BIODATA Riwayat Pekerjaan :
Wakil Dir. Medik & Keperawatan RS Dr. Kariadi , Semarang (1990-1995) Wakil Dir. Umum & Keuangan RS Dr. Kariadi, Semarang (1995-1998) Direktur RS Fatmawati (1998-2002) Dr.Santoso Soeroso SpA(K), MARS Direktur RSPI-Sulianti Saroso (2002-2007) Tempat & Tanggal lahir : Magelang, 22 Chief Operating Officer RS Puri Indah September 1947 (Pondok Indah Group) Alamat kantor : Komite Medik RS Pondok Indah, Jl. Metro Duta Kav UE, Jakarta Selatan Ketua II Health Technology Asseessment Indonesia (2003-2013) Pendidikan : Ketua Bidang Kredensial Komite Medik RS Dokter (FK UNDIP 1973) Dokter Spesialis Pondok Indah Anak (FK UNDIP 1982), Research Fellow Anggota Institut Manajemen Rumah Sakit – Pediatrc Cardiology, University of Lund, PERSI Sweden 1984-1985, Reseach Fellow Pediatric Cardiology , Tokyo Women Medical College, Kepala Divisi Penelitian dan Health Japan, the Heart Institute of Japan, 1991Technology Assessment - PERSI (20091992, SpA Konsultan 1992 sekaramg) MARS (FKM UI , 1996) Sekretaris, Badan Pertimbangan Pemgurus Pusat IDAI (2012 – 2015) Lemhannas KRA XXXIII (2000)
SANTOSO SOEROSO KEPALA KOMPARTEMEN PENELITIAN DAN HEALTH TECHNOLOGY ASSESSMENT PERSI Hotel Peninsula, Jakarta , 3 Juli 2013
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MILLENIUM DEVELOPMENT GOALS
MATERNAL MORTALITY RATIO Jumlah kematian dalam bulan
Region Indonesia Sumatera
Jawa-Bali
Kalimantan
Sulawesi
IBT
Jumlah kematian 17 bulan
1738
3333
587
979
888
7524
Jumlah kematian 12 bulan
1227
2353
414
691
627
5311
Jumlah lahir hidup 12 bulan
1.072.588
2.371.448
280.717
345.556
331.845
4.402.154
Uncorrected Maternal Mortality Ratio per 100.000 live birth
114
99
148
200
189
121
Maternal Mortality Ratio per 100.000 live birth*
262
227
340
459
434
278
*setelah uncorrected MMRDeterminan dikoreksi dengan completeness , yaitu dibagi = 0,4352 18/12/2012 Kematian Maternal_kajian Litbangkes
6
Proporsi kriteria PONEK RSU PEMERINTAH (Data Rifaskes 2011) No
Kriteria PONEK
1
Kamar ops siap 24 jam Tim siap ops 24 jam Pelayanan darah 24 jam Laboratorium 24 jam Radiologi 24 jam Farmasi dan alat penunjang siap 24 jam Ruang Pemulihan siap 24 jam Unit Pelayanan darah 24 jam Tim PONEK Esensial
2 3 4 5 6 7 8 9
18/12/2012
Sumatera N %
Jabal N %
Kalimantan N %
208
69.7
233
81.1
74
67.6
208
70.2
233
84.1
74
208
50.5
233
63.1
208
61.1
233
208
56.3
208
Sulawesi N %
IBT n
%
90 62.2
80
62.5
63.5
90 45.6
80
62.5
74
56.8
90 46.7
80
43.8
75.1
74
63.5
90 52.2
80
52.5
233
70.0
74
55.4
90 41.1
80
47.5
60.1
233
77.3
74
67.6
90 60.0
80
55.0
208
49.0
233
68.7
74
44.6
90 40.0
80
35.0
208
43.3
233
37.8
74
47.3
90 44.4
80
36.3
208
38.5
233
57.1
74
24.3
90 34.4
80
42.5
Determinan Kematian Maternal_kajian Litbangkes
7
KESIMPULAN Pada kajian ini diperoleh uncorredcted ratio kematian ibu. Pada kajian ini perlu dikoreksi dengan completeness sebesar 0,4352; sehingga urutan MMR dari tertinggi sebagai berikut : Region Sulawesi (459/ 100.000 kelahiran hidup) Region IBT (434/100.000 kelahiran hidup) Kalimantan (340/100.000 kelahiran hidup) Sumatera (261/100.000 kelahiran hidup) Jawa Bali (227/100.000 kelahiran hidup) Indonesia (278 /100.000 kelahiran hidup) Kajian ini menyimpulkan kematian ibu masih tinggi di Indonesia. 18/12/2012
Determinan Kematian Maternal_kajian Litbangkes
8
Population: Elderly Society in Thailand Population - 67 million Total fertility rate: 1.6 (2009)
1400
Population (x 1,000)
1200 1000
Life expectancy at birth: 74 Years
800 600 400
Under 5 Mortality: 14/ 1000 live births
200 0 0
20
40
60
Pop 2007
80
100 Age
POP 2020
Source: Health Care Reform Project (2008)
9
Maternal mortality: 48/100,000 live births
The national health security program increased government budget
How Pay for Health Care
Thailand Spends a Relatively High Share of Government Spending on Health
Source: World Bank (2012) Government Spending and Central-Local Relations in Thailand’s Health Sector. Health, Nutrition and Population (HNP) 11
Thailand: Path to Universal Coverage
Source: National Statistic Office, the Health and Welfare Surveys in 1991, 1996, 2001 and 2003. 12
Impacts of Universal Coverage Decrease Poverty from Health Care Spending
2000 280,000 Households
2008 88,000 Households
Source: Limwattananon (2010): analysis of Socioeconomic Survey (various years) Distribution of Patients by Treatment Outcome 100% 80% 60%
Improve Health Outcome
40% 20% 0% 2003-4
2008-9
Hypertension
2003-4
2008-9 Diabetic
No diag
No trearment
Uncontrol
2003-4
Hypercholesterol Control
Source: National Health Examination Survey 2003-2004 and 2008-2009 14
2008-9
Social Sustainability: Legitimacy, People Satisfaction
15
Share of Total Spending Financed by Government Has Been Rising
Source: World Bank (2012) Government Spending and Central-Local Relations in Thailand’s Health Sector. Health, Nutrition and Population (HNP) Discussion Paper (Forth coming) 16
QUALITY Hospital Accreditation Accredited Hospitals Number of hospital
250 200 150
Voluntary program which is conducted by the Institute of Hospital Quality Improvement and Accreditation
100 50 0 1999
2000
2001
2002
2003 Year Hospitals
18
2004
2005
2006
2007
This Thai accreditation process is demanding from both public and private hospitals
Health Care Delivery Development Coverage of health facilities Mainly under Ministry of Public Health (MOPH) •
Provinces (76) exclude Bangkok
– General/Regional hospitals •
Districts
– Community hospitals •
100% nearly 100%
Subdistrict or Tambon
– Municipal health centres (214) – Tambon Health centres (9,738)
19
nearly 100%
EQUITY Income Spending on Health by Income Groups % income spent on health
Declining of gap
9 8 7 1992 2000 2002 2004 2006
6 5
Before UC
4 3 2 1
After UC
Income Deciles
Source: Socio-Economic Survey 1992 - 2006 conducted by NSO. 20
10 ile
9 D ec
ile
8 D ec
ile
7 D ec
ile
6 D ec
ile
5 D ec
ile
D ec
ile
3 D ec
ile
2 D ec
ile
1 D ec
ile D ec
Poorest
4
0
Richest
ACCESSIBILITY
Increase utilization of out-patient and in-patient
Source: HISRO (2008) 21
Perkembangan RS di Indonesia
Number of private hospitals is increasing more than government ones. Number of For-Profit Private-Hospital almost doubled
in the last five years Number of Non-For-Profit-Private Hospital almost remained the same 03
04
05
06
07
08
49
52
55
60
71
85
530
538
538
538
539
539
27
27
28
28
28
29
606
617
621
626
638
653
Owner For Profit Corporation Non-Profit (Foundation) Non-Profit (NGOs)
Total
Specialist distribution (KKI, 2008)
Jakarta: 24% of specialists, serves around 4%
community in a relatively small area
• Provinces in Java: 49% of specialists, serves around 53% community • Rest of Indonesia: 27% of specialists, serves around 43% community in a very large area
Specialist distribution (KKI, 2008) Province
DKI Jakarta Jawa Timur Jawa Barat Jawa Tengah Sumatera Utara D.I.Jogjakarta Sulawesi Selatan Banten Bali Sumatera Selatan Kalimantan Timur Sulawesi Utara Sumatera Barat Propinsi Lainnya
Number
%
Cumulative
People served
Ratio
2.890
23,92%
23,92%
8.814.000,00
1 : 3049
1.980
16,39%
40,30%
35.843.200,00
1 : 18102
1.881
15,57%
55,87%
40.445.400,00
1 : 21502
1.231
10,19%
66,06%
32.119.400,00
1 : 26092
617
5,11%
71,17%
12.760.700,00
1 : 20681
485
4,01%
75,18%
3.343.000,00
1 : 6892
434
3,59%
78,77%
8.698.800,00
1 : 20043
352
2,91%
81,69%
9.836.100,00
1 : 27943
350
2,90%
84,58%
3.466.800,00
1 : 9905
216
1,79%
86,37%
6.976.100,00
1 : 32296
203
1,68%
88,05%
2.960.800,00
1 : 14585
173
1,43%
89,48%
2.196.700,00
1 : 12697
167
1,38%
90,86%
4.453.700,00
1 : 26668
1.104
9,14%
100,00%
52.990.200,00
1 : 47998
12083
100,00%
224.904.900,00
1 : 18613
Specialists Distribution (Pediatrics)
Data: IDAI (Pediatrician Association, 2006)
Obstetric Jumlah Dokter and Spesialis Gynecologist Obsetri dan Ginekologi DKI
240
287
163 168
Jat im 153 154
Jat eng 136 141
Jabar 71
Sumut
101
48 46
Bali 42 40 39
Sulsel Sumsel
46
34
Sumbar DIY Riau Bant en Lampung
17
21 22 17 18 15 16 14 13 13 11 13 20 12 11 11
Kalt im Kalsel Kepri Kalbar Jambi NA D Sult eng Kalt eng
56
28 29 27 29 25 27 23
7
10 12
Sulut NTB M aluku
6
Sultra
5
9 8 8 8
8 7 7
NTT Papua Bengkulu Babel Sulbar
1
10
5 6 4 4 3
3 3 2 4 1 4
Goront alo Papua Barat M alut 0
50
100
150
200 2006
250
300
2008
Typical graphic description of medical specialist distribution
350
Historical Facts , to answer why there is inequitable distribution of health workforce and hospital Indonesia is not a
welfare state since the colonial era Indonesia has market based economy
Hospitals operate within
market ideology Medical Doctors (esp. specialists) operates based on the fundamental demand and supply principles.
Adverse Effects of 30-baht UC in Thailand Demanding huge governmental budget Exodus of doctors from government-run hospitals to private sector Double standards of medication and treatment When fully implemented: catalyzing family breakdown due to more individualism in community
Poll on Current Health Care Matichon, February 5, 2007 A survey report was conducted by the Office of Heath Systems Research Institute and ABAC Poll on 13, 497 people from September 1, 2006- October 31, 2006 :
1) 34% felt that the health care services provided by the government are inadequate. 2) 72.9% urge the government to solve the problem of over crowded tertiary care hospitals urgently. 3) 59.3% felt the government provided insufficient budget for public health; 4) 87.1 % suggested the government to establish more health care centers.
Emerging Elements of Communitarian Health Care System Decentralization of government administration: Establishment of Office of Heath Care Reform Local leaderships with established community centers
(best practices): 1 baht a day for membership, huge fundraising and payment for illness Local infrastructure: village banking system (microeconomics)
Culture has been the forgotten resource for health
care reform in Thailand. Culture of volunteer workers & culture of care in community should be promoted Government supports: knowledge, training, setting standards of activities and programs at the grassroots and networking; Aging population: quality older people Better selection of medical students, nurses, etc.
HEALTH CARE SYSTEM TRANSITION Health care system transition from fee for service out
of pocket or reimbursement to accountable prospective payment will eventually be tied to the quality and outcome of patient care , cost management and the overall population health. This evolution requires tight integration between all those who influence the continuum of patient care with doctor and hospital alignment being the primary component.
SUTOTO PERSI
35
36
Lanjutan…..
37
U.U B.P.J.S psl 10 Membuat kesepakatan dengan Fasilitas
kesehatan mengenai besar pembayaran fasilitas kesehatan yg mengacu pada standar tarif yg ditetapkan pemerintah Membuat atau menghentikan kontrak kerja dengan fasilitas kesehatan Standar Tarif harus dalam harga keekonomian, ada up dating. !!! SUTOTO PERSI
40
PERPRES 12 TH 2013 TTG JAMINAN KESEHATAN Pasal 35 (1) Pemerintah dan Pemerintah Daerah bertanggung
jawab atas ketersediaan Fasilitas Kesehatan dan penyelenggaraan pelayanan kesehatan untuk pelaksanaan program Jaminan Kesehatan. (2) Pemerintah dan Pemerintah Daerah dapat memberikan kesempatan kepada swasta untuk berperan serta memenuhi ketersediaan Fasilitas Kesehatan dan penyelenggaraan pelayanan kesehatan.
41
PERPRES 12 TTG JAMINAN KESEHATAN Pasal 24 Peserta yang menginginkan kelas perawatan
yang lebih tinggi dari pada haknya, dapat meningkatkan haknya dengan mengikuti asuransi kesehatan tambahan, atau membayar sendiri selisih antara biaya yang dijamin oleh BPJS Kesehatan dengan biaya yang harus dibayar akibat peningkatan kelas perawatan.
42
Supasit Pannarunothai
Center for Health Equity Monitoring Faculty of Medicine, Naresuan University
Scope Equity trends in Thailand Benchmarks Phase I Objectives and methods for Phase II
Quantitative data on equity in Thailand Qualitative data from focus group discussion Experiences learnt
Equity trends in Thailand The Constitution
Universal health coverage
The Decentralization Act 2001
Equity Efficiency Social accountability Quality
Benchmarks of Fairness Phase I Scoring of Provincial Health Reforms
Benchmarks 1 Intersectoral public health 2 Financial barriers to equitable access 3 Non-financial barriers to access 4 Comprehensiveness of benefits and tiering 5 Equitable health financing 6 Efficacy, efficiency and quality of health care 7 Administrative efficiency 8 Democracy, accountability and empowerment 9 Patient and provider autonomy Overall score
Score from -5 to +5 with zero representing status quo The overall score was made by implicit weighting Pannarunothai and Srithamrongsawat (2000)
Phayao*
Yasothon
1.8 2.6 2.7 1.4 1.5 2.1 1.8 3.8 1.6 2.1
2.0 2.2 2.0 2.1 1.5 2.0 1.5 1.9 0.8 1.8
Lessons learnt from Phase I The benchmarks provided a comprehensive framework for
evaluation of health system. It could be used as a tool for provincial health system development. If combining with more objective data, the benchmarks should provide more accurate directions for developments.
Mettanando Bhikkhu B.Sc., M.D. (Chulalongkorn), B.A.,MA. (Oxford), Th.M. (Harvard), Ph.D. (Hamburg) Ethics Committee, Faculty of Medicine, Chulalongkorn University, www.mettanando.com
Collaboration Among Health Care Professional, Civil Societies and Politicians: Triangle that moves mountain Accumulation of Knowledge
Health Reform Social Movement
Source: Dr. Prewase Wasi
49
Political Linkage
Volunteer Recruitment 6 million Thai people registered with the Ministry of
Culture as “Volunteers” Volunteering at the grass-roots Promoted by Office of Health Care Reform Prof. Prawes Wasi (Guru of National Health Reform, Rural Doctor Group) Volunteers are active in many areas of health care: cancer, HIV/AIDS, etc.
“Impacts and Constraints of Universal Coverage (UC) in Thailand’s Public Health System” Chalermpol CHAMCHAN Doctor of Area Studies, Graduate School of Asian and African Area Studies (ASAFAS), Kyoto University
24 June 2009
At Faculty of Economics, TU
51
I. Background The UC policy incorporated 1) Financial reforms with closed-end provider payment
method – the capitation method – and
2) Strengthened primary care network with more attention
on health promotion and disease prevention works (PP) – a concept of “Primary Care Unit (PCU)” under “Contracted Unit of Primary Care” (CUP) structure.
Adequacy of the capitation rates and UC budget “Adequacy” ---- survival of the health facility and its financing----enough and the hospital could survive, even with some financial deficits and debts. However, “Adequacy” ---- in relation to assigned work tasks and expected outcomes by the NHSO, the MOPH and the patients----hardly enough and inadequate to have the facility achieving at the quality levels
Adequacy of the capitation rates and UC budget “Investments” for long-term development and quality
improvement of services provided ---- said to be forgotten, due to the limitations and inadequacy of the budget---affects not only the sustainability of the facilities themselves but also of the whole health service provision system.
“Salary subtraction” of the UC budget at the national level &
at the provincial level
“The co-payment”: The fixed 30 baht/visit
2. Linking consequences: From PCUs to Secondary and Tertiary level hospitals Failures of strategies to strengthen service
provisions at primary care level, and health promotion and prevention (PP)---Failures of the SNS and KBKJ strategies
From Secondary level hospitals to Tertiary level hospital Over-referring of In-Patient cases
55
3. Secondary Constraints Backward from Tertiary level hospitals to Secondary level hospitals Infeasible reallocations of health personnel from provincial cities to rural districts Secondary care level hospital to PCUs Infeasible strengthening primary care network
56
Figure 6 Systematic Constraints and Cyclic Consequences in Public Health Service System at the Provincial Level Primary Constraints at Facilities in Primary Care Level + Impacts of the UC implementation
Workloads and Poor performances of service provisions at the primary care level Consequences of Failures at primary care level
Infeasible to strengthen Primary care network
Primary Constraints at Facilities in Secondary Care Level + Impacts of the UC implementation
Workloads and Poor performances of service provisions at the secondary care level Consequences of Over-referring of In-Patient cases
Infeasible Reallocation of health personnel in the province
Primary Constraints at Facilities in Tertiary Care Level + Impacts of the UC implementation June 1) Primary Constraints
Workloads and Poor performances of service provisions at the primary care level At of Economics, TU 2)Faculty Linking Consequences
3) Secondary Constraints
57
“…where shortages (and inequitable
distributions) of health workforces are still prevalence in many areas and sufficient budget funding are not yet acquired, the public health care system (and UC) as a whole is vulnerable and might not be sustainable in the long-run
58
Conclusions Thailand’s health system has achieved intermediate goal but not yet the final one of the UC policy. (1) Assuring (2) (3) universal Ensuring Increasing and adequate the comprehens and effectivenes Source: Docteur et al. 2003 ive health equitable s and insurance access to sustainabilit coverage. ‘Universal inclusion’ is toneeded be achieved, but y of health health “Universal access” is still not ensured that it is system equitable to all insured population service.
UC system is insufficiently provided with health resources, and as a result ineffectively functioning and vulnerable 59
Policy Suggestions To empower Primary Care Unit (PCU) and enhance its staffs To put forward a concrete agenda to relieve shortages of health workforce and its misdistribution nationwide To adjust financing mechanism of UC in term of fund sourcing and budget managements To promote better community participation and patients’ responsibilities 60
