health Policy develop-ment

4 Policy to support community and individual health efforts

5 Enforcement laws/regulations to protect health of the population

6 Researches for innovative solution of public health problems

To ensure

7 Access and quality of health services

8 Availability of professional health workforces 9 CIE and community empowerment in health 1

Partnership with the community to identify and resolve public health problems

USA 2011: 10 Essential

PH function

(9)

Economic properties of PH

Pricin

g an d

insura

nce 

not

appro

priate Budg

Public

goods

Merit

goods

Private

goods

Marginal Cost

no

(small)

large

Excludability

No (free

rider)

small

Yes

Rivalry

No

small

>>>> (ada)

Externality

Large

large

No/small

Light house, park,

etc

Mass transport

_{Basic educn}

Private car,

_House

Vector control Hlth

promotn, sanitation, dll

Immunization,

Th/ tbc, malaria,

etc

Cosmetic surgery,

MCU, etcdll

(10)

Publicly

finance

Private

investment

Users fee

(tarif)

Insurance Other

Public goods

(cost effective)

++++

(*)

+

Merit goods

(cost effective)

+++

++

+

+++

Private goods

(**)

++++

(*) E.g. private non-profit, social institutions

(**) Objective: profit making, for cross subsidization or quality improvement

Financing policy:

1. Gen

eral ta x revenu

e 2. Ear

marke

d tax 3. Oth

er sect ors

(11)

HEALTH FINANCING POLICY IN INDONESIA

Policy (regulation)

Law

1 PH (UKM) is public goods and

publicly funded (tax based)

Law 36

(114)

2 Clinical care is funded through

social insurance

Law 36

(115)

Law-40

3 Government subsidized the

premium for the poor

Law-40

4 5% APBN (non-salary) should be

allocated for health

Law-36

(171)

5 10% APBD (non-salary) should be

(12)

Funding for PH

Tax  Central sources

(APBN)

2010 2011 2013 2014 2015 2016

BOK 390 M 990 M 1.16 T 1.22 T 1.4 T 2.4 T

PBI (*) 19.75

T 19.9 T 25.5 T

BOK (Bantuan Operasional Kesehatan)

 MoH response to DHA results

* Since 2010

* Central funding channeled directly to

Puskesmas

* Only for operating cost of PH activities

* Support 9,750 Puskesmas

* Back bone of PH financing

(*) PBI = premium subsidy for the poor

DAK-nonfis

(13)

Tax  District sources

(APBD)

_{APBD allocation for health (8}

sistricts)

Flot im

Ngad a

TTU SBD Sam pang Bang kala n Bond owos o Situ bond o - 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 2013 2014

Percapita spending for

health

• _{Disparity between}

districts with the same

need

• _{Fluctuate over the}

years following APBD

fluctuation

Already around 10% APBD

Indicating that “10% policy is

(14)

Spending for PH, Clinical services and Health System Strengthening (8 districts)

(15)

Current PH funding

• _{PH continue to suffer underfunding}

• _{By enlarge rely on APBN}

BOK (2010-2015) 

DAK-nonfisik(2016 )

• _{May impact JKN (BPJS funding)}

2014 2015 2016 2017

Deficit 3.30 T 5.85 T 6.80 T  7.4 T ? ? Subsidi for

PBI

19.225 T 25.5 T ?

(16)

23.3 7.5 10.5 8 23.8 11.4 1.5 14.1 _Primary care Delivery Chronic Intensiv e Catastropik Surger y Opthal mology Others 52 Triliun 75% self limiting preventable

with PH (UKM)

High TFR >> Low CPR

Preventable with FP (PH)

Hipertensi, DM, Ca Stroke, CV, renal Failure Aging Smoking Life style  _Screenin g  _Hlth promotio n

(17)

Improving PH funding

• _{Develop user friendly “costing tool” for PH}

• _{Costing PH program in every district (514}

districts)  normative cost for PH intervention

• _{Increase BOK (DAK-nonfisik) accordingly}

• _{Warning !!}

Will be in-effective without sufficient number

of PH-workers (sanitarian, PH-nutrition, FP

workers, health promotion at the primary

health

care (PHC)  Puskesmas

• Infrastruktur • Tenaga

profesional

• Kompetensi

teknis

(18)

• _{Use of tobacco tax for PH}

SBD  household spending for tobacco: Rp 101 billions

The poor (90% of population) contributed Rp 90 billions

Rationales (economic perspective)

Data: tobacco tax is primarily come from the poor spending for tobacco

(19)

• _{Advocating/mobilizing other sectors}

• _{Industry  spending for “food}

safety”

• _{Farming and plantation Industry }

environment friendly

• _{Education  intensifying School}

Health  eg. “healthy food

consumption “

• _Etc

• _{CSR (Corporate Social Responsibility)}

Th

an

(1)

Spending for PH, Clinical services and Health System Strengthening (8 districts)

(2)

Current PH funding

• _{PH continue to suffer underfunding}

• _{By enlarge rely on APBN}

BOK (2010-2015) 

DAK-nonfisik(2016 )

• _{May impact JKN (BPJS funding)}

2014 2015 2016 2017

Deficit 3.30 T 5.85 T 6.80 T  7.4 T ? ? Subsidi for

PBI

19.225 T 25.5 T ?

(3)

23.3 7.5 10.5 8 23.8 11.4 1.5 14.1 _Primary care Delivery Chronic Intensiv e Catastropik Surger y Opthal mology Others 52 Triliun 75% self limiting preventable with PH (UKM)

High TFR >> Low CPR

Preventable with FP (PH)

Hipertensi, DM, Ca Stroke, CV, renal Failure Aging Smoking Life style  _Screenin g  _Hlth promotio n