Si t Sistem Asuransi A i Kesehatan K h t di Maju dan Negara Berkembang Ali Ghufron Mukti Magister Asuransi Kesehatan/JPKM Program Pasca Sarjana UGM
ISU-ISU SISTEM PELAYANAN ISUKESEHATAN DI BERBAGAI NEGARA • PEMERATAAN • PENINGKATAN BIAYA PEL.KES • EFISIENSI • KUALITAS • AKUNTABILITAS& SUSTAINABILITAS (Neg.berkembang)
Sistem Asuransi di Negara • • • • • •
USA Kanada Jerman Filipina Thailand Indonesia
Sistem Asuransi Kesehatan di Amerika • Multipayer y Umumnya y komersial dan lebih percaya pada mekanisme pasar • 38 Juta tidak terasuransi, 85% diantaranya kelompok perkerja. • Medicare • Medicaid • HMO Act 1973
Sistem Asuransi Kesehatan di Kanada • Tidak seperti Inggris, gg tidak seperti Amerika • Dana pemerintah Pusat diberikan ke badan publik independen yg berorientasi nirlaba dan bertg jawab pada PEMDA PROPINSI (50:50) sekarang block grant • Mulai dari rawat inap
Sistem Asuransi Kesehatan di Jerman • Multi payer y • Di laksanakan oleh Bapel swasta • Sifat sosial Nirlaba hanya sedikit komersial • Asuransi kesehatan kontrak dengan asosiasi dokter asosiasi dokter yang mengatur ke dokter
Sistem Asuransi di Filipina Di mulai 1997 dg g UU Asuransi Kesehatan Nasional penyelenggara PHIC Monopoli Paket rawat inap Cakupan Ca upa 60% (wajib) ( aj b)
Health Insurance In Thailand • Medical Welfare Scheme (MWS) : cover indigence, h lth cardd for health f community it lleaders d and d health h lth volunteer • Civil Servant Medical Benefit Scheme(CSMBS) • Compulsory p y Health Insurance : Social Securityy Scheme(SSS), Workmen Compensation Scheme ((WCS), ), and Traffic Accident Insurance (TA). ( ) • Voluntary Health Insurance : Private Insurance (PI), Voluntary Health Card (VHC).
The Civil Servants Medical Benefit Scheme
• Objective : fringe benefits for government workers and to compensate their low salaries. salaries • Basic concepts of these scheme are public welfare f government workers; for k retrospective i FFS payment, free choices of access without copayment.t • Beneficiaries include government workers and their families, estimated 7 millions. • Beneficiaries are free to choose ppublic or pprivate care but limited payment to private care.
Compulsory Health Insurance • The Workmen Compensation Scheme (WCS): cover sickness and injuries due to work-related. work related Contributions are paid by employers based on experience rate experience-rate. • The Social Security Scheme (SSS) : started in 1991 for f enterprises t i with ith 20 andd more workers k and expanded to those with 10 or more workers in 1993 In 1993. I 2001, 2001 it aims i tto extend t d to t those th 1 or more workers. • The Traffic Accident Insurance (TA) : compulsory for all car owners.
Voluntary Health Insurance • Private Insurance pays only limited role, estimation of covered people 1% mainly in Bangkok and urban area. • The Health Card project is a voluntary public subsidized health insurance scheme aiming g to p provide health insurance coverage g those people who are not eligible to PA scheme and may face catastrophic financial burden when they get sick. Target population includes people in informal sector especially in rural area e e.g. g farmer farmer, fishermen fishermen, self selfemployed, workers uncovered by SSS.
Health Insurance In Thailand • 100% public subsidized scheme; MWS, CSMBS • 75% public subsidized scheme; VHC • 25% public subsidized scheme: SSS • unsubsidized scheme; WCS, WCS TAI, PI
Trends and Coverage Scheme 1991 1996 1999 I. Medical Welfare 12.7 12.3 12.4 Schemes 2. Government employee scheme 13 2 11.3 13.2 11 3 7.8 78 • CSMBS 2.1 1.4 1.1 • State Enterprise 3. Social Security including 0 5.5 7.1 WCS and employer welfare 4. Voluntary insurance 1.4 13.2 28.2 • Voluntary Health Card
1996* 29.5
1999* 22.5 (32 1) (32.1)
11.3 11 3 1.4 5.5
7.8 7 8 1.1 7.1
13.2
28.2 ( (18.6) ) 3.1 1.2 1.4 1.2 1.4 • Private insurance 5. Others 0.9 1.1 1.7 1.1 1.7 Uninsured 66.5 54 40.2 36.8 30.1 Total 100 100 100 100 100 Source: National Statistic Office, Health and Welfare Survey 1991, 1996, and 1999.
Financing Model and provider payment methods Schemes I. MWS II. CSMBS III SSS III. IV.WCS V. VHCS VI Private VI. insurance The uninsured Source: OECD 1994.
Model
Hospital p y payment methods Public integrated model Global budget Public reimbursement of patients model Fee for services P bli contract Public t t model d l Fl t rate Flat t capitation it ti Public reimbursement of patients model Fee for service Voluntary integrated model Global budget Voluntary reimbursement of patients Fee for service model Voluntary out of pocket model Fee for service
Sources, responsible agency, mode of financing Scheme
Source of finance
Responsible
Mode of
agency
financing
MWS
Tax
MOPH
Global budget
CSMBS
Tax
M. Finance
Fee-forservices
SSS
Tax, employer,
SSO
Capitation
SSO
Fee-for-
employee WC
Employers
services TA
Car owners
M.Commerce
Fee-forservices
HC
Tax premium Tax,
MOPH
Mixed
PI
Premium
Private insurer
Fee-for-service
Government budget subsidy Scheme
Budget /capita
Expense / capita
Medical Welfare Scheme CSMBS
363
> 363
Discrepa ncy index 1
2,106
> 2,106
5.8
Social Security
519
1,558
1.4
Health Card
250
534
0.69
Data in 1999
Perbandingan Pengeluaran Untuk Kesehatan dan Status Kesehatan Beberapa p Negara g ASIA Negara g
Indonesia
GDP Per IMR Life Pengelu g Pengelu g Kapita Expectancy aran aran 1998 (1998)L/P Kes.(% Kes.(% GDP) Publik) (1995) (1995) 1.102 48 63/67 1,8 37
Fili i Filipina
1 698 1.698
36
67/70
24 2,4
56
Thailand
3.942
29
66/72
5,3
26
Malaysia
5 746 5.746
11
70/74
25 2,5
60
Singapore
12.653
5
75/79
3,5
37
China
1.493
41
68/72
3,8
54
Sumber: WHO, 1999
Perbandingan Asuransi di Berbagai Negara Isu
USA
Coverage
75%
M d l Model
Multi M lti payer
Peran Pmt Minimal
Canada German 100%
90%
Mono payer Multi M M lti payer (Propinsi)
Thai
Filipina
Ind
80%
60%
15%
Oligo Oli payer
Mono M payer
Multi M lti Payer
Besar
Besar
Besar
Besar
Besar
Kompetisi
Tinggi
Rendah
Tinggi
Rendah
Rendah
Tinggi
Premi
Mahal
Murah
Cukup
Murah
Murah
Murah & Mahal
Kesimpulan • Umumnya Sifat asuransi kesehatan notfor profit, kecuali USA • Cakupannya tinggi • Beberapa dikelola oleh badan independen • Satuan terkecil Badan pelaksana bukan distrik tetapi propinsi • Ada keterkaitan sistem asuransi kesehatan dan tingkat kesehatan penduduk
