MOVING TOWARDS UNIVERSAL HEALTH ACCESS IN INDONESIA MINISTER OF HEALTH REPUBLIC OF INDONESIA MOVING TOWARDS UNIVERSAL HEALTH ACCESS IN INDONESIA Ladies and gentlemen, It is a pleasure and an honor to be with you today for this discussion of one of the great issues of public policy that Indonesia will undertake starting in 2014. We will launch our system of universal health coverage with implementation of the first phase of our new National Social Health Insurance scheme. Dr. Nafsiah Mboi, Sp.A, MPH Minister of Health Republic of Indonesia 1

OUTLINE 1. INTRODUCTION 2. EXISTING HEALTH INSURANCE IN INDONESIA 3. POLICY & DESIGN OF INDONESIA’S NATIONAL HEALTH INSURANCE SCHEME The outline for my today’s presentation is as follows : Introduction Existing Health Insurance Program in Indonesia Policy and Design of the National Health Insurance Scheme Conclusion 4. CONCLUSION 2

1. INTRODUCTION A brief comment on the pictures running through this presentation. There is no special connection between the pictures and text but the pictures are to remind us that the purpose of all of our efforts to to give a better life to more Indonesians wherever we find them. We talk here about policy and systems but the point is to serve PEOPLE!

 World’s largest archipelago – 17,000 islands About Indonesia  World’s largest archipelago – 17,000 islands  World’s 4th most populated nation - 230 million people, unevenly distributed World’s largest Moslem population Strong cultural and religious values A quick review for old timers. A brief introduction for new comers

INDONESIAN HEALTH FINANCING 2011 GDP per capita US$ 3,494 Total Health Expenditure  Rp 214,9 Trillion,  2.9% of GDP Per capita Health Expenditure  US$ 101.10 37.5% from public spending, 61.4% from private spending 72% of population  now covered by insurance (various schemes), 28% of population  uninsured We see here Indonesian health financing figures from the year 2011. At that time the situation was as follows : GDP per capita US$ 3,494 Total Health Expenditure  214,9 Trillion IDR, it is 2.9% of GDP Per capita health expenditure  US$ 101,1 37.5% from public spending, 61.4% from private spending 72% of population already covered by insurance (various schemes), 28% of population is still uninsured

National Social Security System Law No. 40/2004 The essence: To synchronize implementation of social security in Indonesia The purpose: To guarantee protection and social welfare for all people The law No 40/2004 on National Social Security System was promulgated in 2004. The law clarified and synchronized Indonesia’s approach to social security in Indonesia with the purpose of guaranteeing protection and social welfare for all Indonesians.

Components of Social Security system 1 Health Insurance 2 Accident insurance 3 Old age pension 4 The National Social Security System includes 5 components : Health Insurance Work Accident Insurance Old age pension Public pension Life Insurance Today we are talking about the up-coming launch of health insurance. Public pension 5 Life insurance

Social Security Concept 1 All employed citizens (in formal or informal sectors) who have income shall contribute to the program Add Your Text 2 Basic benefits guaranteed Add Your Text 3 Those who wish more protection, are free to purchase additional services on commercial basis Add Your Text 4 Slide – self explanatory. Planned, phased implementation 5 Government is regulator

2. EXISTING HEALTH INSURANCE IN INDONESIA Before I talk about preparation for and launch of the new system let me give a bit of information about the situation as of now.

Some Short Comings in EXISTING HEALTH INSURANCE SCHEMES Lack of integration in implementation and coverage. Fragmented fund-pooling & management Different benefit packages and limits among schemes Variations in management systems of different providers Limited and uneven monitoring, evaluation and coordination among schemes While public and private insurance have been growing since independence we find various short comings in the current situation. These work to the disadvantage of the public. The national system to be launched intends to overcome such problems.

EXISTING HEALTH INSURANCE COVERAGE Coverage : June 2013 176.844.161 people covered (72 % of population) JAMKESMAS : 86.400.000 (36,3 %) JAMKESDA : 45.595.520 (16,79 %) ASKES PNS : 16.548.283 (06,69 %) TNI/POLRI/PNS KEMHAN : 1.412.647 (00,59 %) JPK JAMSOSTEK : 7.026.440 (02,96 %) COMPANY SELF INSURANCE : 16.923.644 (07,12 %) COMMERCIAL INSURANCE : 2.937.627 (01,2 %) Content the same as previous slides but shows numbers of people covered under each pgm. : Coverage : as of June 2013 176.844.161 (72 % of population) JAMKESMAS : 86.400.000 (36,3 %) JAMKESDA : 45.595.520 (16,79 %) COMPANY SELF INSURANCE : 16.923.644 (07,12 %) ASKES PNS : 16.548.283 (06,69 %) JPK JAMSOSTEK : 7.026.440 (02,96 %) COMMERCIAL INSURANCE : 2.937.627 (01,2 %) TNI/POLRI/PNS KEMHAN : 1.412.647 (00,59 %)

EXISTING HEALTH INSURANCE COVERAGE (JUNE 2013) 28 36.3 This slide shows the patch work of existing public and private health insurance pgms and the % of the population covered by each. The biggest one is Jamkesmas covering 36.3% of the population NM – suggest adding comment on who is covered by JamKesMas. The second one is Jamkesda covers 16.79% of the population, the third one is self insured population covered by companies, followed by Askes (civil servants), JPK Jamsostek, Commercial Insurance, and Armed Forces and Police. Overall, a total of 72% of the population are already covered by insurance, leaving 28% of population with no coverage.

3. POLICY & DESIGN OF NATIONAL HEALTH INSURANCE (STARTING FROM 1 JANUARY 2014) I will now give you some basic information about practical policy and operations of the new system.

INDONESIA’S NATIONAL HEALTH INSURANCE LEGAL FOUNDATION FOR INDONESIA’S NATIONAL HEALTH INSURANCE Constitution of 1945 Act No 40/ 2004 on National Social Security System (UU SJSN) Act No 24/2011 on Social Security Agency (BPJS) Governmental Decree No 101/2012 on Beneficiaries of Governmental subsidy (PBI) Pres Decree No 12/2013 on Social Health Insurance Other regulations The National Social Health Insurance program has a robust legal basis. As of today most of legal infrastructure is already in place : Constitution 1945 Act No 40/2004 on National Social Security System (SJSN) Act No 24/2011 on Social Security Agency (BPJS) Governmental Decree No 101/2012 on Beneficiaries Govt Subsidy (PBI) Presidential Decree No 12/2013 on Social Health Insurance (JKN)

ROADMAP TO UHC 2012 2013 2014 2015 2016 2017 2018 2019 Transformation from 4 existing schemes to BPJS Kesehatan (JPK Jamsostek, Jamkesmas, Askes PNS, TNI Polri ) Membership expansion to big, middle, small and micro enterprises Procedure setting on membership and contribution Company mapping and socialization Consumer satisfaction measurement every 6 month Integration of Jamkesda into BPJS Kesehatan and regulation of commercial insurance industry Pengalihan Kepesertaan TNI/POLRI ke BPJS Kesehatan Benefit package and sevices review annually Synchronization membership data: JPK Jamsostek, Jamkesmas dan Askes PNS/Sosial – single identity number Coverage of various existing schemes 148,2mio 121,6 mio covered by BPJS Keesehatan 50,07 mio covered by other schemes 257,5 mio (all Indonesian people) covered by BPJS Kesehatan Level of satisfaction 85% Activities: Transformation, Integration, Expansion B S K 73,8 mio uninsured people Uninsured people 90,4 mio Presidential decree on operational support for Army/Police 86,4 mio PBI `Enterprises 2014 2015 2016 2017 2018 2019 Big 20% 50% 75% 100%   Middle Small 10% 30% 70% Micro 25% 40% 60% 80% This is the roadmap which is taking us from launching of the system in 2014 to full achievement of UHC by 2019. This is probably more detail than we need here today but examining the roadmap we see that some activities are part of the on-going scheme from year one – for example from the beginning consumer satisfaction is to be measured every 6 months and benefit packages will be reviewed annually to be sure service is both effective and patient friendly. Coverage, is expanded year by year toward the goal of complete coverage in 2019. 20% 50% 75% 100% 10% 30% 70% 15

MEMBERSHIP Members All people who have paid premium or for whom it has been paid Two categories of members: a. People with incomes below the stipulated poverty line  premium paid by government b. All others pay the premium - workers in formal sector, independent members, including foreigners who work in Indonesia for 6 months or longer. The Indonesian National Social Health Insurance is a compulsory health insurance scheme in which everyone must enroll. MEMBERS : Everyone has paid their own contribution or for whom it has been paid 2 Categories of Members : a. Subsidized members : people with incomes below the stipulated poverty level b. All others who have paid contribution -- workers from formal and informal sector -- including foreigners who work in Indonesia at least 6 months.

Premium of National Health Insurance MEMBER PREMIUM Monthly membership fee (IDR) REMARK SUBSIDIZED MEMBER NOMINAL (per member) 19.225,- Class 3 IP care CIVIL SERVANT/ARMY/POLICE/ RETIRED 5% (per household ) 2% from employee 3% from employer Class 1 & 2 IP care OTHER WORKERS WHO RECEIVE MONTHLY SALARY/WAGE 4,5 % (per household) And 5% (per household) Until 30 June 2015: 0,5% from employee 4% from employer Start from 1 July2015: 1% from employee NON WAGE EARNERS/ INDEPENDENT MEMBERS 1. 25,500,- 2. 42,500,- 3. 59,500,- Class 2 IP care Class 1 IP care The premium of National Health Insurance that will be implemented next year: SUBSIDIZED MEMBER (PBI) : Rp 19.225,- per member per month, in patient benefit in ward class 3 CIVIL SERVANT/ARMY/POLICE/RETIRED : 5% of salary per household per month, which comes from 2% employee contribution and 3% employer contribution OTHER WORKERS WHO RECEIVE MONTHLY SALARY/WAGE: 4,5% of salary/wage per household per month, which comes from 0,5% employee contribution and 4% employer contribution starting from January 2014 until June 2015. And 5% of salary/wage per household per month starting from July 2015, which comes from 1% employee contribution and 4% employer contribution. FOR WORKERS WHO DO NOT RECEIVE MONTHLY SALARY/WAGE: there are 3 choices, the first one is Rp 25.500 per member per month for in patient benefit in ward class 3, the second one is Rp 42.500 per member per month for in patient benefit in ward class 2 and the third one is Rp 59.500 per member per month for in patient benefit in ward class 1.

BENEFIT PACKAGES Benefit package : personal health care covering promotive, preventive, curative & rehabilitative services Benefit package : includes both medical & non medical, such as hosp accommodation, ambulance etc Regulation stipulates services covered The Benefit Package under the scheme will be clearly defined and includes full spectrum of health concerns. The Benefit Package is focused on personal health care and covers promotive, preventive, curative and rehabilitative health services The benefit package includes both medical and non medical services, for example, accommodation and ambulance Regulations will stipulate services covered

FINANCE: CONTRIBUTION (PREMIUM) Contribution for people below the poverty line (PBI)→ paid by central (and local) government Contributions of members paying their own premium Workers in formal employment : premium is shared by employees and employer calculated as a % of salary/wage. Self and non employed: pay nominal/ flat rate (determined by Pres Decree) Contributions/ premiums are pooled and create the major source of funding for the scheme Payment of the individual contributions is an essential component in the design and management of the overall Social Health Insurance system. We have given great care, therefore, to achieve fair and accurate calculations for contributions. Funding for the scheme is made up as follows : Pooling of funds from contributions of individual members Subsidized Contribution for those below the poverty line (PBI) from central and/or local government Structuring the contribution of individual members : Workers in the formal sector : contribution is made up by employer and employee calculated as percentage of salary/ wage. Workers in the informal sector : a stipulated amount of money

HEALTH CARE PROVIDERS AND PAYMENT METHODS Healthcare providers Primary health care providers: Public Health Service, Private clinics, Primary Care Doctors Secondary & tertiary health care providers: Hospitals both public hospitals and private hospitals Payment methods Primary health care providers: capitation & non capitation Secondary and tertiary health care providers: Ina-CBG’s (Case-based Group) Health care providers and payment methods: Healthcare providers Primary health care providers: Public Health Service, Private clinic, Private Doctor Secondary and tertiary health care providers: Hospitals both public hospitals and private hospitals Payment methods Primary health care providers: capitation Secondary and tertiary health care providers: Ina-CBG’s (Indonesian - Case Based Groups)

ADMINISTRATION & MANAGEMENT Administered by BPJS Kesehatan (single payer) BPJS Kesehatan: managing members, healthcare providers, claims, complaints, etc Government: (MoH, MoF, DJSN), regulates, monitors and evaluate implementation MoH : sets regulations on delivery of health services, drug and medical devices, tariffs, etc Administration and management of National Health Insurance Administered by BPJS Kesehatan (single payer) BPJS Kesehatan managing members, healthcare providers, providers claim, member complain, etc Government (MoH, MoF, DJSN): monitors and evaluate implementation of National Health Insurance scheme MoH regulates delivery of health services, drug and medical devices, tariff, etc

NATIONAL HEALTH INSURANCE MINISTER OF HEALTH NATIONAL HEALTH INSURANCE Regulator BPJS Kesehatan Members Healthcare providers Contribution Complain management Contract Claims Payment utilization of service Delivery of service Regulation on delivery of health services Regulation on Quality of care, HR, Pharmaceutical, etc Regulation on standardization of tariff Government Referral system The mechanism which will come into effect from 2014 onward involves the following players with specific roles for each : The Government, specifically MoH : sets regulations for standardization  delivery of health services, tariff, drugs, and medical devices, etc BPJS Kesehatan : administers the health insurance scheme including collection of contributions, complaints management, contract arrangements, claim payments, etc Health Care Providers (public and private): provide health services Members of the public : pay contribution and utilize available services 22

TASK FORCES: Preparing For National Health Insurance Health facilities, referral system & infra-structure Finance, transformation of program & institutions, as needed Regulations Human resources & capacity building Pharmaceutical & medical devices Socialization & advocacy Building this systems for our large population, spread unevenly across our large nation has been a challenge. 6 task forces have worked on different aspects of the system. I include this not for all the details but to give you a sense of the many issues involved. Health facilities, referral system, and infrastructure Finance and transformation of program and institution, as needed Regulation Human resources and capacity building Pharmaceuticals and medical devices Socialization and advocacy

Preparations in line with roadmap/ action plan 1 Task force Tasks 1. Health facilities, referral system, and infrastructure Preparation of health care providers Strengthening of referral system by regionalization Procurement of medical devices Ratio: Medical doctor : 40/100.000 Dentist : 11/100.000 Midwives : 75/100.000: 4/PHC Nurses : 158/100.000: 6/PHC Total hospital : 2.138 hospitals Total bed : 264.303 beds Launcing this scheme is a technical, managerial, and financial challenge. Let me tell you a bit about the activity of the various working groups. Health facilities, referral system, infrastructure task force is doing on: Preparing health care providers Revitalization referral system by strengthening regionalization Procuring medical devices Finance and transformation of programs and institutions, as needed: Setting contributions and tariffs Preparing transformation of existing insurance programs: Jamkesmas, Askes PNS, Army/Police dan JPK Jamsostek Preparing transformation from PT Askes to BPJS Kesehatan for management

Preparations in line with roadmap/ action plan 2 Task force Tasks 2. Finance, transformation of programs and institutions, as needed Setting premiums and tariffs Preparing transformation of existing insurance & programs : Jamkesmas, Askes PNS, TNI Polri & JPK Jamsostek to Nat Soc Health Ins Preparing transformation/ migration of management PT Askes → BPJS Kesehatan Launcing this scheme is a technical, managerial, and financial challenge. Let me tell you a bit about the activity of the various working groups. Health facilities, referral system, infrastructure task force is doing on: Preparing health care providers Revitalization referral system by strengthening regionalization Procuring medical devices Finance and transformation of programs and institutions, as needed: Setting contributions and tariffs Preparing transformation of existing insurance programs: Jamkesmas, Askes PNS, Army/Police dan JPK Jamsostek Preparing transformation from PT Askes to BPJS Kesehatan for management

Preparations in line with roadmap/ action plan 3 Task Force Tasks 3. Regulation – regulatory infrastructure to support imple-mentation Dev of Government Decree No 101/2012 on Beneficiaries of Government subsidy (PBI) Pres Decree No 12/2013 on Social Health Insurance Other Decrees (Presidential & Gov) MoH decrees, regulations, and procedures for management of National Health Insurance Scheme 4. Human resources and capacity building Developing HR mapping, distribution, and assignment Design and carrying out training, as needed 3. Regulation task force : Arranging and passing Governmental Decree No 101/2012 on Beneficiaries of Govt subsidy (PBI) and Presidential Decree No 12/2013 on Social Health Insurance (SJSK). Preparing other Governmental Decrees and Presidential Decrees related to National Health Insurance scheme Preparing MoH decree the management of the scheme) 4. Human Resource and capacity building task force : Mapping of existing human resources and needs of the new national health insurance system, structuring and and assigning staff as needed Designing and carrying out staff training

Preparations in line with roadmap/ action plan 4 Preparations in line with roadmap/ action plan Task Force Tasks 5.Pharmaceutical and medical devices Setting formularies for drugs and medical devices Developing e-catalogue Forming Health Technology Assessment (HTA) team and their tasks 6. Socialization and advocacy Preparing strategy, materials ,and media for socialization of the new National Social Health Insurance scheme Conducting intensive and wide-reaching socialization and advocacy Pharmaceutical and medical devices task force : Setting drug and medical devices formulary Preparing e-catalogue Forming Health Technology Assessment (HTA) team and their tasks Socialization and advocacy task force : Preparing strategy, materials, and media to explain and socialize the new National Health Insurance scheme Conducting intensive and wide-reaching socialization, advocacy

HOW TO ENROLL? Registration: BPJS Kesehatan Offices (Headquarter, Regional and Branch Offices) Online registration  www.bpjs-kesehatan.go.id Mobile customer services HOTLINE: 500400 How to enroll the National Health Insurance? There are 3 ways: Register at BPJS Kesehatan Offices (headquarter, regional, branch offices) Online registration through website: www.bpjs-kesehatan.go.id Register at mobile customer services BPJS Kesehatan Hotline : 500400

Launching of the National Health Insurance Scheme and BPJS Kes 31 December: Year-end Message President SBY 1 Jan 2014: Simultanious launching in all Provinces, Cities and Districts by Governor/ Mayor/ District Head Payment of the individual contributions is an essential component in the design and management of the overall Social Health Insurance system. We have given great care, therefore, to achieve fair and accurate calculations for contributions. Funding for the scheme is made up as follows : Pooling of funds from contributions of individual members Subsidized Contribution for those below the poverty line (PBI) from central and/or local government Structuring the contribution of individual members : Workers in the formal sector : contribution is made up by employer and employee calculated as percentage of salary/ wage. Workers in the informal sector : a stipulated amount of money

CONCLUSION Indonesia’s National Social Health Insurance wil be launched on 1 Jan 2014 → legal basis from Constitution of 1945 to new regulations and decrees, as needed Coverage of National Health Insurance will expand gradually → Universal Coverage in 2019 Implementation of National Health Insurance calls for reforms, in both delivery of health services and health financing. Preparation well advanced for 1 January 2014 launch

Thank You