1. THE ROLE OF INDONESIA HEALTH INSURANCE: IN FAMILY PLANNING SERVICE
Siswanto Agus Wilopo
Center for Reproductive Health
Faculty of Medicine
Gadjah Mada University

2. Introduction
In 2013 Indonesia declared that it would provide affordable health care for all its citizens or more than 250 million peoples by the end of 2019
Under the Law 40/200, the BPJS Kesehatan was mandated to cover not only curative service but to include promotive and preventive services, such as provision of family planning services.
Under Law 24/11, the financial affairs of JKN are run by an independent management agency for the health arm of the Social Security System, called “BPJS Kesehatan”

3. Introduction (cont.)
The President Decree No. 12/2013 stated that contraceptives will be provided by institution which is currently responsible for family planning service (BKBN).
Minister of Health issuing the decree relates to the insurance implementation and current revised tariff which covers contraceptive services and service for male and female sterilization.
Under those regulation, family planning program has clearly been integrated within health insurance system under BPJS-Kesehatan
All cost of FP services will paid by BPJS but pill and condom (under non-capitation scheme)

4. The question and aim of the presentation
What needs to be done to ensure rights-based family planning is more fully included (paid) in insurance benefits packages and other funding mechanisms?
How insurance programs can be designed to increase demand for and utilization of family planning services, as well as to improve their quality and equitable provision FP in Indonesia?

5. POLICY HAS BEEN ON THE RIGHT DIRECTION
How does the program implementation?

6. Family Planning Services Fee for Non-Capitation
Type of Services
Fee 1
Insertion and /or removal of IUD/implant
Rp ,- 2
Contraceptives injection (each injection)
Rp ,- 3
Treatment for family planning complication
Rp ,- 4
Vasectomy at PHC
Rp ,-

7. Tarif for Outpatient Care
 Type of Hospital
PROCEDURE
V STERILIZATION PROCEDURE ON MALE
258 W OPEN PROCEDURE ON TUBA FALOPII
W ENDOSCOPY PROCEDURE ON TUBA FALOPII
Public
Private
Hospital Type A
455,200
478,000
1,666,100
1,749,400
336,700
353,500
Hospital Type B
421,100
442,100
1,424,500
1,495,700
221,700
232,800
Hospital Type C
389,500
409,000
1,349,500
1,417,000
219,400
230,400
Hospital Type D
360,300
378,300
1,214,600
1,275,300
208,300
218,700

8. What the data says?

9. Coverage Insurance According to PMA2015-PMA2016
Insurance coverage
2015
2016 %
(n=3394)
(n=3380)
Current users who say any costs for modern method were covered by insurance
5.7
6.4
Insurance provider for modern contraceptives
(n=225)
(n=249)
BPJS
41.0
65.8
Jamskesda
36.5
18.8
Other insurances
16.5
17.4
Private insurances
4.1
2.1
PMA2016 or round 2 is not yet formally published

10. How can Health Insurance Reinforce FP Program in Indonesia?
Recommendation for BKKBN

11. Focus on five (5) Ps Political Commitment People Package
Need to Expand Coverage
Community-Based and Family Planning Field Workers and Cadres
Designing Pro-Poor Insurance Programs
Package
Securing Contraceptive Supplies
Strengthen system and the infrastructure for quality of FP services
Promotion and Counselling

12. Focus on five (5) Ps Providers Payment
Health Providers and Clinical Networks
Regulation for Private Service
Advocacy to Providers and Policy Makers
Payment
Tying provider reimbursement to quality of service

13. Political Commitment: Recommendation for BKKBN
BKKBN should seek political commitment on the integration of family planning into health insurance under BPJS-Kesehatan from leader at national down to district levels.
BKKBN needs to ensure that the political commitment will be translated into commitment to fund and support integration of family planning services into health insurance, especially among the poor family. Unfortunately, some of poor families do not receive a free insurance fees (PBI) due to miss-classification of their status.
BKKBN should have political commitment form parliament to secure funding for an additional contraceptive needed by all members of BPJS- Kesehatan.

14. People: Recommendation for BKKBN
Need to Expand Coverage
BKKBN needs to help BPJS-Kesehatan and Ministry of Health in expanding coverage of insurance program by recording family who have not registered by BPJS-Kesehatan using a family enumeration survey (Pendataan Keluarga). Based on the result of enumeration survey, promotion of health insurance can be targeted to those unregistered.
In expanding coverage, BKKBN should reshape a self-reliance (KB Mandiri) campaign to become a self-reliance for insurance membership of BPJS- Kesehatan. On this campaign, BKKBN might develop an incentive scheme i.e.: (penghargaan) to local leader where members of their community have already registered by BPJS-Kesehatan and used family planning services.
Any incentive scheme (penghargaan) of the success of family planning leader should take account the success of implementing UHS under BPJS-Kesehatan.
In area where BPJS-Kesehatan have not operated (i.e.: no office and staffs), BKKBN need to continue providing of assistance for family planning service under government and private sectors. This is conducted by ensuring availability of contraceptive commodities and accessibility of services for the poor family, including providing outreach services.

15. People: Recommendation for BKKBN
Community-Based and Family Planning Field Workers and Cadres:
BKKBN should do experiment to involve family planning health worker (PLKB) for the insurance registration, promotion and advocacy through community based movement, such as Posyandu.
Handing out educational materials at Posyandu or mobile service on how to register insurance BPJS-Kesehatan using online system to increase the enrolment of women in health insurance schemes.
PLKB might facilitate women club organization (PKK) and their cadre in helping family to understand benefit and how to register for health insurance.

16. People: Recommendation for BKKBN
Designing Pro-Poor Insurance Programs
BKKBN needs to monitor their family development using existing of family prosperity indictor (Indikator Keluarga Sejahtera) but should include information the ownership of BPJS-card and family planning services under UHC.
Using family prosperity indictor, BKKBN should help to target poor families who are eligible to receive the free payment of their insurance fee by the government.
BKKBN should help to monitor for the integration between UHC and other government interventions for the poor family using data from family enumeration survey.

17. Package: Recommendation for BKKBN
Securing Contraceptive Supplies
BKKBN should secure the need of contraceptive commodities for all clinical facilities and practice providers by developing new logistic system which will link between offices of family planning and all providers and clinical facilities contracted by BPJS- Kesehatan.
The new logistic system should use data on service utilization of family planning from BPJS-Kesehatan to enable more accurate forecasting to prevent stock-outs and ensure that the right quantities and types of contraceptive methods needed.
Monitoring and evaluation of contraceptive supplies should be linked with the number of client served and fund utilized for non- capitation payment.

18. Package: Recommendation for BKKBN
Strengthen system and the infrastructure for quality of family planning services
BKKBN and Ministry of Health need to develop system to improve quality of service for all clinical facility by implementing registration, standardization, accreditation or recognition, and certification for quality of clinical service working with professional organization and association of clinical owner.
BKKBN should actively engage on the process of registration, standardization, accreditation or recognition, and certification of clinical facilities and health provider since BKKBN is responsible to provide contraception and other infrastructures of family planning services, such as IUD kits, gynecologic bed, educational materials and other assistances.
BKKBN provides infrastructure of family planning services and contraceptive supply to increasing utilization of family planning as facilities become better-equipped to provide services and clients gain confidence in the quality of services provided.

19. Package: Recommendation for BKKBN
Promotion and Counselling
BKKBN should ensure that BPJS-Kesehatan recognizes the importance of family planning promotion and counseling in the insurance packet for benefit not only for client but to the company as well. Family planning will reduce direct cost for delivery and the future cost of their member having more children.
BKKBN and BPJS-Kesehatan should provide materials for promotion (poster and fact sheet) and counseling (i.e.: decision making tolls) to all clinics facilities and private practice providers under BPJS-Kesehatan network of services.
BKKBN should develop a better of counseling method, such as applying “Balanced Counseling” to replace existing approach using “Communication Inter-personal and Counseling”.

20. Providers: Recommendation for BKKBN
Health Providers and Clinical Networks
BKKBN working with BPJS-Kesehatan should inform details on how to provide service under BPJS-Kesehatan to all types of provider, including tariff of each contraceptive service.
BKKBN should facilitate a networking between primary care clinics and all type of providers of contraceptive services, especially midwives since most of contraceptive services are provided by midwives in the private sector services.
BKKBN improves on competencies of health workers to provide right based and comprehensive family planning service through pre-service and in-service of clinical training programs.
Specific guidelines for referral system needs to be developed both for managing complication and sterilization services which cannot be performed at primary care clinic or provider.
In the areas where BPJS-Kesehatan has not been established, BKKBN and Ministry of Health should continue to implement mobile services which should link with network of clinical services under BPJS- Kesehatan.

21. Providers: Recommendation for BKKBN
Regulation for Private Service
BKKBN and MOH should regulates on registration, standardization, accreditation or recognition and certification of provider and clinics who are eligible to have assistance from the government, especially from BKKBN.
Regulating providers and clinics on accreditation needs BKKBN involvement as a way to standardized quality of services, planning purposes and providing incentive and disincentive for the private providers.
BKKBN should establish a new logistic system and produce technical guideline for private sectors on contraceptive distribution and infrastructure assistances.
BKKBN should works with BPJS and MOH to integrate their data for monitoring and evaluation for private services which focuses on the consistency between number of service provided and number of contraceptive distributed or procured by BKKBN.

22. Providers: Recommendation for BKKBN
Advocacy to Providers and Policy Makers
BKKBN should advocate to all policy makers and program managers on the benefits of integration of family planning services under BPJS-Kesehatan.
BKKBN should promote more technical details for policy makers and program managers on how to participate in the BPJS-Kesehatan
The district and community leaders shall be given acknowledgment for their achievement to bring their community using family planning under BPJS-Kesehatan.

23. Payment: Recommendation for BKKBN
Tying provider reimbursement to quality of service
BKKBN should work with the FP-UHC Reference Team (BPJS- Kesehatan; Ministry of Health; and Association of Professional organization, district and owner clinical facilities) to obtain general agreement on tying provider reimbursement to quality of service similar with the use of partograph for delivery report according to Jampersal policy.
BKKBN should create ‘a summary guideline on tariff’ to inform definition of the essential package and articulate the essential and more comprehensive items to all level of providers.
BKKBN should provide incentive for follow-up after clinical visit (outside clinical facility or at home) and continues to move on a new counseling approach as “Balanced Counseling”.

24. Conclusion UHC Policy is already on the right tract
A slow progress on the utilization of FP service under UHC- Scheme
BKKBN needs to ensure that all parties involved implement enacted policies
BKKBN should reform its operational system according to UHC-services, including for advocacy and promotion acitivities
BKKBN should work closely with BPJS-Kesehatan, including for ME

25. Terima kasih

26. What is the Importance of Family Planning?
Family planning is a key success for advancing reproductive, maternal, and child health in the developed and developing countries
Compared with the current situation, global unintended pregnancies would drop by 70%, from 74 million to 22 million per year.
Maternal deaths would drop by 67%, from 290,000 to 96,000 and newborn deaths would drop by 77%, from 2.9 million to 660,000.
The burden of disability related to pregnancy and delivery experienced by women and newborns would drop by two-thirds.

28. Peserta Program JKN 170,954,111 (per 18 November 2016)

29. Provider JKN