ThirdPlenarySession

IndonesianHealthCareSystem,Policyand
TheRoadtoUniversalHealthCoverage
HasbullahThabrany,MD,PhD,MPH
Professor,FacultyofPublicHealth
UniversityofIndonesia
Depok,Indonesia
Speaker Speaker
CurrentHealthCareSystemandthe
FutureHTAinIndonesia
HasbullahThabrany
Universitas Indonesia
PresentedattheISPOR5
th
AsiaPacificConference
Taipei,September4th,2012
Personalview,hasbullah.thabrany@ui.edu
Current Status of Health System and
Challenges
1. By design: Indonesia has mixed public and
private health care system
2. Relative Stagnant of Health Financing and
Health Outcomes for more than 40 years
3. Geographic and economic disparities, due
predominant market mechanism
4. Low utilization of health services due to
market mechanism
5. Epidemiologic and demographic transitions
IndonesianHC SystemnPolicy Thabrany IndonesianHC SystemnPolicy Thabrany
DistributionofthenumberofHospitalsby
ownershipandtypes,August2012
Category/Owner General Specialities Total
Government 687 94 781
MOH 15 18 33
Provincial 48 40 88
District 408 15 423
Municipalities 73 17 90
Military 107 4 111
Police 36 0 36
Private 756 366 1092
Private forprofit 271 152 420
PrivateNotforProfit 485 214 672
StateEnterprise,ForProfit 66 6 72
Total 1,507 465 1,977
PublicHealthCenters(Puskesmas)Growth:
Shiftingfromprimarytosimpletertiarycare
Type of HC 2004 2005 2006 2007 2008 2010
%
Growth
Without bed 5.540 5.592 5.518 5.551 5.858 6.033 8,9
With Beds 2.010 2.077 2.497 2.683 2.690 2.704 34,5
Total 7.550 7.669 8.015 8.234 8.548 8.737 15,9
Ratio per
100.000 3,48 3,50 3,56 3,65 3,75 3,67 5,5
IndonesianHC SystemnPolicy Thabrany
EpidemiologicalTransition ShiftingDemand
forNCDProducts.HigherneedsforHTA
0
10
20
30
40
50
60
70
1980 1985 1992 1995 2001 2007
Infect.Dis.
CVD
Neoplasm
Perinatal
Maternal
Injuries
Others
IndonesianHC SystemnPolicy Thabrany
Trendoftheproporionofcauseofdeathsbytypesof
diseases,19802007
TheSystemConsequencesandResponses
1. Increasingpercapitaincomecreatesnewdemandfor
healthservices
2. ShiftingtoNonCommunicableDiseaseswillrequire
moreskilledpersonnelandhigherhealthcare
expenditures,thusmorepressurestocontrolcosts
andhigherneedforHealthTechonolgyAssessment
3. Systemalreadyrespondedbyincreasingproviders
andhealthpersonnel,aswellasfinancing.Yet,access
andqualityremainpoor
4. Appropriateresponseisbeingpreparedusinga
NationalHealthInsuranceProgram(NHIP)
IndonesianHC SystemnPolicy Thabrany
IndonesianHC SystemnPolicy Thabrany
MapofPublicInsurance/SocialSecurityCoverage.About55
60%arecoveredin2012
Population (239
million)
2. Elderly > 56 years +
( 17 million), Some are
Covered by Jamkesmas
1. Labor Forces
( 104 million)
12. Unemployed
( 9 million )
1.1. Employed
1.3. Self-employed rural:
Farmers, fishermen, etc
(38,4 million)
1.4. Self-employed urban :
Retailers, vendors, taxi/ojek drivers,
servants, etc
Some are
Covered
by Jamkesmas
Some are
Covered
by Jamkesmas
a. Government
(5.5 million)
Taspen, Askes, ASABRI :
Pension, health, Occup ins
b. Private &
State OE
(35.8 million)
Jamsostek: Partial
Health, Occupational,
Provident Fund, and Death
benefit
To be
Expanded
2014-20
3. Youths and Children
( 119 million). Some are
Covered by Jamkesmas
Some are
Covered
by Jamkesmas
To Be
Covered by
2014-20
100%covered
+5%covered
TheFutureNHIP
1. Mandatoryforall
2. Funding:mandatorycontribution(estimated adequate
contributionisproposedaround5%salary 3%employerand2%
employee)ofmonthlysalary
3. Thepoorandlowincome:governmentpayingcontribution,
nominal.Thisneedstoberevalued.ItiisproposedIDR27,000per
capitapermonth,increasedfromIDR6,500ofthecurrent
contribution
4. Benefits:Comprehensive.Medicallynecessary
5. Payment:primaryoutpatientcare capitation.Outpatient
specialistandinpatient DRG. Drugstender:using
open/competitiveeprocurementtowhichhospitalcould
purchasestandardprices
6. Agency/administrator(BPJSKesehatanInaMedicare):Single
payer transformationofAskes
7. Privateinsurance:supplementalcashpaymentand
complementarybenefits
IndonesianHC SystemnPolicy Thabrany 9
ExchangerateAg12,USD1=IDR9,500
CurrentHTAStatus
1. HTAisservedbyanadhoccommitteeunderthe
MinistryofHealth.But,noroutinebudget
2. Mostworksareassessingeffectivenessofan
interventionusingpublisheddocumentstobe
licensedinIndonesia
3. Nocost/economicassessmenthasbeen
implementedundertheMoHorpublic
insurance
4. Economicevaluation,mainlyfordrugcoverage,
underAskes(publicservanthealthinsurance
scheme)basedoncostminimization.
IndonesianHC SystemnPolicy Thabrany
IndonesianHC SystemnPolicy Thabrany
290.961
507.516
665.949981.5241.248.740
1.678.499
2.006.661
2.538.606
2.720.207
3.492.589
4.513.653
5.818.122
6.926.352
159.104
235.301
243.055
300.936
361.391
441.327
482.325
704.704
716.298
1.001.510
1.247.537
1.641.543
1.725.432
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Realisasi
2011
Proy
2012
Biaya Pelkes
Biaya Obat
Source: Lapmen Source: Lapmen Source: Lapmen Source: Lapmen
Trend of Askes Drugs Expenditures
(IDR Mill) 2000 2011
AllServices
Drugs
Thegrowthofdrugsexpenditureshavebeensmallercomparedtothe
overallexpendituresforallservicesduetoCostMinimazation,noHTA
hasbeenimplemented
Source:AskesReport2012
DrugsandProceduresare
selectedbyapanelofexperts
annually,basedoneffectiveness,
prices,andevidencesfromother
countries
TheRoadtoHTA
1. HTAisaneconomictoolstoimprovevalueformoney.In
thehighinformationasymetry,HTAworkbestwhen
1. Thereisalarge/dominantpayer
2. Thereishighresourceconstraints(highexpenditure)
2. SincehealthcareinIndonesiasofarhasbeenunder
funded,alwaystheTotalHealthExpenditure<3%GDP,
Indonesiaispreparingtoexpandcoveragefirst.
3. Currently,specificwordrequiringestablishmentofHTA
includingeconomicevaluationtoreviewandincludea
medicalinterventionintheNHIPiswriteninthedraft
regulationscheduledtobeenactedbytheendof2012
IndonesianHC SystemnPolicy Thabrany
CurrentRegulation,beingdevelopedand
HTAwillplaymoreimportantroles
1. TheNHIP(INAMedicare)willcoverall
populationby2019
2. Newtreatmentsandormedicalprocedures
mustundertakeHealthTechnology
Assessment.
3. AModelforHTAmorelikelyfollowtheNICE
model toconsidercostandeffectivenessis
beingdevelopedintheMOHalongwiththe
INAMedicare
IndonesianHC SystemnPolicy Thabrany
Conclusion
1. Indonesiaisexperienceingincreasingnon
communicablediseasesandincreasingsupplies
ofhealthcare
2. Previousattempttocontrolcostsofmedicines
mainlyviacostminimizationmethods.
3. TheIndonesianhealthcaresystemisbeing
reformbyestablishmentoftheNationalHealth
InsuranceProgram(INAMedicare)thatwillbe
thelargestsinglepayer intheworld,
4. Ateamtoselectcosteffectiveinterventionsfor
benefitpackageofINAMedicarewillbe
established
IndonesianHC SystemnPolicy Thabrany