Strengthening Indonesia s Health System through the National Health Security

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1 Strengthening Indonesia s Health System through the National Health Security Prof. Dr. dr. Fachmi Idris, MKes President Director 1st Sriwijaya University International Conference on Public Health: Public Health Responses to Health Systems Strengthening Palembang, 5 Oktober

2 Topics I. INTRODUCTION II. STRENGTHENING HEALTH SYSTEM THROUGH THE IMPLEMENTATION OF NATIONAL HEALTH INSURANCE III. CHALLENGES

3 INTRODUCTION

4 HEALTH SYSTEM World Health Report 2000: Health System (Gro Harlem Burtland) System Building Blocks (6 blocks) Leadership/Governance Health Care Financing Presidential Decree 72/2012: National Health System Subsystems of National Health System (7 blocks) Health Effort on Personal and Community Research and Development on Health Health Financing Health Workforce Health Workforce Medical Products, Technologies Pharmaceutical, medical devices and food supply Information Research Management, Information and Regulation on Health Service Delivery Community Empowerment 4

5 HEALTH SYSTEMS PERFORMANCE FRAMEWORK (WHO 2000) Responsiveness people s expectation) Stewardship Creating Resources (Investment & Training) Financing (collecting, Pooling and Purchasing) 6 sub systems of financing Delivering Services Health Fair Financial Contribution National Health Insurance 5

6 Presidential Decree No 72/2012 National Health System 3,5 Strengthening Sustainability Health Effort on Personal and Community Health Financing Pharmaceutical Medical Devices and Food Supply Research and Development Years of JKN-KIS June 2017 Stimulating Success Information management Regulation on Health Health Workforce Community Empowerment Sustainibility : Affordability Acceptability Adaptability Success* : Healthy community Superior healthcare Fairness *Fineberg V. F. (2012)

2016 1st semester (18 August 2017) 0 Germany

Japan 97,2 % Pop (50,9 Jt ) 20 36 yrs 100 %

7 The progress towards universal health coverage 3,5 years towards UHC UHC: International comparison > 70% of the population yrs 118 yrs st semester (18 August 2017) 0 Germany Belgium Austria Luxemburg Costa Rica 26 yrs Japan 97,2 % Pop (50,9 Jt ) yrs 100 % Pop (126,7 Jt ) yrs 87 % Pop (4,8 Jt ) yrs 100 % Pop (582,291) yrs 99 % Pop (8,7 mill.) % Pop (11,4 mill.) % Pop (80,6 mill.) South Korea Source: LPP Jamsoskes 7

8 JKN s effect on National Health System Health Life expectancy rate in Indonesia is increasing (OECD 2016) Responsiveness JKN is effective in improving health equity for poor and near poor community (PRAKARSA, 2017) Costumer satisfaction index of JKN Participants is 78,6% (BPJS Kesehatan, 2017) Fair Financial Contribution With the new JKN scheme, the level of OOP spending among the insured population is decreasing (WHO, 2017) 8

9 STRENGTHENING HEALTH SYSTEM THROUGH THE IMPLEMENTATION OF NATIONAL HEALTH INSURANCE

Key Function of Health Care System Tertiary Hospital Secondary Hospital Primary Care with Inpatient Gatekeeper Primary Care Individual/ family 1.

10 Key Function of Health Care System Tertiary Hospital Secondary Hospital Primary Care with Inpatient Gatekeeper Primary Care Individual/ family 1. Arrangement of provider distribution capacity planning 2. Gatekeeper 3. Healthcare Standard (human resource, facilities, guidelines) 4. Regulation 5. Reverse referral system (referral from secondary to primary care for chronic disease patients in stable condition) 6. Sufficient incentives 7. Continuous, accurate and real 9. time Emergency management information system 10. service Monitoring andadministration evaluating 8. Standardized 11. Continuous communication with healthcare providers and beneficiaries Source: Adapted from Ministry of Health Decree No. 01/2012 and 71/2013 By Deputy of Primary Financing Insurance 10

Health care benefit Focus on individual health rather than public health Health promotion, disease prevention, curative, rehabilitative, drug & medical

(spectacles) Promotive & preventive: 1.Individual health counseling 2.Screening (diabetes, hypertension, cervical cancer) 3.

11 Health care benefit Focus on individual health rather than public health Health promotion, disease prevention, curative, rehabilitative, drug & medical devices based on medical indication using referral system Primary care Medical Secondary care Ambulance Non medical Inpatient accommodation Supplement (spectacles) Promotive & preventive: 1.Individual health counseling 2.Screening (diabetes, hypertension, cervical cancer) 3.Immunization (basic and advance) 4.Family planning Curative & rehabilitative 1. Outpatient 2. Inpatient 3. Obstetric 4. Emergency care Vaccine, contraception provided by government 11

12 Healthcare Utilization Improving Access and Degree of Health 133, Audited Report by Dec 66,8 PHC 2015 Audited Report by Dec PHC 4,2 Inpatient Total Cost: 42 T ,9 PHC 50,4 39,8 Outpatient Outpatient Outpatient 171,9 Audited Report by Dec 100,6 21,3 156,79 7,6 6,3 Inpatient Total Cost: 57 T Inpatient Total Cost: 69 T 12

Health Utilization and Catastrophic Care per 1st

CONTRIBUTION: Enhance health recovery and prevent

prevention Improve the productivity of the community

poverty and the poor from catastrophic health

2014 2015 2016 4,02 7 cases 10,6 trillion IDR 10,3

37,32 %** 32,41 %** 24,81 %** Outpatient Inpatient Data

(loading month) * Cardiovascular, cancer, kidney

13 Health Utilization and Catastrophic Care per 1st Semester ,3 1st Semester 72,8 DIRECT CONTRIBUTION: Enhance health recovery and prevent disablement through health promotion and disease prevention Improve the productivity of the community both socially & economically Protect community from poverty and the poor from catastrophic health expenditure PHC Cost of catastrophic diseases* 29, ,02 7 cases 10,6 trillion IDR 10,3 cases 13,9 trillion IDR 9,8 cases 12,7 trilllion IDR 37,32 %** 32,41 %** 24,81 %** Outpatient Inpatient Data source : LPP Jamsoskes source : Data BOA, per June 2017 (loading month) * Cardiovascular, cancer, kidney failure, stroke, thalassemia, cirrhosis Hepatic, leukaemia, haemophilia ** Percentage from total hospital costs 13

14 Healthcare Facilities: more than 50% private hospitals accepted referrals 78,8%* Data source : LPP Jamsoskes *of registered hospital 14

Healthcare Cost Healthcare Cost 2014-2016 168 T Primary and

15 Healthcare Cost Healthcare Cost T Primary and Secondary Repeated outpatient increasing (Q ) 19.7 mil cases (2014) 34.4 mil cases (2016) Cost: 3.7 T 4 6. T (2016) Triple Burden Of Diseases Infectious Diseases Chronic Diseases Mental Disease

Trend of Healthcare Cost Ratio 2014-2016 90% Primary care Secondary care 80% 80,35% 79,66% 78,38% 70% 60% 50% 40% 30% 21,62% 20,34%

16 Trend of Healthcare Cost Ratio % Primary care Secondary care 80% 80,35% 79,66% 78,38% 70% 60% 50% 40% 30% 21,62% 20,34% 20% 19,65% 10% 0% There is a decreasing trend of cost ratio for primary care compared to secondary care from 2014 to 2016

CME Planning Outonomy (BLUD) Health promotion & disease prevention Peer Review Per PHC Campaign Monitoring and Evaluating

17 Strengthening Primary care function Credentialing/ Recredentialing Support from related parties Optimum Reverse Referral System Access to high quality PHC Simple administration Sufficient drug supplies Presence of pharmacy Therapy Management CME Planning Outonomy (BLUD) Health promotion & disease prevention Peer Review Per PHC Campaign Monitoring and Evaluating Pay for Performance & Walk Through Audit PROLANIS revitalisation & development Early detection Monev Implementation Research

Health promotion & disease prevention strategy BPJS members Healthy Risky Maintain/ promote Prevent from being sick Sick Prevent complication Disease management Health

18 Health promotion & disease prevention strategy BPJS members Healthy Risky Maintain/ promote Prevent from being sick Sick Prevent complication Disease management Health promotion & disease prevention programs Good quality of life Sustained JKN Important role of primary care doctors in implementing health promotion & disease prevention programs 18

19 CHALLENGES 19

Challanges 1 Healthcare facilities supply 2 Cost containment 3 Referral system The growth of healthcare facilities is lower than the growth of participants Uneven healthcare

20 Challanges 1 Healthcare facilities supply 2 Cost containment 3 Referral system The growth of healthcare facilities is lower than the growth of participants Uneven healthcare facilities distribution Need improved understanding about INA CBGs payment system Most people are specialist and hospitalminded, reluctant to visit primary care facilities as their first contact

21 Challenges (2) 4 Adverse Selection The behavior where people seek health insurance when they need healthcare

EFFORTS TO IMPROVE NATIONAL HEALTH SECURITY BPJS Kesehatan Care Center 1500-400 Mobile JKN Virtual Office 1. 2. 3. 4. 5.

22 EFFORTS TO IMPROVE NATIONAL HEALTH SECURITY BPJS Kesehatan Care Center Mobile JKN Virtual Office Registration Contribution payment status Medical history check Healthcare facilities location Change participant data Ease of registration access Drop Box system in BPJS branch office Registration in banks and malls Mobile JKN and BPJS Kesehatan website BPJS Kesehatan Care Center Mobile Customer Service Drop Box on sub district office BPTSP (one-roof registration) Kader JKN (door-to-door agents) E-Dabu (web-based registration for business entities) Web-based application BPJS Kesehatan ATM Traditional and modern PPOB (minimarket, online shop) SMS Banking, Internet Banking PT. POS Indonesia Healthcare facilities location Healthcare facilities registered as BPJS Kesehatan provider Real-time online referral system to hospitals Improving Services Ease of payment access Information Complaint handling Teleconsulting 6. Bridge Information System between healthcare facilities and BPJS Kesehatan Developing Coordination of Benefit (COB) No cost sharing Reverse referral system optimization Health promotion & disease prevention programs: - Prolanis - IVA Papsmear - Health screening through Mobile JKN - Exercises HFIS application to simplify provider registration process

23 CONCLUSION The JKN program is one of the government's efforts to strengthen the health system in Indonesia. For 3.5 years BPJS Health operates, has reached more than 180 people so that they are protected both access and financial. Many things that must be done to maintain the continuity of this program, ranging from revisions of laws and regulations that can synergize positively to build programs, alternative sources of financing and benefit packages. Support from various parties is also needed, one of them is related to the distribution of health facilities to improve access.

WHO Health System Building Blocks: considerations for NCD prevention and control. Dr Sudhansh Malhotra Regional Advisor, Chronic Disease Management

WHO Health System Building Blocks: considerations for NCD prevention and control Dr Sudhansh Malhotra Regional Advisor, Chronic Disease Management " A health system consist of all organisations, people