NOTULENSI 12th Asia Pacific Future Trend Forum Roadmap to National Health Insurance: Acceleration through Public Private Partnership - SMERU
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NOTULENSI
12th Asia Pacific Future Trend Forum
Roadmap to National Health Insurance:
Acceleration through Public Private
Partnership
Kementerian Kesehatan Republik Indonesia – SMERU Research Institute –
Novartis I Hotel Westin & Kementerian Kesehatan Republik Indonesia, Jakarta
I Rabu - Kamis 20 - 21 November 2019
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EXPERT MEETING
20 November 2019 - Westin Hotel Jakarta - Padang Room
Hari pertama rangkaian acara Future Trend Forum ke 12 ini berisi diskusi para pakar yang berasal dari negara-
negara Asia Pasifik. Acara dibuka oleh Asep Suryahadi, PhD sebagai Peneliti Senior SMERU Research Institute,
dilanjutkan sambutan pembuka dari Sekertaris Jenderal Kementerian Kesehatan Republik Indonesia, drg.
Oscar Primadi, MPH. Sebagai Setting the Stage, Somil Nagpal dari Bank Dunia menyampaikan paparannya.
Athia Yumna, We can start now; the minister of health will join us later on. Saya Athia Yumna dari
MSc - MC SMERU yang akan menjadi MC hari ini. Acara ini didukung secara ilmiah oleh Novartis.
Tema tahun ini adalah “Peta Jalan Menuju Jaminan Kesehatan Nasional: Percepatan
melalui Kemitraan Pemerintah-Swasta”.
Selama 2 hari kita akan menggali pengalaman negara Asia Pasifik, tahun ini (adalah
tahun) ke lima Indonesia menjalankan JKN dan melihat tantangannya. Pelayanan
kesehatan yang lebih baik. Forum ini melibatkan pemangku kepentingan swasta dan
pemerintah, inovasi dan kebijakan-kebijakan dalam mengelola sistem kesehatan
terpadu. Ada wakil dari kementerian kesehatan, kementerian keuangan, bank dunia,
kalangan akademisi dan pihak swasta.
Untuk membuka, kami persilahkan peneliti utama yang akan membawakan paparannya
berjudul “Seeking Sustainability in National Health Insurance through Innovation in
Financing and Big Data Utilization”. Untuk Pak Asep Suryahadi kami persilakan.
Asep Suryahadi, The focus of this year’s Future Trend Forum (FTF) is National Health Insurance. I think
PhD - SMERU Indonesia has the biggest – if not, one of the biggest health insurance system in the whole
Research Institute world. After five years, we now have the chance to reflect upon the problems that we
encountered along the way; and also, to review promises that we made, and things that
we managed to achieve.
Scaling up, countries in the Asia Pacific region are moving towards delivering National
Health Services to all of their citizens. According to the World Health Organization
(WHO), in South-East Asia region alone, there is an increase in the average percentage of
‘Essential Health Services Coverage Index,’ from 46% in 2010 to 61% in 2019. Although
the increase in the percentage might be caused by natural catastrophe happening
between those periods.
Therefore, it’s important for us to learn from our fellow Asia Pacific countries, because
we are walking down the same path now. We might be able to gain new insights on how
we can improve our National Health Insurance system, and identify things that must be
changed or “reformed” in order to achieve such improvement. In this forum, Indonesia
– together with Malaysia, Thailand, Vietnam, South Korea, Singapore, Taiwan, and other
countries – will share their experiences in managing the National Health Insurance
system, while also tackling with the international limitation of the system.
Aside from that, we realized that we need to learn from the latest researches and the
current technological advancement on the field – since they both are our most valuable
resources in understanding our challenges, as well as our keys to achieve our goal:
providing a thorough National Health Insurance system. During today’s forum, we will
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also learn from the private sectors: the players and providers in the health care service
industry.
Today’s discussion will focus on two issues: first, how to achieve the ‘sustainable
financing’ of the National Health Insurance - since this is the key for a strong and
sustainable National Health Insurance system; and second, how to utilize ‘big data’ in
order to improve our National Health Insurance system.
To conclude, National Health Insurance is an instrument to help people achieve good
health; but we often forget that it could also serve as an instrument for economic
development, and economic development leads to the betterment of people’s wellbeing.
I would like to end this ‘lengthy’ speech by extending my gratitude to, first, the Ministry
of Health of the Republic of Indonesia; The SMERU Research Institute; Inke Maris &
Associates; and Novartis – for their effective collaboration in organizing this forum. Also,
I would like to extend my gratitude towards all of the participants, and of course, my
colleagues from the organization committee, who were very helpful in making this 2019’s
FTF happens.
I’m looking forward to a productive discussion in today and tomorrow’s sessions; thank
you for your attention, Assalamualaikum Warahmatullahi Wabarakatuh.
Didik Kusnaini, Pak Asep Suryahadi, Senior Field Researcher from SMERU; Somil Nagpal from World
SE, MPP - Bank; our crews: Pak Laksono, Bu Asih, Bu Pegi, and all distinguished speakers; experts;
Ministry of ladies and gentlemen; good afternoon.
Finance,
First of all, let us begin by extending our gratitudes towards God Allmighty, for the good
Indonesia
health He bestowed upon us, so that we can attend this annual FTF, with the topic of
“Roadmap to National Health Insurance: Acceleration through Public-Private
Partnership”.
I would like to express my gratitude towards the Ministry of Health of the Republic of
Indonesia, in cooperation with SMERU Research Institute, Inke Maris & Associates, and
Novartis – for organizing this important forum. It’s an honor for me to be given a chance
to deliver the keynote speech for this event.
Ladies and gentlemen, the topic of Universal Health Care Services is very relevant for us
nowadays, as the global economy is leading us towards the ‘middle-income trap’
challenge. A lot of developing countries underwent rapid economic growth, which raises
their statutes from ‘low-income countries’ to ‘high-income countries’.
Unfortunately, many of these countries were caught within this ‘middle-income trap’
situation. Although the debate on how to break free from the trap is still ongoing, most
agree that labors’ – or human resources’ productivity is the key to conquer the trap, with
the emphasis on reaching the highest productivity rate, since it’s the key for
development.
According to a research in 2007, country’s insvestment in health care development may
foster economic growth. This could be explained through a statement, that “by
improving their health care services, countries are able to save more funds; due to the
lower morbidity and mortality rate, and higher life expectancy rate”. This will lead to the
increase in labor productivity and forster the economic growth.
Moreover, there’s also a relationship between public health and poverty. Poverty might
cause people to get sick, and sick people tend to be poor - that’s from the household
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point-of-view. From the fiscal perspective, there’s a correlation between public health
improvement and taxes. Improving public health – that is usually financed through strict
budget or other means – may result in the increase of productivity; in this case, increasing
creativity and innovation, major components to achieve economic growth. The economic
growth will contribute towards the country’s revenue through the increase of money
obtained from taxes.
Governments, especially in developing countries like Indonesia, realized that it is
important to improve the general public health. They began developing health care
programs, starting from creating National Health Funds, and partnering with other
parties in providing health care services.
However, the problem lies in the scale of program implementation that are often too
large, and the ‘monitoring and evaluation’ mechanism for such program. Again, this is
due to the limited amount of budget that can be allocated for the program, since there
are a lot of other programs that need to be funded, and they are all equally important.
Ladies and gentlemen; allow me to share a brief overview on Indonesian Health
Insurance, as well as our strategies – Indonesian government’s strategies – in tackling
challenges related to the implementation of the program, including fiscal challenges.
Indonesian government is committed in improving Indonesian citizens’ quality of life,
income, and opportunities to obtain incomes; these commitments are reflected in our
national budget allocation for education sector, health sector, and social affairs sector.
All of those sectors play important roles in improving the quality of Indonesia’s human
capital.
Our law and constitution required us to allocate a minimum of 20% of our national
budget for education, and another 5% for the national health care system. We also
allocated a significant amount of our national budget for social welfare programs; such
as food/nutritional assistance program, and much more.
We need to ensure that our human capital are able to compete in the regional and global
grounds, and that’s why starting from a couple of years ago, we stopped funding
inefficient programs and redirect the funds allocated for ‘subsidy programs’ to a more
effective, and well-targetted programs in human capital development category, as well
as infrastructure category.
Talking about universal health coverage, it brings us to one of our key development
priorities – and it’s not only about supporting the UN SDGs – but also to advance the
Indonesian development agenda. This universal health coverage is important for
Indonesia, since it allows us to improve our productivity rate, while taking advantage of
the demographic bonus.
Thus, it’s important to provide a health care system that accommodates the health of
individuals starting from the pregnancy period, up to the early stages of child
development; but not until their elderly years. In short, the universal health coverage is
needed in order to strengthen the foundation of Indonesian productive capacity, to
ensure its growth, and to serve as a building block towards sustainable economic
development.
Now that we agree that universal health coverage is needed, the next question will be
“what kind of coverage system that we need?” and “how we can afford such system?”.
Thus, let me share our experiences and perspective in regards to this matter. First, there
will be limitations and gaps in designing effective universal health coverage; such as
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limitations in financial, infrastructure, and manpower components. Therefore, the design
of the Indonesian Universal Health Coverage system should be made as realistic as
possible. It should be designed to target productive and vulnerable population coming
from medium-low income households.
Second, the Universal Health Coverage should be based on a system that allows all users
to contribute, as opposed to a fully subsidized model. In this case, Indonesia’s National
Health Insurance system or Jaminan Kesehatan Sosial (JKN) is on the right track. The
National Health Insurance system enables recipients to choose different benefit
packages.
Having different benefit packages allows recipients with more income to choose
insurance package with higher-class facilities; which requires them to contribute more
towards the system. This helps the government with limited fiscal space as more people
join the program.
Third, to complete our Universal Health Coverage, we need to keep developing and
expanding our health care infrastructure and manpower. This can be done effectively
with the support of private sector.
Nevertheless, in the case of Universal Health Coverage in Indonesia – where the issue of
manpower supply is not just a matter of number, but also a matter of distribution –
effective education program and labor policy has been introduced to local-level
educational institutions located in low-income areas. This will benefit both the medical
trainees and health care providers practicing in remote areas.
I believe that a competitive health care industry is good for the Universal health coverage
system, and we should be supportive towards that. It’ll strengthen the system by cutting
government-provided costs, improving its efficiency, and improving the quality of the
health care services delivery.
Creating an efficient health care industry will foster the trust from our middle- and high-
income groups; and in turn, it’ll drive them to sign-up for the National Health Insurance
program. The more people signing-up for the program, the more effective and
sustainable the program is; but we realize that this will take some time to be established.
Ladies and gentlemen, I’m going to share the journey of our National Health Insurance
program. During less than five years since its establishment in 2014, the program has
successfully covered more than 222 million people as of October 31th, 2019 – or more
than 83% of our population. They all signed-up for the JKN Program.
In addition, around 27.300 health care providers have also been integrated into the
network as of November 2019. So the synergy between the National Health Insurance
program and other programs – including educational programs – shows a promising
result.
Indonesia’s Human Capital Index as of 2018 is 0.53, compared to the world’s average
Human Capital Index at 0.57; we’re just slightly under the average. But in terms of our
survival rate from age 0-5, we are currently sitting on the world’s average at 0.97. The
rate of children who doesn’t experience ‘stunted growth’ is 0.66, compared to the
world’s average at 0.77; and the rate of survivability among adults is 0.83 compared to
the world’s average of 0.85. Maternal mortality cases are gradually decreasing from 346
cases in 2015 to 306 in 2019; while the number of infant mortality cases is also decreasing
from 19 in 2015 to 11 in 2019.
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Looking at the current situation of supply-and-demand, the National Health Insurance
program is expected to contribute around 136 million rupiahs to the economy from 2016
to 2021; and within the same time period, it is also expected to create more than 800.000
new jobs. Allocating some of the household spending for the National Health Insurance
program is estimated to spare more than one million people from poverty in 2015.
Despite all of these achievements, there are still, issues to be addressed, gaps to be
bridges, alongside the challenges and opportunities.
The challenges we encountered provide us with the opportunity as follow: First, we need
to involve the local government more, as they need to take part in the public health care
system too. In 2004, we passed the bill on ‘Fiscal Decentralization,’ and we’ve been
providing local health insurance called Jaminan Kesehatan Daerah or JAMKESDA for poor
people living in rural areas. Today, since the trend is for the central government to
transfer the national budget to local or sub-regional budget, the role of the local
government in the whole health care ecosystem could be expanded to support not only
in demand category, but also in supply category. They need to step in and take the role
of National Health Insurance facilitator, helping with registration and fee collection in the
local scope.
Second, the private partnership, or Public-Private Partnership (PPP), should be improved.
Right now we only have partnership in infrastructure-related sectors; but the truth is
there are a lot of opportunities that we can explore, for example, to have PPP in the
Health Care Services provider sectors, too.
Among the development projects that we are handling right now, some of them are
funded through the PPP scheme; for example, the development of Sidoarjo’s Regional
Hospital in East Java, Medan’s Regional Hospital in North Sumatera, as well as Central
Government Hospital in Manado, and also, several hospitals in Jakarta. The PPP approach
will change the old paradigm: that the government is the sole actor in developing the
health care infrastructure. The PPP approach will also ensure better value for money on
public expenditure, as they will all be managed by both public and private sectors,
splitting the risks among those two. The PPP will also improve the performance of public
health care services, since the performance from the private sectors will be measured
and evaluated by both the users and the government.
The PPP approach could serve as the alternative in delivering, and financing hospitals as
well as other health care services or infrastructures. It creates a more reliable health care
system, and the government is commited to this agenda. We will be providing a number
of fiscal services – such as VGF scheme, viability supplement, and others – to promote
the PPP approach/
However we do understand that there are challenges and rooms for improvement. We
at the Ministry of Finance will work together with other government agencies as well as
private parties to ensure that the sceme will achieve targeted goals of delivering a more
reliable and affordable health care services for all Indonesians, from Sabang in the
westernmost part of Aceh, to Merauke in the easternmost part of Papua
Ladies and gentlemen, allow me to conclude that affordable and universal health care
system is the responsibility of all stakeholders, including the National Health Insurance
recipients, to achieve the sustainable development. Thank you, and I wish for a fruitful
discussion for all of us. Assalamualaikum Warahmatullahi Wabarakatuh.
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Drg. Oscar Thank you, honorable representative from the Ministry of Finance, Pak Didik.
Primadi, MPH -
I would like to extend my gratitudes to Senior Researchers from SMERU Research
Ministry of
Institute, Senior Health Specialist from World Bank, the representatives from the
Health, Indonesia
Ministry of Health of Malaysia, the Director of Health System Disease from University of
Hongkong, representatives from Healthcare Microsoft Asia, the Director of Development
Planning and Management Analysis from the BPJS Kesehatan Indonesia, Dewan Jaminan
Sosial Nasional, academics and researchers, and all participants of today’s meeting.
Assalamualaikum Warahmatullahi Wabarakatuh. It’s a great honor for me to deliver a
keynote speech in this forum. First, I’d like to congratulate SMERU Institute for their
success in organizing this years’s Asia Pacific Future Trends Forum – the 12th FTF, in which
we’ll discuss and explore our roadmap towards achieving universal health coverage.
Indonesia is moving towards its goal to achieve universal health coverage by reforming
its National Health Insurance system: Jaminan Kesehatan Nasional or JKN. The presence
of universal health coverage is mandated by the Constitution of the Republic of
Indonesia, and the JKN system was chosen specifically to carry the task. The National
Health Insurance system, particularly, focuses on achieving ‘equity of access’ to health
care services and financial protection; measured through the number of targets covered,
and equal benefits and satisfactions with the services.
Ladies and gentlemen, with the establishment of the National Health Insurance system,
Indonesia has entered a new era of single-payer healthcare system. This system is
financed by the people and for the people – reducing the health care services cost each
time an insurance package is purchased. Numbers related to the National Health
Insurance system are quite promising – data from BPJS until 31th October 2018 shows
that the number of people signing up for the National Health Insurance has reached 222
million people, or 94% of Indonesia’s population. There are also growing numbers of
health care facilities participating in the National Health Insurance program.
Our data shows that until 1st October 2019, the Social Security Department has contacted
around 23.145 primary health care service providers and 2519 healthcare facilities to
become service providers in the National Health Insurance program. Since the
implementation of the National Health Insurance system in 2014, the total government
expense for health-related expenditure in Indonesia has decreased from 54.8% in 2010
to 31.8% in 2017.
Ladies and gentlemen; there are a number of challenges that we have to overcome in
order to achieve universal health coverage, such as the ‘rising amount of informal sector
workers,’ that became members of the national health insurance program; and that
Indonesia is currently undergoing a rapid epidemiological transition, with Non-
Communicable Diseases now becomes the largest threat, while at the same time, we are
still struggling with Communicable Diseases such as tuberculosis – not to forget that we
are still dealing with problems like malnutrition. The geographical context, alongside the
economic gaps, pose as challenges, especially in closing the disparity in access to
healthcare services. The demand for health care services has also increased, since
acquiring the membership of the National Health Insurance system became mandatory.
The increase in such demand needs to be balanced with the availability of equal health
care services, the readiness of health care service provides, and adequate supplies for
the fundamental health care services.
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Ladies and gentlemen, we are commited in achieving universal health coverage; but
again, we would like to learn from experiences in other countries in order to strengthen
our National Health Insurance system, and solve the challenges that will be discussed in
this forum. I hope that this meeting will be valuable for both me and all of the FTF
participants. Assalamualaikum Warahmatullah Wabarakatuh.
Somil Nagpal - I think both Pak Rudi and Pak Oscar were very clear in explaining the context; so now,
World Bank let’s see what happens in Asia. Indonesia has made quite an investment in human capital,
as it’s getting ready to become one of the ‘World’s Top 5 Largest Economies,’ and also,
as its trying to reach the SDGs. Thus, now is the perfect chance to discuss the progress
from Indonesia, including their overall performances, and to talk about big data.
Scaling up, there are some major achievements in terms of Indonesia’s Public Health Care
Services; and these are in line with the ‘strong commitments’ mentioned by the Minister
of Finance. According to the 2000-2015 report, Indonesia has managed to reduce the
pocket expenditure related to health care services to less than 1%. This needs to be
congratulated, and the report is available for the public to access. The next achievement
is that the government managed to formulate a pro-poor National Health Insurance
system, the JKN, as opposed to the pro-rich insurance system that existed before. The
JKN is financed through the public’s fund, but still, there are some notes related to how
it doesn't cover the informal sectors.
There are several challenges such as how to implement a good monitoring system, and
how the system should deal with Non-Communicable Disease, since we simply don’t
have enough data. Moreover, it’s important to move forward from giving promises to
implementing such promises. If the government is unable to provide good, equal health
care services that would mean that they are breaking the promises they made.
In term of funding, this program is not expensive, as it only needs around 14% of the
government’s spending. We call it “the tail wagging the dog”. They made fundamental
change to create a successful program; they have to change their accountability
paradigm, they have to utilize the data and evidences available, but still, we don’t know
for sure whether the system will work, or not; which creates a new challenge and risk to
be addressed. We need to come up with a sustainable program, which means that we
need to spend efficiently; but again, it might costs more that we think.
That’s my notes, thank you for your patience.
Session 1
Innovative Healthcare Financing: Transforming Ideas into Impacts
Chair: Dr. Jeremy Lim, MD, MPH
(Associate Professor of Saw See Hock School of Public Health, National University of Singapore)
Sesi pertama Diskusi Para Pakar dimoderatori oleh Dr. Jeremy Lim (MD,MPH), seorang Associate Professor
dari Saw See Hock School of Public Health, National University, Singapura. Sedangkan pemateri disampaikan
oleh Dr. Muhammad Anis bin Abd Wahab, MSc dari Kementerian Kesehatan, Malaysia dan Dr. Nopporn
Cheanklin, Direktur Health System Institute Thailand. Sementara sebagai panelis adalah dr. Kalsum
Komaryani, MPPM, Kepala Pusat Pembiayaan dan Jaminan Kesehatan Kementerian Kesehatan RI dan dr. Asih
Eka Putri, MPPM, MM, anggota Dewan Jaminan Sosial Nasional RI
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Athia Yumna, Commitment and ambition, two strong words. What’s after these two?
MSc - MC
Now we move towards the first session, with the topic of “Innovative Healthcare
Financing: Transforming Ideas into Impacts”
I would like to invite Dr. Jeremy Lim, (MD, MPH) as the moderator.
Dr. Jeremy Lim, So the question is, can we design a strong financing system that can push the service
MD, MPH – providers, patiens, and the general population to do the right thing – that will allow us to
National achieve the best health outcome with the lowest possible cost?
University of
This idea has been discussed since the 1980s, but of course back then it didn’t take into
Singapore
account the advances in technology; and that’s the teaser for the discussion on the next
session where we talk about big data and AI. Would technology allow us to escape from
this ‘triangle’ (problem)? Without further ado, allow me to invite dr. Anis to share first,
followed by dr. Noporn afterwards that will share about the curretnt condition in
Thailand. Then we can give the floor to two of our panelists to have a comment, and then
everybody can join the discussion. Maybe I should ask both of you first, would you like
to take any questions during presentations or do you rather wait until the end?
Dr. Muhammed Okay. Thank you organizers for inviting me. It was only two weeks ago that my secretary
Anis bin Abd general asked me to represent him and the Ministry of Health of Malaysia; as I just
Wahab, MSc - became the Ministry of Health of Malaysia two weeks ago. I would like to extend my
Ministry of gratitudes to all distinguished participants.
Health, Malaysia
When I was informed on the topic of this forum: health insurance, I thought I won’t be
able to do justice, since Malaysia is five years behind Indonesia; or even more. Thus, I’ll
be sharing on the aspect of technicality, and the financial system behin Malaysia’s health
care system. Let’s start with the context first. I’d like to describe Malaysia’s health care
system as a dichotomy: both the public health care services and private health care
services coexist, and both are independent of each other. Of cours public health care
services are mostly funden by our general revenue and taxes, while the private sectors
are funded through out-of-pocket health insurance and employee’s benefit.
While the public sector is more holistic in providing their services, the private sector
tends to focus on the curative aspect of the health care system. Thus, emphasizing on
preventive care is important in regards to this case. There’s a large gap between private
and public health care services that need to be addressed: 90% of the total clinics in
Malaysia are owned by private sectors, but 60% of the total patiens in Malaysia are being
treated in public health care facilities.
If we look at our national health expenditure, 40% of our GDP is allocated to the health
sectors. That’s over $14 million. 52% of our national health expenditure is being funded
by the public, and 40% of our national health expenditure is funded by the Ministry of
Health. Aside from that, we have 38% out-of-pocket spending, which is high. Compared
to other OECD countries, we are way behind.
Moving on to the private sector expenditure, 75% of the expenditure is out-of-pocket
spending, and only 15% of those are covered by private health insurance companies. This
leaves quite a room to direct more funds towards the health expenditure.
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Talking about the performance, if we are looking at Malaysia’s mortality rate, maternal
mortality rate, and so on – yes, it seems like we have succeeded, but the truth is, the
progress is becoming more and more stagnant. We could have done so much better.
We also conducted a research on our public health sector and made an assessment to
our national health care services performances. From the outcome, we can see that we
are still struggling in managing non-communicable diseases, although our national health
care system is providing the necessary preventive care. Although we’ve allocated 35% of
our GDP for health sectors, we’re still facing the risk of impoverishment, since most of
the population still have to pay to access public health services
Now looking at citizen’s level of satisfaction, we’ve managed to gather enough feedback
as more people are registered to the public health care system. There are complaints
related to waiting time, and complaints on the cost of the health care services in private
sectors. We also conducted a fiscal analysis to improve budgeting efficiency and reducing
subsidy; and we found that only 30% of the total population is registered as tax payers.
This is a challenge for us to make more people contribute to the country’s revenue.
Malaysia is going to expand the budget on health sectors, as we allocate 10% more for
the next year, but we aren’t going to the privatization route. I don't think if would feasible
in the short term.
We all know the paradox that once you see a success in public health intervention; you
tend to cut the expense for that sector in the government budget. We subsidized public
health sector, but we need to be aware that our facilities are also being used by foreign
workers and insurance companies. That’s our fiscal analysis Thus, increasing our
expenditure in public health sector doesn’t seem like a good move.
We also have private insurances, but they are inneficient. They have high administrative
cost: around 20% - 30% of their revenue is used for administration cost. We are going to
buy private insurance packages, but we’re going to use a different partnership
mechanism.
We don’t have insurance program for the poor or vulnerable. Only 35% of the total
population has private health insurance. So there’s a room to move towards a more
efficient scheme.
I hope I managed to deliver a brief introduction on why we need to move forward, why
we need to ‘reform’ our health care system. We are also looking at Public-Private
Partnership (PPP) now. If we want to use family doctors; if we want to adopt patient-
centered health care approach, and introduce different benefit packages; we need to
reform the financial model. We are going to work with private sectors on the correct
supply and demand incentive.
The current government is more open to the idea of public sector autonomy. So the
strategy to improve health care funding is to mobilize the funds. We want to solve the
38% out-of-pocket spending challenge, so that the money can be ‘mobilized’ for the
betterment of our health care system. Also, we would like to work alongside the private
sectors. These are our options and considerations while moving forward. We need to
consider hybrid financing as an option. We have a new government on board, and we are
trying to garner the trust from the general public.
There’s also a new program spearheaded by the new government called Peduli Sehat or
‘Care for Health’ program. We established a non-profit agency called ‘Protect Health
Cooperation’ with the sole purpose of strategic purchasing. Through the agency, we
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began purchasing insurance services provided by private sectors, and we started by
buying basic health screening services from private GPs to move toward reduction of
NCE. We emphasized on the quality of the service, and we also do micro auditing. I
consider this as a small step towards Malaysia’s National Health Insurance system. We
will work on means to collect revenues later, but now we are focusing on strategic
purchasing. My colleague, Desi, will explain on the macro aspect of the health care
reform, as we are also working on the electronic platform.
We are now focusing our health care services to the ‘B40,’ people at the bottom 40% in
terms of income. We are on the data collection stage, as we gather all data related to
healt care services. We started collecting data from private sector, which we never did
previously. We are working together with six private labs, as we were able to secure a
good deal. These labs are not obliged to follow our standards, but since we’re purchasing
their services, we can impose our policies on them. Even in public sector, our patiens still
have to pay for implants and so on.
With that, I end my presentation.
Dr. Jeremy Lim, Thank you very much; maybe for the sake of time efficiency, we can proceed to dr.
MD, MPH – Noporn’s presentation, and after that we’ll allocate five minutes for each panelist to
National respond, and then we’ll have our panel afterwards.
University of
Singapore
Dr. Nopporn Thank you. This is what Thailand’s have been doing for the past 10 years. We made quite
Cheanklin - a progress from charging $30 for each person up to more than $100 per-person now. The
Health System role of political commitment is crucial, especially in the early stage of the universal health
Research coverage program; as we will not be able to go anywhere without the commitment. The
Institute, focus of Universal Health Coverage is equality; that no one will be left behind. I’ll give you
Thailand a brief example so that it’s easier to understand. Thailand has 100% cooperation rate.
Currently, Thailand’s population sits around 35 million, and universal health coverage is
the biggest program scheme in Thailand. We do have private insurance, but people are
not forced to sign-up for that, it’s optional, and usually rich people are the one signing
up for it – but they are also eligible to receive universal health coverage. They can, in fact,
undergo a surgery that costs $30.000 and use the universal health coverage scheme in
order to cover the cost, instead of using their private insurance. The system survives for
more than 10 years because not everyone is using this scheme (but they are still paying
the subscription fee).
Sometimes people choose to pay out-of-the-pocket because they don’t want to queue,
or they don’t want to spend a long time in the hospital. We have three-layered insurance
scheme here in Thailand, with 15% of the funding goes to the insurance scheme for civil
servants like me; because If you are working for the government, you can reimburse
almost everything. The cost is quite high. It covers me until I die, even if I retire now;
while also covering my father and my offsprings. It's really difficult to tell exactly how
many persons that this scheme covers.
We are trying to minimalize the cost. We can achieve quite a good result by using around
100 billion Thai Baht up until now. Most of our expenditures went to the pharmaceutical-
related spending. I can give you a rough estimation, around 40% went to the drug
expenditure, and 30% went to the labor cost. This is a sensitive topic, when it comes to
10Nama Keterangan
cutting the labor cost, since health care workers are the centerpoint of the universal
health coverage system. So, since cutting the labor cost would cause resistance, we tried
to cut the pharmaceutical-related costs instead. For example, usually for a drug to be
approved, it needs to follow a series of expensive testing procedures. If we can reduce
the amount of procedures that are needed to be taken, we can cut some of our budget
and improve our service. We can also provide more benefit packages.
Normally, just like other countries, we utilize around $5,000 to consider putting it in
benefit coverage. In terms of service availability and pharmaceutical products, we have
around 100 regional and provincial hospitals that could provide sophisticated services.
We need to make sure that most of the hospitals, if not all, are able to provide high-end
services, as we don't want our patience to travel a long distance just to receive proper
treatment.
Related to budget impact, you can see that it’s quite complicated to introduce different
benefit packages. There are a lot of demands for high-end services, but we have to work
hard to make sure that particular procedures are followed, and the pharmaceutical
products are within our budget availability. We cut the price of expensive drugs at every
hospital that are part of Thailand’s National Health Insurance program. I’m part of the
BCS committee, and we do bargains with multinational companies. We met with the
producers and tell them “can decrease your spending on marketing, so you can reduce
the price of your medicine for up to 40%? – and that’s one of our most important
achievement up until now.
Previously, I worked as a CEO in a pharmaceutical company. One of my colleagues once
asked me, is it possible for Indonesia, Malaysia, Thailand, and Vietnam to sit down
together and ask the company to get a cheaper price? Sometimes it’s very difficult to get
paid for providing health care services. I really think we can work together. For example,
we spent almost $10 millions a year for some particular antitoxin. We always use it
together with neighboring countries like Vietnam, Laos, and Cambodia. It shows that it’s
possible for us to sit together and share what we currently have with each other – and
that’s the thing that I want to put forward in this forum. We cannot decrease the labor
cost, but we can decrease the pharmaceutical-related costs. We can decrease the
procedure time by working together with private sectors. They might ask for something
in return, but at the same time, we also need a quality pharmaceutical products.
Thank you very much.
Dr. Jeremy Lim, Thank you very much dr. Noporn. So there are three main issues that we can underline
MD, MPH – from both presentations: 1) Resource mobilization; 2) Risk mitigation; and 3) Efficient
National procurement strategy, in terms of cutting the pharmaceutical-related cost. Beyond that,
University of we can also think about a centraliced service, because it doesn’t make sense that in a
Singapore small region like ASEAN, everyone have their own complex procedures to follow. For me,
it doesn't make sense for every country to own all kind of facilities; while in practice you
can actually share, or borrow other ASEAN country’s facilities. Now I would like to invite
our two panelist: Dr. Kalsum and Dr. Asih to give their comments on Malaysia’s and
Thailand’s experiences; and also, to share their opinion on what Indonesia can learn from
those experiences.
11Nama Keterangan
Panel Discussion, Q&A:
dr. Asih Eka Putri, Thank you moderator. First of all, I would like to express my appreciation to the
MPPM, MM – presentation from Malaysia and Thailand. These two countries have their own ways to
National Social fund their health care system. Malaysia utilizes their tax revenue to fund their health care
Security Council, services, while Thailand offers up to three social security schemes. I think for both of the
Indonesia countries, their total expenditure exceed the 4%. They both also share a same burden in
form of non-communicable diseases.
Looking at Indonesia’s current healthcare system, our total spending is still considered
low, at 3.2% of GDP. But for the public and private sector’s funding, the number is almost
equal at 51%. Since Indonesia launched the National Health Insurance, the number of
out-of-pocket spending has decreased from 46% in 2013 to 33.8% in 2017 – in the
security spending category, the number is increasing from 13.8% in 2013 to around 21%
in 2017. These shows that there are still challenges that we need to face, in terms of
matters related to social health insurance scheme and tax-based funding. In Indonesia,
although we are using the social health insurance scheme, it’s not purely social, since the
government pays for more than half of the spending.
Since it’s funded through tax revenue, we need to learn from both Malaysia and Thailand
on how to sustain the program. From my point of view, there are two aspects that we
need take into account: 1) To make sure that the revenue is suffiecient to fund the
program, and 2) To control the spending. We need to implement the HDA, while also
implementing strategic purchasing strategy. We also need to choose the right provider
for the payment mechanism. Aside from that, we need to think about the monitoring and
evaluation mechanism. Indonesia is currently facing a financial turbulence, and we need
to refine the strategy from both the revenue side, and the spending side.
Thank you.
dr. Kalsum Good afternoon; thank you for the presentation, our colleagues from Malaysia and
Komaryani, Thailand. It’s really interesting to hear the journey from these two countries in the quest
MPPM –Minister to find a better way to finance their health care systems; as it resembles the journey that
of Health, Indonesia underwent in before 2014. For our collague from Malaysia, Bapak Muhammad
Indonesia Anis, I have a concern related to Malaysia’s resource management. Your country has a
limited fiscal space, while foreign workers also receive the benefit of tax-funded public
health insurance program. The private insurance program, on the other hand, are
inneficient and costly. You are now in a middle of a crossroad, whether you want to
continue and develop a National Health Insurance or to claim your role as additional
agencies focusing on purchasing insurance services.
From my point of view, based on Indonesia’s experience, in order to develop a National
Health Insurance you need to have more tools in disposal to mobilize your resources.
How to move money from people? How to integrate private sectors and public providers
into the system? How to buy their services? What kind of regulations that are needed?
These are some of the questions that you need to answer. Also, the transition between
schemes requires a lot of money, so you’ll need a tool to collect the money, handle it
correctly, and also, you have to deal with the foreign workers. The issue on strategic
purchasing is also, quite interesting, since the service provided by the public and private
sectors are almost the same.
12Nama Keterangan
For Thailand, Mr. Noporn, I’m really interested with this figures, as it also reminds me of
Indonesia before 2014, when our system was still fragmented and scattered. Back then
civil servants enjoy the most lucrative services, while others were basically struggling to
obtain the same level of services. Our previous system jeopardizes the notion of gotong
royong, solidarity, and the idea of equality & equity – so this is a challenge. Also, it’s
interesting that private companies employees are excluding their dependent. Imagine in
one household the husband covered by SSS scheme and dependent, the children,
covered by SSO. I don’t know that do in order to relieve the tension. If insurances
provided by private companies are better than the public one, the number of public
insurance user will be decreased. Based on this situation, I think you’ll have to integrate
the schemes by strengthening purchasing function. Thank you very much.
Dr. Jeremy Lim, Thank you very much, it’s really nice to see that all of us are struggling together, because
MD, MPH – it means that we are all motivated to help each other to find a solution that works for
National our own case, and that could potentially work for everyone else. We have around 10
University of minutes to have a general discussion. I know some of us are itching to ask something to
Singapore our speakers, so can I take a step back and ask, would anyone make any comments about
any aspects? Yes please.
Farouk Meralli – I’m Farouk, and there was an interesting point from Malaysia’s presentation, that
mClinica Thailand and Indonesia should consider cutting their pharmaceutical costs in order to
increase drugs’ accessibility. The regulatory environment in which we all work is so
different that it’s almost impossible for me to imagine that. Yes when you cut the
marketing cost, we can come up with competitive price, but in doing so we are kept
universal packaging from the patients. I think it’s important to address this matter, thank
you.
Dr. Jeremy Lim, Would you like to answer it?
MD, MPH –
National
University of
Singapore
Dr. Nopporn Thank you. We do have regional cooperation. Even within our own country we need to
Cheanklin - be able to pull that procurement process because we're talking about different
Health System ministries; ministry of defence, ministry of education. Then in Malaysia, they are working
Research with private sectors.
Institute,
Thailand
Fran Milnes, MBA Maybe we shouldn’t focus solely on the procurement process. A single assessment
- Novartis process is, in my opinion, one of the things that we need to focus on as we move towards
universal health care coverage. One of the questions that I have is how do you determine
the rational use of a medicine, related to the universal health coverage system. This is
one of the things that Europe has been exploring for a while now. It is the same way you
have single registration decision. Can you have single value assessment which need more
resources and expertise in the country level? That could be the starting point to
determine, that yes, this is the product that we feel would bring benefit to Asian patients.
Thank you.
13Nama Keterangan
Dr. Jeremy Lim, Thank you. In the National University of Singapore, we are very strict in terms of
MD, MPH – methodology. We’re using a three-step process: First, we build the capacity of individual
National countries to work with HDA. The next step is to have ach countries develop their own
University of infrastructure. I think Singapore is very late to the game but over the course of five years,
Singapore we have improved greatly. Once there are capabilities in terms of expertise and skills,
then it's the right time to think about how we can work together to have common
conduit, common assessment process. We are now in the process of harmonizing our
pace, and I applaud Thailand for sharing all of their knowledge with Singapore, Philipines,
and Malaysia. I think they are at the forefront of the health care development.
Dr. Nopporn Each country has their own unique system. What we have now is a country demand.
Cheanklin - Everybody knows how much money they have in their pocket. May I have some time to
Health System answer questions from my colleagues here? In the last 5 years we're talking a lot about
Research these three different schemes; and we faced a lot of resistance, especially from the
Institute, health care service providers (workers). Because by outsourcing health care service
Thailand providers, we can cut their salaries really low. With these three schemes, with their own
money and the employers put in, the benefit is not only for the treatment. There are
more benefits included in the social security system. So again, it’s impossible to combine
these two. What will happen then? It’s a big question now. Nobody talks about it in the
last 10 years.
Dr. Jeremy Lim, Thank you. Before 2015, the experience in Thailand has led the Indonesian government
MD, MPH – to combine all of these schemes together, as they realized that there would be chaos for
National a number of years. But there was also this kind of optimism, as some believed that the
University of chaos would gradually disappear after five years. Clearly, this will always be a work-in-
Singapore progress. There is a strong push toward having equity across different economic strata.
There is different motivation and I guess Thailand has different part with the 3 schemes.
We have time for one more comment.
Somil Nagpal - Jeremy, you are supporting Indonesia’s inititive in bringing together all of the related
World Bank institutions that have a role in the platform. We see this as an important point to learn,
to share their expertise with each other. It will not be easy, but there’s a possibility to
discover a common market. So yes, there will be multiple countries with different
structures, but you could still say that this is the market, and by aggregating these
countries in a single market, you’ll get your own selling point. There is a lot of contingency
supply and will be mentioned in the discussion. So, this cannot be stopped in every
country. But there are several things that we can organize on the regional level. There
are a lot of efforts that ASEAN technology support the region can think about. Let’s take
into account the idea of supranational coalition, and think of it as one of the possibilities.
Thank you.
Dr. Jeremy Lim, Absolutely. I propose a last comment before we are taking our break?
MD, MPH –
National
University of
Singapore
Jorge F. Wagner, Just a short comment, I do not see that there is opportunity of scale. It’s about economic
B.Eng, MBA – scale, there there are 2 aspects. First, they focus on creating innovation price. Sometimes
14Nama Keterangan
Novartis by pushing too much you can also delay the innovation. The second part is better
Indonesia explained through an example. In Indonesia, 70% of our market is local market. The
largest party also generics. Indonesia has achieved it through centralized purchasing. For
countries like Thailand and Malaysia, you can focus on the deployment of your insurance
system in your own countries first, rather than focusing on a large-scale market; because
you’ll need the insfrastructure in order to construct a single, large-scale market, and it’s
a lot of things to do.
Dr. Jeremy Lim, So it’s a gentle reminder that we should stick on the ecosystem approach. I think this
MD, MPH – discussion ends with one, big question: how to optimize our health care system? Thus,
National we’ll talk about in on the next session, as we discuss technological advancement and
University of innovation that can help us to get out of this box and improve our productivity. We are
Singapore going to take 10 minutes break.
Session 2
Big Data in Healthcare: Challenges and Innovations
Chair: Dr. Jeremy Lim, MD, MPH
Associate Professor, Saw See Hock School of Public Health, National University of Singapore
Pada sesi kedua ini masih dimoderatori oleh Dr. Jeremy Lim (MD, MPH). Tiga orang pemateri pada sesi
kedua ini adalah Prof. dr. Iwan Dwiprahasto, MMedSc, PhD, Ketua Formas Indonesia yang juga Profesor di
Fakultas Kedokteran, Kesehatan Masyarakat, dan Keperawatan, Universitas Gajah Mada, Dhesi Baha Raja,
MD, MPH, DrPH, seorang Advisor untuk Kementerian Kesehatan, Malaysia, serta Keren Priyadharsini, PhD,
Bussiness Lead for healthcare Microsoft Asia. Pematik diskusi adalah Dr. Mundiharno, MSi, Direktur
Pengembangan Perencanaan dan Manajemen Risiko BPJS Kesehatan, Indonesia dan Sriganesh Lokanathan,
Data Science Lead, PULSE LAB.
Athia Yumna, I would like to invite Dr. Jeremy to be our moderator for the next session. The theme of
MSc - MC the second session is “Big Data in Health Care: Challenges and Innovations”. Please, Dr.
Jeremy
Dr. Jeremy Lim, While we wait for the participants to get back on their seat, I want to share some
MD, MPH – information. In April, the National University of Singapore is hosting a conference on
National Precision Public Health. The first conference was held in San Francisco, and the second
University of one was held in Perth, Australia. Singapore was asked to host the next conference,
Singapore because of its location and strong focus on public health technology. So I think it’s very
relevant to the topic that we are about to discuss in a minute.
Also, I want to share about Portugal, as one of the most advanced country in terms of
data transparency. Citizens of Portugal are given the access to track how many vaccines
that are given every single day, for a specific type of disease. They all can access those
health care data from website. They even have the data on the geographical distribution,
so you can calculate the vaccine coverage rate. Impressive, and they managed to push
for it, for the reform, in the middle of financial turbulence. I think we should keep this in
mind as a positive example.
Now talking about big data, I would like to introduce our distinguished speakers; Dr.
Iwan, that is going to talk about utilizing Indonesia’s health care database in decision-
making process. I guess most of us are familiar with the term precision medicine; that by
15Nama Keterangan
pulling different data from different sources, we are able to come up with better
diagnosis, better decision. Now how to achieve that?
Prof. Dr. dr. Iwan First I would like to extend my gratitude towards the organizing committee; thank you
Dwiprahasto, for inviting me to this event to talk about “Utilzing Indonesia’s Health Care Database in
MMedSc – Decision Making Processes”. I’m not being pessimistic, but the problem is way bigger
Indonesian than the solution itself. Let me start with this; in 2014 we initiated the Universal Health
National Coverage program, the JKN. We managed to help a lot of people, we gave them access
Formulary to public health facilities for free; something that wasn't accessible for most of them
Committee before the JKN. This is the main principal of National Social Security system; but of course,
it should be carried out with caution. We have to deal with the mutual cooperation, non-
profitability, openness, and accountability of the program. People who are traveling from
one place to the other should be given the same access too, no matter where they are.
The mandatory membership mandated by our constitution makes sure that the national
social security cost is shared with everybody. That’s the main principle, and changing the
scheme to cover only selected groups of people is against the constitution.
This is the patient’s journey. In the past they weren’t able to access secondary and
tertiary health care services. But right now, even those who are living in remote areas
are given access to the hospitals. Indonesia has around 17.000 islands, and more than
20% of those islands are only inhabited by 20-25 households per island. For those who
live in remote areas, even primary care is considered to be a luxury. Through JKN, we are
helping them to gain access to primary health care. What if they need secondary or
tertiary health care services? They could refer back to primary care. For some dieases,
after patients are diagnosed in the secondary or tertiary health care facility; they can
receive their treatments in the primary health care facility. Treatment for diabetes
mellitus, for example; patients are guaranteed to receive subsidized montly medication
for the rest of their live. The BPJS scheme covers all of this, under the National Medicine
Formulary.
The National Medicine Formulary is regulated under the law, presidential decree, and
ministerial decree. In normal cases, hospitals are allowed to prescribe any kind of
medicines for the patients, but in case of JKN patients, they have to follow the National
Medicine Formulary. Of course we’re all aware of the different service cost between, let’s
say, secondary and tertiary hospital; same goes with the level of severity from a disease,
which contributes to the difference in service cost. The formulary addresses these issues.
Related to medicines, those who are under the referral program for nine types of
diseases are guaranteed free medicines; diabetes mellitus, cardiovascular diseases,
asthma, COPD, epilepsy, schizophrenia, stroke, and systemic lupus erythematosus. They
can get their initial treatment at secondary or terriary hospital, and be referred back to
the primary health care facility. People suffering from HOT (Hemophilia, Oncology,
Thalassemia) are also guaranteed free medications. Thus, people with cancer are given
treatments for free; including chemotherapy. Targeted therapies are treated separately
by BPJS.
The next issue is the accuracy of randomized controlled clinical trial. The trials were
conducted on mostly Caucasian subjects; around 95-97%, and might not be directly
applicable for people of Asia’s descend. So for people under this blue line, the treatment
might not be as effective as it’s shown in the clinical trial. The thing is, it’s happening in
the JKN. People might skip their treatments, might not come to the hospital according to
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