Vice Ministry of Health Prof dr Ali Ghufron Mukti Msc, Phd,

1. 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 Mukti Msc, Phd, “International Conference: on Health Equity in Asia: Reproductive Health / Disaster and Health Management to Achieve MDGs” University of Indonesia, 12 December 2012

2. Presentation Outline KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Equity and Health Financing System • UHC In ASEAN Countries • National Priority Agenda : Towards UHC • Preparation of Social Security Law implementation and challenges • Roadmap of membership and Premium Estimation • Roadmap benefit package, health services & subsidy Scheme 5. Health Human Resources Conclussion Indonesia Vice MoH: UHC & Challenges

3. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 1. EQUITY AND Health Financing System Indonesia Vice MoH: UHC & Challenges

4. Equity in Health Financing System As part of National Health System Goal Performance Health System Performance Functions the system Perform Objective of the system Stewardship Responsiveness Resources (Man, Facility, Equipment, Farmacy) Health Status Health Services Financing Fairness/ Equity WHOWorld Health Report, 2000 Indonesia Vice MoH: UHC & Challenges

5. Policy on Health Financing KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 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 Indonesia Vice MoH: UHC & Challenges

6. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Health Service System & Finance Private Goods Public Health& Goods Clinics; Laboratory, inpatient care Integrated health post;PHN, sanitatiion;, health promotion; school health, school dental health; comm dental health Health Insurance (Individual Health) Community Health Refferral system Premium BPJS Healthy Individu and DTPK Sick Individu Indonesia Vice MoH: UHC & Challenges

7. Key HCF indicator in ASEAN Countries 2007

8. UHC IN ASEAN Countries Financial protection * measured by OOP as % of THE, 2007 8

9. Fiscal Space and the Government Health Exp and UHC Figure 2Fiscal 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. 9

10. HRH Availability vs GDP per capita

11. Densities of doctors, nurses, and midwives, per 1,000 population

12. Production capacity of doctors, nurses, and midwives, per 100,000 population

13. NATIONAL HEALTH SYSTEM AND SOCIAL SECURITY IN INDONESIA HEALTH DEVELOPMENT PLAN KEMENTERIAN KESEHATAN REPUBLIK INDONESIA NATIONAL PARADIGM: (PANCASILA, UUD 1945,WASANTARA,TANNAS,) (Law no 36/2009 Health, Law No 17/2007 RPJPN) Develpment Based on Health Current conditions Community health status not optimally yet Public Goods Community Health Status National Health System National Long-Term Plan Development National Goals KUALITAS SDM Healthy & Productive People INDONESIA Basic problem on health development: • 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 Private Goods (SJSN) Law no 40/2004 STRATEGIC ENVIRONMENT: (IdeologiYPolitiC, EConomiY, Soscal Culture and national security) Sumber: Rancangan Perpres R.I ttg Sistem Kesehatan Nasional 2012 (12-4-2012) Modifikasi dari Presentasi Hapsoro GLOBAL, REGIONAL, NATIONAL, LOCAL Opportunity and Barrier Indonesia Vice MoH: UHC & Challenges

14. Indonesia MoH Vission: 8 National Focus & 7 Priority Reformation KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Universal Coverage 2014 8 NATIONAL FOCUS PRIORITY FOR HEALTH Improving maternal health and fam planning Comm nutrition improvement CD and NCD control, environmental health Fulfiling Health HR Improving Availbility, affordability, safety, quality, food and farmacys Jamkesmas (health insurance for the poor) Community development, disaster and crisis management Improving primary, secondary and tertiary health care 7 PRIORITY HEALTH REFORMATION • HEALTH INSURANCE • Health services in very remote area (DTPK) • Availability of farmacy, health equipment in every health facility • Birocration Reform • BantuanOperasionalKesehatan (BOK) • Overcoming districts Health problem (PDBK) • Indonesia World class Hospital RPJMN 2010 – 2014 (National Middle Development Plan) MDGS2015 VISSION : Self Reliant Healthy People within a just health care system Indonesia Vice MoH: UHC & Challenges

15. Social Security Law & The Implementation KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Universal Health Coverage Law No 40 Year 2004: National Social Security System (SJSN): Law No 17 Year 2010 : National Development Middle Plan (RPJMN) Law No 24 Year 2011: Secial Security Carrier (BPJS) • 5 Program  the 1st program implementation is HEALTH • Execute based on humanity, benefit, & social fairness MoH Indonesia was planned to achieve UHC in the 2014 To provide basic life need nesessarily for all member Indonesia Vice MoH: UHC & Challenges

16. Implementation National Social Security System (SJSN) for Health Program KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Government BPJS Kesehatan Regulation of health system (refferral, dll) Regulation (stadarization) h service quality; farmacy, medical supplies Regulator Pay Premium Contract Kendali Biaya & kualitas Yankes Claim Claim payment Benefit Package Regulation of Health Service Tarriff and Cost-sharing Provide Services Health Insurance Member Health Facility Public Health & Goods Program Handling Searching services Refferral system Non member; who finally become member Handling health services in very remote area (DTPK), dll Indonesia Vice MoH: UHC & Challenges

17. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Roadmap: Membership & premium, Health services, Benefit package, 2. Preparation of social security law implementation and Challenges Indonesia Vice MoH: UHC & Challenges

18. UHC as a Global Priority Agenda • The Universal Health Coverage Dimentions KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Benefit Package Financing Membership Sumber: WHO, The World Health Report. Health System Financing; the Path to Universal Coverage, WHO, 2010, p.12 Indonesia Vice MoH: UHC & Challenges

19. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 2a. Roadmap Membership and premium estimation Indonesia Vice MoH: UHC & Challenges

20. Membership of Social Health Insurance : Towards UHC KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Iuran/premiuj Non poor JK Free choice Health insurance Compulsory Population Poor Iuran/premi Government Premium Subsidy Receiver (PBI ): Indonesia Vice MoH: UHC & Challenges

21. Membership Roadmap towards Universal Health Coverage 96,4 million subsidy 2,5 subsidy for people without ID KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Activities : Transformation, Integration, extention 124,3million member be managed by BPJS Health Program 257,5 million (all citizen) manage by BPJS Keesehatan Citizen has been cover with several scheme 148,2 million 50,07 million managed by non BPJS Kesehatan 90,4 million has not yet being member Membership Satisfaction level 85% 73,8 million has not yet being member Transforming JPK Jamsostek, Jamkesmas, PJKMU to BPJS Kesehatan Integration member of Jamkesda/PJKMU Askes comercial to BPJS Kesehatan President Regulation of TNI POLRI Operational Health Support Transforming TNI/POLRI membership to BPJS Kesehatan Membership Extention of big company, midle, smal and micro Setting up Systen Procedure of Membership and Premium Companies Mapping and socialization B S K Sinkronizing Membership Data of JPK Jamsostek, Jamkesmas and Askes PNS/Sosial – using citizen ID Membership satisfaction measurement periodically, twice a year Review of Benefit Package and Health Services Refinement Indonesia Vice MoH: UHC & Challenges

22. Health Insurance Coverage, Year 2011 KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Indonesia Vice MoH: UHC & Challenges

23. 2014 Membership Prediction KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Indonesia Vice MoH: UHC & Challenges

24. Membership (article 20, SJSN) KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Member: is every single citizen 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 additional premium Premium Will be differentiated b/w subsidy receiver and non subsidy Indonesia Vice MoH: UHC & Challenges

25. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 2B. Roadmap: benefit package, health services Indonesia Vice MoH: UHC & Challenges

26. Benefit Package in UHC KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • NON Medical Benefit Package • It was agreed: At least similar to current benefit Medical Benefit Package Based on Medical Need : Health Service covered Health Service limited H Service with cost-sharing Health Service NOT covered Indonesia Vice MoH: UHC & Challenges

27. Benefit Package and Premium Similar Benefit package • Benefit Package standart is comprehensive as medical need • Differ in hospitality Various Benefit of various scheme, not yet based on medical needs Activities KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Premium Relatively equal to economic level for all population Various premium Premium : Differentiate between PBI from Non PBI Jamkes President Regulation adjusted Consensus Benefit package; stated on President Regulation, by Nov 2011 Jamkes President Regulation adjusted Review periodically on sallry, premium, benefit package effectiveness, payment among region Premium agreed for PBI: Rp. 22.201) Premium for Non PBI still on going discussion :5% of sallary 3% - 2%; Utilization Review to ensure eficiency, reduce moral hazard, improve satisfaction of membership, human resources and health facility Indonesia Vice MoH: UHC & Challenges

28. Health Service Aspect • Jumlah mencukupi • Distribusi merata • Sistem rujukan berfungsi optimal • Pembayaran dengan cara prospektif dan harga keekonomian untuk semua penduduk • health facility extention and development incl human health resources • Evaluastion and determined payment Activities KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Health facility distribustion not optimum; various quality of services, referral helth system not optimum yet; payment system not optimum yet Action plan of health facility, HHR, referral health system and infrastructure Implementasi roadmap: facilty development, HR, referral system, and other infrastructure. Periodically Review of health facility eligibility, credensialing, Quality of care, and payment and tarrif economically adjusted Designing Standart and payment procedure, and health facility Implementation, monitoring and referral health refinement and utilization review Implementation payment mechanism : Kapitation, INA-CBGs; including serta penyesuaian payment and tarrif economically adjusted every 2 years Indonesia Vice MoH: UHC & Challenges

29. Referral Health System KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • The referral health system has been renewd  Ministry of Health Regulation 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 Indonesia Vice MoH: UHC & Challenges

30. Referral Health System KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Indonesia Vice MoH: UHC & Challenges

31. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Source: RIFASKES, 2011 • Water & Electricity Source: PODES, 2010 Indonesia Vice MoH: UHC & Challenges

32. The Distribution of Hospital &Health Center (Puskesmas) Beds per Provinsi KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Condition Per-April 2012 Beds Disparity Indonesia Vice MoH: UHC & Challenges

33. Primary Care Policy adjustment (1) KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Type Urban Type Standart (Rural) Type DTPK (very remote) • Adjustment of Main function 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 Information Technology : How is the ervices system, referral among Primary Care, Standart tarrif, etc Indonesia Vice MoH: UHC & Challenges

34. Secondary – Tertiery Care Policy KEMENTERIAN KESEHATAN REPUBLIK INDONESIA RS Pratama? Hospital Type A,B Hospital TypeC,D Private hospital type Clinic Spesialistic? GP / Spesialis individual Practice? Main Function : How is main function 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/Tertiery Care? How is System Informasi Technologi: Indonesia Vice MoH: UHC & Challenges

35. RS Pertamina Klayan RS TANGKIL RS GUNUNG DJATI RSUD ARJAWINANGUN RST CIREMAI RS PELABUHAN RS MITRA PLUMBON Anjung MIGAS Lepas pantai Penghasil MIGAS Pertamina Industri Rotan Industri kue PINTU TOL YANG ADA RSUD WALED Mapping model Regionalizationreferral system using GIS approach: At Ciayumajakuning Jabar KEMENTERIAN KESEHATAN REPUBLIK INDONESIA RSD INDRAMAYU RSIA SUMBER KASIH RS SUMBER WARAS RS PUTRA BAHAGIA RSD MAJALENGKA RSD MAJALENGKA RS MEDIMAS RSD KUNINGAN Industri Batik Trusmi Indonesia Vice MoH: UHC & Challenges

36. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 3. Health Human Resources Indonesia Vice MoH: UHC & Challenges

37. Development & Empowerment of HHR in relation with Health Development & HHR Stndard Social , Religion & Culture Educ based on HS standard Determine std of educ & competences Educ Institutional regulation Inst educ Accrediatation KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 3.Educ Standard Advocation, coord, strengthening plan Need Pllanning Establishing Prof Std & competencies Estimating types, amoubt, Science & Technology Fundamen of Moral Humanity Deploying Diistribution HHR R & D HHR Planning Resources & HRR Quality Monitor Health Facility Economic Environment Health Environment Health Management Deploying Diistribution HRR Direction, strengthening Regulation support, sertification, registration, Compentency exam IT support Resources support 2.Prof Standard 1.ServiceStandard Selection, recruitment, deploy Compensation Carrier dev Training External HRR Culture Changes Phisical & Biological Envi 4.Prof ethic Politics & Law Envi HRR Development & Empowerment Health Development Indonesia Vice MoH: UHC & Challenges Blue Print IT

38. Fufilling the HR Gap Strategy KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Medical Doctor Spesialities Program (PPDS) • Program Doctor Plus • Non Permanent Employer (PTT) • Individual special assigment (Residen& D-3 Nakes) • Team special assigment (team based)- contracting & contracting out • Revising recruitment and posing regulation including carrier path Indonesia Vice MoH: UHC & Challenges

39. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA 4. CONCLUSSION Indonesia Vice MoH: UHC & Challenges

40. Conclusion (1) KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Ensuring access to health prevention and health care services - especially for some particular groups like newborn baby, under-5 children, and pregnant mother will be fostering the achievements of MDGs. • Empowering the community in improving health and sanitation which will result to the improvement of health status of the society Indonesia Vice MoH: UHC & Challenges

41. Conclussion (2) KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Indonesia is going to achieve UHC • The Indonesia Law No (40/2004; 17/2010; 24/2011)  support to achieve Universal Health Coverage • End of 2011 has already reached 63% of population or 142 million people have health insurance with different type of insurance and benefit package Indonesia Vice MoH: UHC & Challenges

42. Conclussion (3) KEMENTERIAN KESEHATAN 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 Indonesia Vice MoH: UHC & Challenges

43. Conclussion (4) KEMENTERIAN KESEHATAN REPUBLIK INDONESIA • Agreed that the premium will be differentiated between PBI (subsidy for the poor) and Non PBI (non subsidy for non poor) • The amount of Premium is still undergoing discussion Indonesia Vice MoH: UHC & Challenges

44. KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Indonesia Vice Ministry of Health Thank youTERIMA KASIHmatur nuwun Indonesia Vice MoH: UHC & Challenges