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Primary Health Care in Indonesia:Challenges and Opportunities
Prof. Dr. dr. Akmal TaherDirectorate General of Health Services
Ministry of Health Indonesia
Indonesia is an archipelagic nation containing over 18,000 islands.Number of Population : 259.940.857Land Sizes : 1,904,569 km2Number of Provinces : 34 ProvincesNumber of Districts : 497 DistrictsNumber 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
1. Mpther & child2. Nutrition3. Sanitation4. Communicable disease control (+ NCD)5. Health promotion6. Basic medical & emergency care
6
Percentage of Public Health Center (CHC) with Number of Doctor below Standard
KONDISI KETENAGAAN DI FASYANKES PRIMER
32,86% of 9.510 PHC with number of doctor < standard14,7% 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
Sumbar
Kalsel
Aceh
Riau
NTB
Sulteng
Jabar
Indonesia
Banten
DIY
Kaltim
Sulsel
Kep.Ria
u
Kalteng
Malu
t
Sulbar
Sulut
0.0
20.0
40.0
60.0
80.0
100.0
23.2
47.0
2007 2013
Proportion of Married Women of 15-49 years old in Family Planning Program, 2010-2013
Pa
pu
aM
alu
kuN
TT
Pa
ba
rK
ep
.Ria
uS
um
ut
Ma
lut
Ace
hS
ulb
ar
Su
lse
lS
ultr
aS
um
ba
rD
KI
DIY
Ria
uK
alti
mN
TB
Su
lten
gIN
DO
NE
SIA
Ba
nte
nJa
timJa
ten
gB
ali
Jab
ar
Ba
be
lG
oro
nta
loS
ulu
tK
als
el
Su
mse
lB
en
gku
luK
alte
ng
Jam
bi
Ka
lba
rL
am
pu
ng0.0
20.0
40.0
60.0
80.0
100.0
55.8
59.7
2010 2013
Ante Natal Care, 2010-2013*M
alu
kuP
ap
ua
Pa
ba
rM
alu
tS
ulb
ar
Su
lten
gK
alte
ng
Su
ltra
Go
ron
talo
NT
TS
uls
el
Ka
lba
rS
um
sel
Su
mu
tJa
mb
iS
ulu
tK
als
el
Ace
hB
en
gku
luS
um
ba
rR
iau
Ka
ltim
Ba
nte
nIN
DO
NE
SIA
Ba
be
lN
TB
Jab
ar
Jatim
La
mp
un
gK
ep
.Ria
uD
KI
Jate
ng
Ba
liD
IY
0.0
20.0
40.0
60.0
80.0
100.0
61.4
70.0
2010 2013
* Periode 3 tahun terakhir
Proportion of Anemia during Pregnancy in Urban & Rural Area, 2013
Perkotaan Perdesaan INDONESIA0.0
10.0
20.0
30.0
40.0
50.0
36.4 37.8 37.1
*) 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
Pa
pu
aM
alu
kuM
alu
tS
ulb
ar
NT
TP
ab
ar
Ka
lten
gS
ulte
ng
Ka
lba
rS
ultr
aS
uls
el
Su
lut
Jab
ar
Ba
nte
nK
als
el
Ria
uIN
DO
NE
SIA
Jam
bi
Su
mse
lL
am
pu
ng
Ka
ltim
Ba
be
lA
ceh
Go
ron
talo
NT
BS
um
ba
rS
um
ut
Jatim
Be
ng
kulu
Ke
p.R
iau
Jate
ng
DK
IB
ali
DIY
0.0
20.0
40.0
60.0
80.0
100.0
79.0
86.9
2010 2013
1) Dr kandungan, dr umum dan bidan2) Periode 3 tahun terakhir, penolong terakhir3) 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
Ma
luku
Ma
lut
Ka
lten
gP
ap
ua
Jam
bi
Su
ltra
Pa
ba
rB
en
gku
luK
alb
ar
Su
lten
gK
als
el
Su
lba
rR
iau
Su
mu
tN
TT
Su
lut
Ace
hS
uls
el
Su
mse
lL
am
pu
ng
Ba
nte
nIN
DO
NE
SIA
Jab
ar
Ba
be
lK
alti
mG
oro
nta
loS
um
ba
rN
TB
Jatim
Jate
ng
Ke
p.R
iau
DK
IB
ali
DIY
0%
20%
40%
60%
80%
100%
76.1
23.7
Faskes dan Polindes/Poskesdes Rumah dan Lainnya
30.469.6
Memanfaatkan Yankestrad
Tidak Memanfaatkan Yankestrad
Keterampilan Tanpa Alat
Ramuan Keterampilan Dengan Alat
Keterampilan Dengan Piki-
ran
0.0
20.0
40.0
60.0
80.0
100.0
77.8
49.0
7.12.6
Proportion of Household Using Traditional Medicine, 2013
Proportion of Household Know the Community based Health Program* by Province, 2013
Bengkulu
PapuaSulu
t
Sulteng
Jam
bi
Sulsel
Sumut
Sultra
Babel
Sumbar
Kalsel
Kaltim
Indonesia
Jatim
Jawa T
engahNTB
Bali0.0
20.0
40.0
60.0
80.0
100.0
65.2
* The activity mainly preventive and promotive, ie,education, under five year children
The Prevalence of Diabetes Mellitus by Province, 2007-2013
Lampung
Kalbar
Jam
bi
Sumse
l
Kep,Ria
u
Banten
Sumbar
Sultra
Kalsel
Malu
kuM
alut
PapuaJa
tim
Kaltim DKINTT
Sulut
0.0
1.0
2.0
3.0
4.0
5.0
1.1
2.1
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)
MembersHealthcare providers
Contr
ibutio
n C
ompla
in m
anag
emen
t Contract
Claims
Payment
utilization of service
Delivery of service
Standardization of health care delivery
Standardization of medicine, equipment, etc
Regulation on tariff
Government
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Roadmap To UHC
20% 50% 75% 100%
20% 50% 75% 100%
10% 30% 50% 70% 100% 100%
`Enterprises 2014 2015 2016 2017 2018 2019
Big 20% 50% 75% 100% Middle 20% 50% 75% 100% Small 10% 30% 50% 70% 100% Micro 10% 25% 40% 60% 80% 100%
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 enterprisesProcedure 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
BMS
73,8 mio uninsured people
Uninsured people 90,4 mio
Presidential decree on operational support for
Army/Police
86,4 mio PBI
20
Referral System & National Formulary
community
Primary care
secondary
tertiary
Gate keeper155 disease/symptoms should be resolved in primary care
National formulary923 items
PUBLIC GOODS AND PRIVATE GOODS IN PRIMARY HEALTH CARE
Public Health Medical Care
Public Insurance Body
Program at national level
Family planning and prevention of complications of delivery/labor
Community based health services Integrated health service Center HIV Screening Malaria prevention TB Dots
National Social Health
Insurance
Medical care in primary health care facilities
(capitation fee)
Vaccine for basic immunization
Basic contraception methods
FUNDED BY GOVERNMENT
JAMINANKESEHATANNASIONAL
Provider Payment MechanismKEMENKES
23
BPJS KES
Paym
ent M
echa
nism
Primary carea) Capitation (per member per month) 0.3 – 0.6 USD (Urban and semi urban) 0.8 – 1.0 USD (Remote)b) Other mechanism (non capitation)
Secondary and Tertiary Care INA-CBG’s (casemix)
PUBLIC & PRIVATE GOODS IN PRIMARY HEALTH CARE
Public Health Medical Care
Public Insurance Body
Program at national level
Family planning and prevention of complications of delivery/labor
Community based health services Integrated health service Center HIV Screening Malaria prevention TB Dots
National Social Health
Insurance
Medical care in primary health care facilities
(capitation fee)
Vaccine for basic immunization
Basic contraception methods
FUNDED BY GOVERNMENT
Visits and Referral in Primary CareJanuary-February 2014
25
Month Visits Referral (%)
January 914.560 120.697 (13,1)
February 1.514.796 220.480 (14,5)
Sumber Data BPJS Kes, 2014Utilization rate : 12%