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

19

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%