Teguh AryandonoProfessor of Surgery,

Dean of Faculty of MedicineUniversitas Gadjah Mada,

Yogyakarta

IntroductionHealth Care System in IndonesiaUniversal Health Coverage in IndonesiaRole of Academic Health CentersSome problem and solutionSummary

Population : more than 240 millionsMore than 17,000 islandsMulti ethnicsMulti culture background

  estimate capita by the Female Male mortality Males Females <20 ≥65   (in millions) (US$) Worldbank per 1000 live births years of ageSource UN World Bank WHO* WHO* WHO* UNESCO UNESCO

Table 1. Health and Development Indicators per ASEAN Country for 2008  

Country Population GDP per Classification Life expectancy1 Infant Literacy rate (% age ≥15) Proportion     Brunei

 0.4

 43,751

 High income 77 75

 3 97 94 36 3

Cambodia 14.5 741 Low income 64 59 31 85 71 47 3Indonesia 225.9 2,180 Lower middle income 69 66 19 95 89 37 6Laos 6.2 829 Low income 63 61 20 83 63 50 4Malaysia 26.8 7,866 Upper middle income 76 71 3 95 90 40 5Myanmar 49.4 233 Low income 56 53 48 95 90 37 5Philippines 89.6 1,907 Lower middle income 74 67 15 95 96 45 4Singapore 4.6 41,291 High income 83 79 1 98 92 25 9Thailand 67.0 4,098 Upper middle income 74 66 10 96 92 30 7Vietnam 86.6 1,047 Low middle income 75 70 9 95 91 37 61at birth; WHO, World Health Organization *(http://www.who.int/whosis/whostat/2010/en/); UN, United Nations (Population Reference Bureau, UN Statistics Division); IMF, International Monetary Fund (http://www.imf.org/external/data.htm#data);

 1The George Institute for Global Health, 2The University of Queensland, Queensland Children’s Medical Research Institute and School of Population Health, 3University of New South Wales, School of Medical Sciences *For correspondence: mkimman@ georgeinstitute.org.au

Located in the central part of Java IslandPopulation: 3.5 millionFour districts and 1 city: ◦ Yogyakarta city◦ Sleman◦ Bantul◦ Kulonprogo◦ Gunungkidul

Universitas Gadjah Mada (UGM)established on December 19, 1949

Faculty of Medicine UGMestablished on March 5, 1946

UNIVERSITAS GADJAH MADA

Education Research Services

67 Years FM UGM

UNDERGRADUATE

Medical Doctor

Nursing Health Nutrition

1946 - now

2000 - now

2003 - now

GRADUATE

MSc/MPH

Biomedical Science

Public Health

Tropical Medicine

Clinical Medicine

Occupational Health

Medical Education

Nursing

Specialist 20 residency training programme

PhDBasic Medical Science, Public Health, Clinical Medicine, Medical Education

Webometrics 2009-2014◦ First Rank in Indonesia◦ Ranked 12 in South-east Asian (2014)

Accreditation of Higher Academic Institution◦ Highest score in Indonesia

For International College University (4ICU) Asia: ◦ 53rd (2011); 42th (2014)

18 Faculties and 2 Schools1 Academic hospitalAffiliated teaching hospitals (JCI accredited for AMC at Sardjitohospital)

Sardjito hospital

Faculty of Medicine UGM

3 undergraduate programs ( Medical, Nursing, Health Nutrition)6 master programs1 doctoral program20 clinical specialization programs 26 Departments14 Research centers‐WGs>1,000 staffs  (teaching and administrative)>500 new undergraduate students>600 new graduate students and residents

FERCAP recognition to the Ethical CommitteeReward from the National Body for NarcoticaReward from the National Innovation CommitteeYoung Scientist Award from ProSPER.Net-ScopusThe best scientist in Ristek-Kalbe Science AwardTsutsui-Fujino Prize (Japan)WHO‐TDR Regional training centre for Good Clinical Practice, Good Clinical Laboratory Practice , Good Health Research Practice Regional training centre for TB & neglected disease Regional training centre for Family planning and reproductive health (Oct, 2014)

1. Clinical Epidemiology & Biostatistics Unit (1985‐)2. Bioethics and Medical Humanities (1992) 3. Reproductive Health (1993‐)4. Tropical Medicine (1996‐)5. Health Policy and Management (1997‐)6. Health Promotion and Behaviour (2000‐)7. Financing Policy & Insurance Management (2003‐

)8. Health and Human Nutrition (2007‐)9. Herbal Medicine (2012‐)10. Pediatric Research Office11. Cancer and other working groups

Biomolecular labYayasan Tahija Dengue  labMDR‐TB labAnimal  labShared lab 

0 10 20 30 40 50 60

2008

2009

2010

2011

2012

2013

Oral Rv3 rotavirus vaccine research in

Indonesia (Bill&Melinda Gates

Foundation)

Malaria Transmission Consortium

(Bill&Melinda Gates Foundation)

Monitoring progress Family Planning 2020 (Future Institute and Bill&Melinda Gates

Foundation)

USAID-TBCTA Regional Training

Centre for TB control & Neglected Infectious Disease Diagnostic Consortium (EU)

Primary Care Accelerator Program and InterUniversity

Consortium on Global Health (New Proposal)

Knowledge Sector Initiative, HIV-AIDS,

Sister hospital (Ausaid), Health policy

network (Ausaid, IDRC)

Eliminate Dengue Project-Tahija

Foundation and Dengue Waening

Signs (WHO-TDR)

Fever Study-INA Respond (NIH USA R&D in collaboration with MOH & Teaching

Hospitals)

Translational research on Nasopharyngeal Cancer and other types of Cancer (IRAC, AvL and

partners)

Development Plan I2005-2009

Development Plan II2010-2014

Development Plan III2015-2019

Development Plan IV2020-2025

Health development is directed to improve access and quality of health services

Community access to a qualified of health services has been improving

Community access to a qualified of health services has been steady

Community access to a qualified of health services has been reaching out across the country

CURATIVE-REHABILITATIVE

The development of health through curative and rehabilitative approaches moving toward promotion and preventive approaches according to the condition and needs.

VISION:AN INDEPENDENT HEALTHY COMMUNITYPROMOTION-

PREVENTION

27

Health Center

Sub Health Center

Mobil Health Center

District Health Officer

Doctor Practice

Hospital Type D

Hospital Type C

Hospital Type B

Private Hospital

Hospital Type A

Private Clinic Multi

Specialist

PUBLIC HOSPITALPUBLIC

PRIMARY CAREPRIVATE HEALTH

CARE

Private Clinic Mono

Specialist

Midwive Practice

Posyandu

Dominated by: Curative careEpisodic careFee for serviceSelf-referralMulti incomeMulti jobs

Nurse Practice

Village Health

Pos

8.737

22.651

755

768

51.996

266.827

241 million pop (2011) 55% Uninsured, 45% Insured

C O M M U N I T Y

Bias loyalityConflict interest

PHC implementation

Copy IDI 2013

Year 2014 : 80 millions population2015 : 120 millions2019 : 100%

30

STRATA 3 :

Subspecialist, specialist

( Sardjito General UnivHosp)

STRATA 2:

Specialist

( UGM Academic Hospital)

STRATA 1 :

Primary Health Care, Family Doctor, Clinics,

Gadjah Mada Medical Centre

Referral in Health Care System

Not equitable

optimum

• Not equitable distribution

• Quality varies• Referral

system not optimum

• Payment system not optimum

• Development

agreement

• Development of health facilities & health professional comprehensively

• Evaluation & payment agreement

• Adequate numberEquitable

economical price for citizen

• Adequate number

• Equitable distribution

• Referral system well function

• Payment via prospective and economical price for citizen

PROGRAM ACTIVITIES

202012

202013

202014

202015

202016

202017

202018

202019Action Plan on

the development of

Health Facilities,

Health Professional,

Referral System & Infrastructure

Roadmap Implementation: development of health facilities, health professional, referral system and other infrastructures

Yearly Review on the eligibility of health facilities, credential, service quality and tariff adjustment

Implementation, monitoring and improvement of referral system and utilization study

Implementasi pembayaran Kapitasi dan INA-CBGs sertapenyesuaian besaran biaya dua tahunan dengan harga

keekonomian

Preparation of Standards, Procedures and Payment of Health

Facilities

Source: Paparan Wamenkes, Perkembangan Persiapan SJSN, 20-11-2012

Development of Health FacilitiesDevelopment of Health ProfessionalsReferral SystemIntegrated Health System

Primary Health Care

Referral Health Care

Other Health Care

Value added

COMMERCIAL HEALTH

INSURANCE

NATIONAL HEALTH

INSURANCE

COORDINATION OF BENEFIT (COB)

Perpres No. 12 Th. 2013 ttg Jaminan

Several University Hospital and Faculty of Medicine

Regulation of Ministry of Health together with Ministry of Education

Academic Health Centers : Makassar, Yogyakarta, Bandung, Semarang, Jakarta

Try to find the system and structure

Faculty of Medicine, UGM- one of the best faculty of medicine in IndonesiaMember of WFME, AUN, PAASCU Accreditation (on going)

Sardjito General University Hospital, Joint Commission International Accreditation for Academic Medical Center, 750 beds , Type A, tertiary Hospital

UGM Academic Hospital , 125 beds, Type B, secondary hospital

Suradji Tirtonegoro Hospital, Klaten – important Teaching Hospital of FM, 432 beds, type B ongoing A, secondary hospital

10 teaching hospitals – for undergraduate and profession students32 referral hospitals – for residency training

Sister Hospitals- send senior residents, specialists- improve managerial capacity building, facilities- collaboration with health authority and local

district government- fund : AUSAID, local government

Remote hospital : Bajawa, Flores

Scholarship specialist training – Ministry of Health

Funds : Ministry of Health16 -20 hospitals in remote areasResidents and supervisor, ITImprove clinical services quality

AHC as coordinator

Education- standardized curricula for undergraduate,

profession and residents for teaching and partner hospitals

- share education facilities, IT- capacity building for staffs in teaching hospitals : TOT- Education Coordinators in and between institutions

Research- Coordinated Ethical Committee in Faculty of Med

and University Hospital- Sharing research budget, scholarships- Sharing Laboratory Facilities- Capacity building for researchers :GCP, GCLP- Organize clinical trial

Patients carePriority / Center of Excellence : different for 3 hospitalsImprovement quality ( JCI Accreditation)Sharing Facilities : CT Scan, MRI, Gamma Camera, ICU – not only 3 hospitalsSharing health professionals : send specialist to referral hospitalsSend senior residents for health services

Referral system

Sardjito General University Hospital (Tertiary Healthcare)Cancer CenterCardiac CenterGeriatric center with homecare

UGM Academic Hospital ( Secondary Healthcare)NeuroscienceNephrologyChildren Growth and Development , for disable

Suradji Hospital,KlatenGeriatric Center , comprehensive care

Limited facilitiesnew referral system – long waiting list

Limited manpower/ specialistsmostly in the big citiesspecialist reluctancy to go to remote areasproblem of distribution

Limited budgetHospital priority

Different owner of HospitalsMinistry of Research and Higher Education, Ministry of Health, Ministry of Defense - budget

Regulation and renumerationDifferent Ministry

IntegrationFor education, research and patients careSharing Budget, PrioritySharing Facilities

Integration Team : planning, action, monitoring, evaluation ( Prof. Budi Mulyono, Dr.Endro Basuki)Hospital Supervisor ( Prof Yati Soenarto, et al)

High level integration : Structural Integration : One Board of Directors or Integration of Function between Institutions( on going)

New Health Care System : promising for improving population health

Integration of Faculty of Medicine, University Hospitals and Referral Hospitals in education, research and patient care in AHC system, support and accelerate Universal Health Coverage for the community

Partnership with National and International Collaborators very important (AAHCI)