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

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

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

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

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

KONDISI KETENAGAAN DI FASYANKES PRIMER Percentage of Public Health Center (CHC) with Number of Doctor below Standard Provinsi dengan persentase jumlah dokter di bawah standar tertinggi ada di provinsi Papua Barat (84,38%), Papua (80,31%), Maluku Utara (68,07%), Maluku (67,42%), dan Sulawesi Tengah (63,64%). 32,86% of 9.510 PHC with number of doctor < standard 14,7% of PHC without doctor

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

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

Ante Natal Care, 2010-2013* * Periode 3 tahun terakhir

Proportion of Anemia during Pregnancy in Urban & Rural Area, 2013 *) Nilai rujukan menurut WHO/MNH/NHD/MNN/11.1,2011 dan Kemenkes,1999 **) Cut off points anemia Ibu Hamil, Hb < 11,0 g/dl

Proportion of Deliveries Attended by Skilled Health Personal 1, 20102-20133 Dr kandungan, dr umum dan bidan Periode 3 tahun terakhir, penolong terakhir Periode 3 tahun terakhir, jika > 1 penolong dipilih kualifikasi tertinggi

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

Proportion of Household Using Traditional Medicine, 2013

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

The Prevalence of Diabetes Mellitus by Province, 2007-2013 *) Diabetes Melitus (DM) responden 15+ berdasarkan wawancara menurut diagnosis dokter dan gejala

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

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

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

National Social Health Insurance (JKN) Regulator Insurance body (single payer) Members Healthcare providers Contribution Complain management Contract Claims Payment utilization of service Delivery of service Standardization of health care delivery Standardization of medicine, equipment, etc Regulation on tariff Government The National Social Health Insurance mechanism which come into effect from Jan 2014 involves the following players with specific roles : 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 : provide health services Members of the public : pay contribution and utilize available services 19

Roadmap To UHC 2012 2013 2014 2015 2016 2017 2018 2019 Transformation from 4 existing schemes to national insurance scheme (employee, poor people, civil servants ,army/police scheme) 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 local government insurance scheme into national social insurance and regulation of commercial insurance industry membership transfer of army/police scheme to 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 148,2 mio 111,6 mio covered by BPJS Keesehatan 60,07 mio covered by other schemes 257,5 mio (all Indonesian people) covered by national insurance scheme Level of satisfaction 85% Activities: Transformation, Integration, Expansion B M S 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% Members/Enrolees everyone who has paid contribution/premium or for whom it has been paid. Two categories of members: a. People with 40% the lowest incomes  the so called PBI (Penerima Bantuan Iuran), premium/contribution is paid by the government. b. All others pay the premium  workers formal & informal sector, includes foreigners who work in Indonesia 6 months or longer. Formal worker: contribution comes from sharing of employees and employer as a percentage of salary/wage. Informal worker: contribution as a nominal/ flat rate. Approx $6 PMPM (per month per member) for the 1st ward inpatient; $4,5 PMPM for 2nd ward inpatient; and $2,5 PMPM for 3rd ward inpatient. The numbers are determined by Presidential Decree and will be evaluated maximun in every two tears. These contributions from members are pooled as a major source of funding for the scheme. 20% 50% 75% 100% 10% 30% 70% 20

Referral System & National Formulary tertiary National formulary 923 items secondary Primary care Gate keeper Dalam Sistem Pelayanan Kesehatan kita (sesuai dengan dengan Perpres 72 tahun 2012), terdiri dari UKM (Usaha Kesehatan Masyarakat) dan UKP (Upaya Kesehatan Perorangan), dengan jenjang mulai dari Usaha Kesehatan Berbasis masyarakat, pelayanan primer, pelayanan sekunder dan pelayanan tersier. Semua ini masuk dalam suatu sistem kesatuan yang utuh. 155 disease/symptoms should be resolved in primary care community

PUBLIC GOODS AND PRIVATE GOODS IN PRIMARY HEALTH CARE Public Health Medical Care 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 HIV Screening Malaria prevention TB Dots Vaccine for basic immunization Basic contraception methods Medical care in primary health care facilities (capitation fee) Seperti yang sudah kami sampaikan di depan, Pelayanan kesehatan Primer terdiri dari dari 2, yaitu UKM dan UKP. Dan untuk pembiayaannya, untuk UKM dibiayai oleh Pemerintah sedangkan untuk UKP pembiayaannya dilakukan oleh BPJS Kesehatan. Public Insurance Body FUNDED BY GOVERNMENT

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

PUBLIC & PRIVATE GOODS IN PRIMARY HEALTH CARE Public Health Medical Care 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 HIV Screening Malaria prevention TB Dots Vaccine for basic immunization Basic contraception methods Medical care in primary health care facilities (capitation fee) Seperti yang sudah kami sampaikan di depan, Pelayanan kesehatan Primer terdiri dari dari 2, yaitu UKM dan UKP. Dan untuk pembiayaannya, untuk UKM dibiayai oleh Pemerintah sedangkan untuk UKP pembiayaannya dilakukan oleh BPJS Kesehatan. Public Insurance Body FUNDED BY GOVERNMENT

Visits and Referral in Primary Care January-February 2014 Month Visits Referral (%) January 914.560 120.697 (13,1) February 1.514.796 220.480 (14,5) There is significant increase of visits to primary care in the first 2 months, but the refferal was quite normal around 15% Utilization rate : 12% Sumber Data BPJS Kes, 2014