Primary Health Care in Indonesia: Challenges and Opportunities

1. Primary Health Care in Indonesia:Challenges and Opportunities Prof. Dr. dr. Akmal Taher Directorate General of Health Services Ministry of Health Indonesia

2. Indonesia is an archipelagic nation containing over 18,000 islands. Number of Population : 259.940.857 Land Sizes : 1,904,569 km2 Number of Provinces : 34 Provinces Number of Districts : 497 Districts Number of Community Health Centers: 9655 Puskesmas

3. Public Health Center as the Back Bone of Primary Health Care • Program started early 1970s, mandated by Presidential Decree • Working unit at subdistric level and responsible for that area • One PHC for 30.000 to 100.000 people • More than 9500 PHC in all over Indonesia • Large variations in geographic accessability • Remote interior • Isolated island

4. Public Health Services Program • Stimulate and supervise community based health services • Managing preventive health services • Managing basic medical care affordable for all • Coordination and collaboration with other sector in distric and subdistric level • Ministry of Education • Minsitry of Social Affair

5. Program in Public Health Center Generic Health Program Local-specific Program Essential Health Services Health services to overcome specific problem ie, yodium deficiency, diabetic, geriatry Mpther & child Nutrition Sanitation Communicable disease control (+ NCD) Health promotion Basic medical & emergency care

6. KONDISI KETENAGAAN DI FASYANKES PRIMER Percentage of Public Health Center (CHC) with Number of Doctor below Standard 32,86% of 9.510 PHC with number of doctor < standard 14,7% of PHC without doctor

7. Proportion of Good Washing Hand Behavior*) ,by Province 2007-2013 *) bila cuci tangan pakai sabun sebelum menyiapkan makanan, setiapkali tangan kotor (memegang uang, binatang dan berkebun),setelah buang air besar, setelah menceboki bayi/anak, dan setelah menggunakan pestisida/insektisida, sebelum menyusui bayi.sebelum makan, dan setelah memegang unggas/binatang

8. Proportion of Married Women of 15-49 years old in Family Planning Program, 2010-2013

9. Ante Natal Care, 2010-2013* * Periode3 tahunterakhir

10. Proportion of Anemia during Pregnancy in Urban & Rural Area, 2013 *) NilairujukanmenurutWHO/MNH/NHD/MNN/11.1,2011 danKemenkes,1999 **) Cut off points anemia IbuHamil, Hb < 11,0 g/dl

11. Proportion of Deliveries Attended by Skilled Health Personal 1, 20102-20133 • Drkandungan, drumumdanbidan • Periode 3 tahunterakhir, penolongterakhir • Periode 3 tahunterakhir, jika > 1 penolongdipilihkualifikasitertinggi

12. Proportion of Births in Health Facilities by Province, 2013* *) Kelahiran Periode 1 Januari 2010 - wawancara

13. Proportion of Household Using Traditional Medicine, 2013

14. Proportion of Household Know the Communitybased Health Program* by Province, 2013 * The activity mainly preventive and promotive, ie, education, under five year children

15. The Prevalence of Diabetes Mellitus by Province, 2007-2013 *) Diabetes Melitus (DM) responden 15+ berdasarkanwawancaramenurut diagnosis dokterdangejala

16. Key Challenges of Primary Health Care Governance in Indonesia • Decentralization, which implemented since 2001, affect • Health financing and integrated planning • Health information systtem difficulty to develop strategies and monitor health program in provinces and distric level • Human resources for health and service provision • Low level of health financing (2-2,3% of total gov budget) • Compare to other nation • Compare to allocation for hospital (curative more than preventive) • Maldistribution of medical doctors • no obligatory government services program • Not enougfh insentives to work in remote area

17. Quality and competency of medical doctor working in primary health care • No formal education after graduation • Temporary job • Working in primary care is not a “carrier” • Many Public Health Centers more focus on curative program instead of promotive and preventive. • Fee for services • More income

18. Strategic Action • Amendment of The Act of Local Government • Clear authority and responsibility between Central Government, Province, and Distric in providing Health services and resources • Increase the quality of medical doctor working in primary care • Primary Care Physician • 2-3 years training post graduate • More competency, more salary, and more attractive • Universal Health Coverage • National Social Health Insurance

19. National Social Health Insurance (JKN) Insurance body (single payer) Government Standardization of health care delivery Standardization of medicine, equipment, etc Regulator Contribution Contract Payment Claims Complain management Regulation on tariff Delivery of service Members Healthcare providers utilization of service 19

20. Roadmap To UHC 86,4 mio PBI Activities: Transformation, Integration, Expansion 111,6mio covered by BPJS Keesehatan 257,5 mio (all Indonesian people) covered by national insurance scheme Coverage of various existing schemes148,2mio 60,07 mio covered by other schemes Uninsured people 90,4mio Level of satisfaction 85% 73,8 mio uninsured people Transformation from 4 existing schemes to national insurance scheme (employee, poor people, civil servants ,army/police scheme) Integration of local government insurance scheme into national social insurance and regulation of commercial insurance industry Presidential decree on operational support for Army/Police membership transfer of army/police scheme toBPJS Kesehatan Procedure setting on membership and contribution Company mapping and socialization Membership expansion to big, middle, small and micro enterprises B M S Synchronization membership data: JPK Jamsostek, Jamkesmas dan Askes PNS/Sosial – single identity number Consumer satisfaction measurement every 6 month 20 Benefit package and sevices review annually

21. Referral System & National Formulary tertiary National formulary 923 items secondary Primary care Gate keeper 155 disease/symptoms should be resolved in primary care community

22. PUBLIC GOODS AND PRIVATE GOODS IN PRIMARY HEALTH CARE Medical Care Public Health Program at national level National Social Health Insurance • Family planning and prevention of complications of delivery/labor • Community based health services • Integrated health service Center • HIVScreening • Malariaprevention • TB Dots • Vaccine for basic immunization • Basic contraception methods Medical care in primary health care facilities (capitation fee) Public Insurance Body FUNDED BY GOVERNMENT

23. Provider Payment Mechanism KEMENKES Primary care Capitation (per member per month) 0.3 – 0.6 USD (Urban and semi urban) 0.8 – 1.0USD (Remote) Other mechanism (non capitation) Payment Mechanism Secondary and Tertiary Care BPJS KES INA-CBG’s (casemix)

24. PUBLIC &PRIVATE GOODS IN PRIMARY HEALTH CARE Medical Care Public Health Program at national level National Social Health Insurance • Family planning and prevention of complications of delivery/labor • Community based health services • Integrated health service Center • HIVScreening • Malariaprevention • TB Dots • Vaccine for basic immunization • Basic contraception methods Medical care in primary health care facilities (capitation fee) Public Insurance Body FUNDED BY GOVERNMENT

25. Visits and Referral in Primary CareJanuary-February 2014 Utilization rate : 12% Sumber Data BPJS Kes, 2014