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Primary Health Care in Indonesia: Challenges and Opportunities Prof. Dr. dr. Akmal Taher Directorate General of Health Services Ministry of Health Indonesia.

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Presentation on theme: "Primary Health Care in Indonesia: Challenges and Opportunities Prof. Dr. dr. Akmal Taher Directorate General of Health Services Ministry of Health Indonesia."— Presentation transcript:

1 Primary Health Care in Indonesia: Challenges and Opportunities Prof. Dr. dr. Akmal Taher Directorate General of Health Services Ministry of Health Indonesia

2 Indonesia is an archipelagic nation containing over 18,000 islands. Number of Population: Land Sizes: 1,904,569 km2 Number of Provinces: 34 Provinces Number of Districts: 497 Districts Number of Community Health Centers: 9655 Puskesmas

3 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 to people More than 9500 PHC in all over Indonesia Large variations in geographic accessability – Remote interior – Isolated island

4 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

5 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 & child 2.Nutrition 3.Sanitation 4.Communicable disease control (+ NCD) 5.Health promotion 6.Basic medical & emergency care

6 6 Percentage of Public Health Center (CHC) with Number of Doctor below Standard KONDISI KETENAGAAN DI FASYANKES PRIMER 32,86% of PHC with number of doctor < standard 14,7% of PHC without doctor

7 Proportion of Good Washing Hand Behavior *),by Province *) 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

8 Proportion of Married Women of years old in Family Planning Program,

9 Ante Natal Care, * * Periode 3 tahun terakhir

10 Proportion of Anemia during Pregnancy in Urban & Rural Area, 2013 *) Nilai rujukan menurut WHO/MNH/NHD/MNN/11.1,2011 dan Kemenkes,1999 **) Cut off points anemia Ibu Hamil, Hb < 11,0 g/dl

11 Proportion of Deliveries Attended by Skilled Health Personal 1, )Dr kandungan, dr umum dan bidan 2)Periode 3 tahun terakhir, penolong terakhir 3)Periode 3 tahun terakhir, jika > 1 penolong dipilih kualifikasi tertinggi

12 Proportion of Births in Health Facilities by Province, 2013* *) Kelahiran Periode 1 Januari wawancara

13 Proportion of Household Using Traditional Medicine, 2013

14 Proportion of Household Know the Community based Health Program* by Province, 2013 * The activity mainly preventive and promotive, ie, education, under five year children

15 The Prevalence of Diabetes Mellitus by Province, *) Diabetes Melitus (DM) responden 15+ berdasarkan wawancara menurut diagnosis dokter dan gejala

16 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

17 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

18 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

19 National Social Health Insurance (JKN) Regulator Insurance body (single payer) Members Healthcare providers Contribution Complain management Contract Claims Payment utilization of service Delivery of service Standardization of health care delivery Standardization of medicine, equipment, etc Regulation on tariff Government 19

20 Roadmap To UHC 20%50%75%100% 20%50%75%100% 10%30%50%70%100% `Enterprises Big20%50%75%100% Middle20%50%75%100% Small10%30%50%70%100% Micro10%25%40%60%80%100% Transformation from 4 existing schemes to national insurance scheme (employee, poor people, civil servants,army/police scheme) 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 enterprises Procedure 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 Activities: Transformation, Integration, Expansion BMSBMS 73,8 mio uninsured people Uninsured people 90,4 mio Presidential decree on operational support for Army/Police 86,4 mio PBI 20

21 Referral System & National Formulary community Primary care secondary tertiary Gate keeper 155 disease/symptoms should be resolved in primary care National formulary 923 items

22 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   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  Vaccine for basic immunization  Basic contraception methods FUNDED BY GOVERNMENT

23 JAMINAN KESEHATAN NASIONAL Provider Payment Mechanism KEMENKES 23 BPJS KES Payment Mechanism Primary care a)Capitation (per member per month) 0.3 – 0.6 USD (Urban and semi urban) 0.8 – 1.0 USD (Remote) a)Other mechanism (non capitation) Secondary and Tertiary Care INA-CBG’s (casemix)

24 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   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  Vaccine for basic immunization  Basic contraception methods FUNDED BY GOVERNMENT

25 Visits and Referral in Primary Care January-February Month VisitsReferral (%) January (13,1) February (14,5) Sumber Data BPJS Kes, 2014 Utilization rate : 12%


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