!universal!health!coverage!in!asean!countries! and!its ... 8! uhc!in!asean!countries! 8! country pop...
TRANSCRIPT
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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 MukB Msc, Phd, “InternaBonal Conference: on Health Equity in Asia: ReproducBve Health /
Disaster and Health Management to Achieve MDGs”
University of Indonesia, 12 December 2012
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PresentaCon Outline 1. Equity and Health Financing System 2. UHC In ASEAN Countries 5. NaConal Priority Agenda : Towards UHC 6. PreparaCon of Social Security Law
implementaCon and challenges a) Roadmap of membership and Premium
EsCmaCon b) Roadmap benefit package, health services &
subsidy Scheme 5. Health Human Resources Conclussion
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012 Indonesia Vice MoH: UHC & Challenges 2
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1. EQUITY AND HEALTH FINANCING SYSTEM
Indonesia Vice MoH: UHC & Challenges 3
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012
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12/12/2012 Indonesia Vice MoH: UHC & Challenges 4
Resources (Man, Facility,
Equipment, Farmacy)
Health Services
Health Status
Stewardship
WHO World Health Report, 2000
Responsiveness
Financing Fairness/ Equity
Equity in Health Financing System As part of National Health System
Health System Performance
Goal Performance
FuncCons the system Perform ObjecCve of the system
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Policy on Health Financing
12/12/2012 Indonesia Vice MoH: UHC & Challenges 5
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
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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KEMENTERIAN KESEHATAN REPUBLIK INDONESIA Health Service System &
Finance
Public Health& Goods Private Goods
Health Insurance (Individual Health)
Community Health
Healthy Individu and DTPK Sick Individu
Reffe
rral sy
stem
6 Indonesia Vice MoH: UHC & Challenges 12/12/2012
Clinics; Laboratory, inpaCent care
Integrated health post;PHN, sanitaCion;, health promoCon; school health, school dental health; comm dental health
Premium BPJS
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Key HCF indicator in ASEAN Countries 2007
THE, %
GDP
GGHE, % THE
Priv. HE, % of THE
GGHE, %
government
expenditure
External, % of THE
SHI, %
THE
OOP, % THE
THE per capita US$
THE Per capita
PPP int. $
Malaysia 4.4 44.4 55.6 6.9 0.0 0.4 40.7 307.2 604.4 Thailand 3.7 73.2 26.8 13.1 0.3 7.1 19.2 136.5 285.7 Indonesia 2.2 54.5 45.5 6.2 1.7 8.7 30.1 41.8 81.0 Philippines 3.9 34.7 65.3 6.7 1.3 7.7 54.7 62.6 130.2 Viet Nam 7.1 39.3 60.7 8.7 1.6 12.7 54.8 58.3 182.7 Lao DPR 4.0 18.9 81.1 3.7 14.5 2.3 61.7 26.9 83.9 Cambodia 5.9 29.0 71.0 11.2 16.4 0.0 60.1 36.8 108.1 Low income 5.3 41.9 58.1 8.7 17.5 4.6 48.3 26.8 67.0 Lower middle Income 4.3 42.4 57.6 7.9 1.0 15.8 52.1 80.2 181.0 Upper middle Income 6.4 55.2 44.8 9.4 0.2 21.0 30.9 487.9 757.0 High Income 11.2 61.3 38.7 17.2 0.0 25.6 14.0 4,405.2 4,145.0 GLOBAL 9.7 59.6 40.4 15.4 0.2 24.6 17.7 802.3 862.5
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8
UHC IN ASEAN Countries
8
Country Pop coverage
Health service coverage Financial protection*
Malaysia 100% PHC services focus on MNCH. But long waiting time, and limited number of family physicians; Survey reports 62% of ambulatory care was provided by private clinics
40.7%
Thailand 98% Comprehensive benefit package, free at point of service for all three public insurance schemes
19.2%
Indonesia 48% Good policy intention but low per capita government subsidy for the poor of US$ 6 per year
30.1%
Philippines 76% High level of co-payment, 54% of the bill are reimbursed 54.7%
Vietnam 54.8% Benefit package comprehensive but substantial level of co-payment, 5-20% of medical bills
54.8%
Lao PDR 7.7% Low level of government funding support to the poor results in a small service package
61.7%
Cambodia 24% The poor covered by the health equity fund but the scope and quality of care provided at government health facilities are limited
60.1%
Financial protecCon * measured by OOP as % of THE, 2007
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9
Fiscal Space and the Government Health Exp and UHC
9
Figure 2 Fiscal 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.
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HRH Availability vs GDP per capita
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DensiCes of doctors, nurses, and midwives, per 1,000 populaCon
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ProducCon capacity of doctors, nurses, and midwives, per 100,000 populaCon
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13
ProducCon capacity of doctors, nurses, and midwives
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Community Health Status
National Goals
NaBonal Health System
NaBonal Long-‐Term Plan
Development
Current conditions
Community health status not optimally yet
Basic problem on health development:
STRATEGIC ENVIRONMENT: (IdeologiY PolitiC, EConomiY, Soscal Culture and
national security)
GLOBAL, REGIONAL, NATIONAL, LOCAL
Opportunity and Barrier
NATIONAL PARADIGM:
(PANCASILA, UUD 1945,WASANTARA,TANNAS,)
(Law no 36/2009 Health, Law No 17/2007 RPJPN)
Develpment Based on Health
Healthy & Productive People
-‐ 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
NATIONAL HEALTH SYSTEM AND SOCIAL SECURITY IN INDONESIA HEALTH DEVELOPMENT PLAN
Sumber: Rancangan Perpres R.I ttg Sistem Kesehatan Nasional 2012 (12-‐4-‐2012) Modifikasi dari Presentasi Hapsoro
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012 Indonesia Vice MoH: UHC & Challenges 14
Private Goods (SJSN) Law no
40/2004
Public Goods
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Indonesia MoH Vission: 8 NaConal Focus & 7 Priority ReformaCon
8 NATIONAL FOCUS PRIORITY FOR HEALTH
1. Improving maternal health and fam planning
2. Comm nutrition improvement 3. CD and NCD control,
environmental health 4. Fulfiling Health HR
5. Improving Availbility, affordability, safety, quality, food and farmacys
6. Jamkesmas (health insurance for the poor)
7. Community development, disaster and crisis management
8. Improving primary, secondary and tertiary health care
7 PRIORITY HEALTH REFORMATION 1. HEALTH INSURANCE 2. Health services in very
remote area (DTPK) 3. Availability of farmacy,
health equipment in every health facility
4. Birocration Reform 5. Bantuan Operasional
Kesehatan (BOK) 6. Overcoming districts
Health problem (PDBK) 7. Indonesia World class
Hospital
RPJMN 2010 – 2014 (National Middle Development Plan)
MDGS 2015
VISSION : Self Reliant Healthy People within a just health care system
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
Universal Coverage 2014
12/12/2012 Indonesia Vice MoH: UHC & Challenges 15
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Social Security Law & The ImplementaBon
12/12/2012 Indonesia Vice MoH: UHC & Challenges
Law No 40 Year 2004: NaBonal Social Security
System (SJSN):
Universal Health Coverage
Law No 24 Year 2011: Secial Security Carrier
(BPJS) -‐ 5 Program à the 1st program implementaBon is HEALTH -‐ Execute based on humanity, benefit, & social fairness
To provide basic life need nesessarily for
all member
16
Law No 17 Year 2010 : NaBonal Development Middle Plan (RPJMN)
MoH Indonesia was planned to achieve UHC
in the 2014
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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ImplementaCon NaConal Social Security System (SJSN) for Health Program KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
Regulator
BPJS Kesehatan
Health Insurance Member
Health Facility Searching services
Provide Services
RegulaCon of health system (refferral, dll)
RegulaCon (stadarizaCon) h service quality; farmacy,
medical supplies
RegulaCon of Health Service Tarriff and Cost-‐
sharing
Public Health & Goods Program Handling
Handling health services in very remote area (DTPK), dll
Kend
ali Biaya & kualitas Yankes
Government
17 Indonesia Vice MoH: UHC & Challenges
Refferral system Non member; who
finally become member
12/12/2012
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2. PREPARATION OF SOCIAL SECURITY LAW IMPLEMENTATION AND CHALLENGES
Indonesia Vice MoH: UHC & Challenges 18
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012
ROADMAP: a. MEMBERSHIP & PREMIUM,
b. HEALTH SERVICES, BENEFIT PACKAGE,
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Financing
Membership
Benefit Package
Sumber: WHO, The World Health Report. Health System Financing; the Path to Universal Coverage, WHO, 2010, p.12
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012 Indonesia Vice MoH: UHC & Challenges 19
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2A. ROADMAP MEMBERSHIP AND PREMIUM ESTIMATION
Indonesia Vice MoH: UHC & Challenges 20
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012
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Health insurance
Compulsory Population
Non poor
Poor
JK Free
choice
Government
Iuran/premi
Iuran/premiuj
Premium Subsidy Receiver (PBI ):
Membership of Social Health Insurance : Towards UHC
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Membership Roadmap towards Universal Health Coverage
20% 50% 75% 100%
20% 50% 75% 100%
10% 30% 50% 70% 100% 100%
`Company (Perusahaan) 2014 2015 2016 2017 2018 2019
Big company 20% 50% 75% 100% Middle company 20% 50% 75% 100% Small co 10% 30% 50% 70% 100% Micro co. 10% 25% 40% 60% 80% 100%
2012 2013 2014 2015 2016 2017 2018 2019
Transforming JPK Jamsostek, Jamkesmas, PJKMU to BPJS Kesehatan
Membership ExtenCon of big company, midle, smal and micro Sejng up Systen
Procedure of Membership and Premium
Companies Mapping and socializaBon
Membership saBsfacBon measurement periodically, twice a year
IntegraCon member of Jamkesda/PJKMU Askes comercial to BPJS Kesehatan
Transforming TNI/POLRI membership to BPJS Kesehatan
Review of Benefit Package and Health Services Refinement
Sinkronizing Membership Data of JPK Jamsostek, Jamkesmas and
Askes PNS/Sosial – using ciBzen ID
CiCzen has been cover with several scheme 148,2 million
124,3 million member be managed by BPJS Health Program
50,07 million managed by non BPJS
Kesehatan
257,5 million (all ciCzen) manage by BPJS Keesehatan
Membership SaCsfacCon level 85%
AcCviCes : TransformaCon, IntegraCon, extenCon
B S K
73,8 million has not yet being member
90,4 million has not yet being member
President RegulaCon of TNI POLRI OperaConal Health Support
96,4 million subsidy 2,5 subsidy for
people without ID KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
22 Indonesia Vice MoH: UHC & Challenges 12/12/2012
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Health Insurance Coverage, Year 2011
12/12/2012 Indonesia Vice MoH: UHC & Challenges 23
Jamkesmas, 76,400,000 ,
32%
Govt employ & Fam,
19,564,265 , 8% Jamostek &
Fam, 5,183,479 , 2%
Jamkesda, 31,866,892 ,
13%
Private Insurance,
2,856,539 , 1%
Company , 15,351,532 , 7%
No Insurance, 87,055,320 ,
37%
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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2014 Membership PredicCon BPJS Health Program, 2014 membership % Premium subsidy receiver w/ complete ID 96.400.000 39,34% Premium subsidy receiver w/o ID 2.500.000 1,02% Govt emply & Fam 19.363.208 7,90% Jamsostek & Fam 6.075.200 2,48% sub-‐ Total 124.338.408 50,75%
Non BPJS Health Program 0,00% Jamkesda 31.866.390 45,13% Company provide insurance 15.351.532 21,74% Private insurance 2.856.539 4,05% Sub-‐Total 50.074.461 70,92% PopulaCon with health insurance 174.412.869 121,66% PopulaCon without health insurance 70.608.831 100,00% PopulaCon 245.021.700 221,66% 12/12/2012 Indonesia Vice MoH: UHC & Challenges 24
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Membership (arCcle 20, SJSN)
• Member: is every single ciCzen 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 addiConal premium
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
Will be differenBated b/w subsidy receiver and non subsidy
Premium
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2B. ROADMAP: BENEFIT PACKAGE, HEALTH SERVICES
Indonesia Vice MoH: UHC & Challenges 26
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012
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KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
Medical Benefit Package
Based on Medical Need :
1. Health Service covered 2. Health Service limited
3. H Service with cost-‐sharing 4. Health Service NOT covered
NON Medical Benefit Package
• It was agreed: At least similar to current benefit
Benefit Package in UHC
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Benefit Package and Premium
2012 2013 2014 2015 2016 2017 2018 2019
Consensus Benefit package;
stated on President
RegulaCon, by Nov 2011
Jamkes President RegulaCon adjusted
Various Benefit of various scheme, not yet based on medical needs
-‐ Benefit Package standart is
comprehensive as medical need
-‐ Differ in hospitality
Premium : DifferenBate between
PBI from Non PBI
Similar Benefit package
Premium RelaCvely equal to economic
level for all populaCon
AcCviCes
Various premium
Review periodically on sallry, premium, benefit package effecCveness, payment among region
UClizaCon Review to ensure eficiency, reduce moral hazard, improve saCsfacCon of membership, human resources and health facility
Jamkes President RegulaCon adjusted
Premium agreed for PBI : Rp. 22.201) Premium for Non PBI sCll on going discussion : 5% of sallary 3% -‐ 2%;
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Health Service Aspect
2012 2013 2014 2015 2016 2017 2018 2019 AcCon plan of health facility, HHR, referral
health system and infrastructure
Periodically Review of health facility eligibility, credensialing, Quality of care, and payment and tarrif economically adjusted
ImplementaCon, monitoring and referral health refinement and uClizaCon review
• Health facility distribusCon not opCmum; various quality of services, referral helth system not opCmum yet; payment system not opCmum yet
-‐ health facility extenCon and
development incl human health resources
-‐ EvaluasCon and determined payment
• Jumlah mencukupi • Distribusi merata • Sistem rujukan berfungsi opCmal
• Pembayaran dengan cara
prospekCf dan harga keekonomian untuk semua penduduk
AcBviBes
Implementasi roadmap: facilty development, HR, referral system, and other infrastructure.
Designing Standart and payment
procedure, and health facility
ImplementaCon payment mechanism : KapitaCon, INA-‐CBGs; including serta penyesuaian payment and tarrif economically adjusted every 2 years
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Referral Health System
• The referral health system has been renewd à Ministry of Health RegulaCon 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
12/12/2012 Indonesia Vice MoH: UHC & Challenges 30
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Referral Health System
TerCary Care
Secondary Care
Primary Care
12/12/2012 Indonesia Vice MoH: UHC & Challenges 31
Hospital type A/ B Hospital with sub-‐spesialist doctor
Hospital type D/C Hospital type D: Hospital with GP & 4 basicc specialist (Obgyn, pediaCcs, surgery, internist)
Health Centers, Private Clinics, private doctors
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Water & Electricity Health Center without Water 852 Health Center with no 24 hours electricity 4.160 Source: PODES, 2010
Source: RIFASKES, 2011
12/12/2012 Indonesia Vice MoH: UHC & Challenges 32
5385, 64%
2026, 24%
828, 10% 198, 2%
Health Center condiBon
Good
slight damage
mild damage
severe damage
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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The DistribuCon of Hospital &Health Center (Puskesmas)
Beds per Provinsi KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
(20,000)
(15,000)
(10,000)
(5,000)
-‐
5,000
10,000
DKI JAK
ARTA
SUMUT
DIY
SULU
T
NTT
SULSEL
NAD
KALTIM
MAL
UKU
SUMBA
R
B A L I
KEPR
I
SULTEN
G
PAPU
A
IRJABA
R
MAL
UT
GORO
NTA
LO
BABE
L
BENGK
ULU
KALBAR
SULBAR
J A M
B I
R I A
U
JATENG
KALTEN
G
SULTRA
NTB
KALSEL
SUMSEL
LAMPU
NG
JATIM
BANTEN
JABA
R
Beds Disparity
CondiCon Per-‐April 2012
12/12/2012 Indonesia Vice MoH: UHC & Challenges 33
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Primary Care Policy adjustment (1)
12/12/2012 Indonesia Vice MoH: UHC & Challenges 34
Type Urban Type Standart (Rural)
Type DTPK (very remote)
Adjustment of Main funcBon 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
InformaBon Technology : How is the ervices system, referral among Primary Care, Standart tarrif, etc
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Secondary – TerCery Care Policy
12/12/2012 Indonesia Vice MoH: UHC & Challenges 35
Hospital Type A,B
Hospital TypeC,D
RS Pratama?
Main FuncBon : How is main funcBon 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/TerBery Care?
How is System Informasi Technologi:
Private hospital type
Clinic SpesialisBc?
GP / Spesialis individual PracBce?
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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RSD MAJALENGKA
RS Pertamina Klayan
RSUD ARJAWINANGUN
RS TANGKIL
RS MITRA PLUMBON
RSUD WALED
RS GUNUNG DJATI
RST CIREMAI
RS PELABUHAN
PINTU TOL YANG ADA
Industri Rotan
Penghasil MIGAS Pertamina
Anjung MIGAS Lepas pantai
Industri kue
RS PUTRA BAHAGIA
RS SUMBER WARAS
RS MEDIMAS
RSIA SUMBER KASIH
Industri BaCk Trusmi
RSD INDRAMAYU
RSD KUNINGAN
RSD MAJALENGKA
Mapping model Regionalization referral system using GIS approach:
At Ciayumajakuning Jabar
36 Indonesia Vice MoH: UHC & Challenges
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12/12/2012
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3. HEALTH HUMAN RESOURCES
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Development & Empowerment of HHR in relaBon with Health Development & HHR Stndard
HHR Health Resourc
es
Comm Empowement
Health Effort
Comm Health Status
1. AdvocaCon, coord, strengthening plan
2. Need Pllanning 3. Establishing Prof Std &
competencies 4. EsCmaCng types,
amoubt,
1. Educ based on HS standard 2. Determine std of educ &
competences 3. Educ InsCtuConal
regulaCon 4. Inst educ AccrediataCon
Social , Religion & Culture
Resources & HRR Quality Monitor
HHR Planning
Deploying DiistribuBon HRR
Health Development Blue
Print IT
1. SelecCon, recruitment, deploy
2. CompensaCon 3. Carrier dev 4. Training 5. External HRR
Health Environment
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
38 Indonesia Vice MoH: UHC & Challenges 12/12/2012
Deploying DiistribuBon HHR
HRR Development & Empowerment
4.Prof ethic
3.Educ Standard
2.Prof Standard 1.Service
Standard
Economic Environment
R & D
Health Management
Culture Changes Phisical & Biological Envi
PoliCcs & Law Envi
Health Facility
Fundamen of Moral Humanity
Science & Technology
1. DirecCon, strengthening RegulaCon support,
1. serCficaCon, registraCon, 2. Compentency exam 3. IT support 4. Resources support
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Fufilling the HR Gap Strategy
1. Medical Doctor SpesialiCes Program (PPDS) 2. Program Doctor Plus 3. Non Permanent Employer (PTT) 4. Individual special assigment (Residen & D-‐3
Nakes) 5. Team special assigment (team based)-‐à
contracCng & contracCng out 6. Revising recruitment and posing regulaCon
including carrier path
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12/12/2012 Indonesia Vice MoH: UHC & Challenges 39
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4. CONCLUSSION
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
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Conclusion (1)
• Ensuring access to health preven2on and health care services -‐ especially for some par2cular groups like newborn baby, under-‐5 children, and pregnant mother will be fostering the achievements of MDGs.
• Empowering the community in improving health and sanita2on which will result to the improvement of health status of the society
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Conclussion (2) KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
Indonesia is going to achieve UHC • The Indonesia Law No (40/2004; 17/2010; 24/2011) à support to achieve Universal Health Coverage
• End of 2011 has already reached 63% of populaCon or 142 million people have health insurance with different type of insurance and benefit package
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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
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Conclussion (4) KEMENTERIAN KESEHATAN
REPUBLIK INDONESIA
• Agreed that the premium will be differenCated between PBI (subsidy for the poor) and Non PBI (non subsidy for non poor)
• The amount of Premium is sCll undergoing discussion
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THANK YOU TERIMA KASIH MATUR NUWUN
KEMENTERIAN KESEHATAN REPUBLIK INDONESIA
12/12/2012 Indonesia Vice MoH: UHC & Challenges 45