BIODATA

Dr.Santoso Soeroso SpA(K), MARS Tempat & Tanggal lahir : Magelang, 22

September 1947 Alamat kantor : Komite Medik RS Pondok

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)Direktur RSPI-Sulianti Saroso (2002-2007)Chief Operating Officer RS Puri Indah

(Pondok Indah Group)Ketua II Health Technology Asseessment

Alamat kantor : Komite Medik RS Pondok Indah, Jl. Metro Duta Kav UE, Jakarta Selatan

Pendidikan :Dokter (FK UNDIP 1973) Dokter Spesialis

Anak (FK UNDIP 1982), Research Fellow Pediatrc Cardiology, University of Lund, Sweden 1984-1985, Reseach Fellow Pediatric Cardiology , Tokyo Women Medical College, Japan, the Heart Institute of Japan, 1991-1992, SpA Konsultan 1992

MARS (FKM UI , 1996)Lemhannas KRA XXXIII (2000)

Ketua II Health Technology AsseessmentIndonesia (2003-2013)

Ketua Bidang Kredensial Komite Medik RS Pondok Indah

Anggota Institut Manajemen Rumah Sakit –PERSI

Kepala Divisi Penelitian dan Health Technology Assessment - PERSI (2009-sekaramg)

Sekretaris, Badan Pertimbangan PemgurusPusat IDAI (2012 – 2015)

SANTOSO SOEROSOKEPALA KOMPARTEMEN

PENELITIAN DAN HEALTH TECHNOLOGY ASSESSMENT PERSIHotel Peninsula, Jakarta , 3 Juli 2013

cx=-[

``

MILLENIUM DEVELOPMENT GOALS

Jumlah kematian dalambulan

Region

IndonesiaSumatera 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

MATERNAL MORTALITY RATIO

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

18/12/2012 Determinan Kematian Maternal_kajian Litbangkes 6*setelah uncorrected MMR dikoreksi dengan completeness , yaitu dibagi = 0,4352

Proporsi kriteria PONEK RSU PEMERINTAH(Data Rifaskes 2011)

No Kriteria PONEKSumatera Jabal Kalimantan Sulawesi IBTN % N % N % N % n %

1 Kamar ops siap 24 jam

208 69.7 233 81.1 74 67.6 90 62.2 80 62.5

2 Tim siap ops 24 jam 208 70.2 233 84.1 74 63.5 90 45.6 80 62.53 Pelayanan darah 24

jam208 50.5 233 63.1 74 56.8 90 46.7 80 43.8

jam4 Laboratorium 24

jam208 61.1 233 75.1 74 63.5 90 52.2 80 52.5

5 Radiologi 24 jam 208 56.3 233 70.0 74 55.4 90 41.1 80 47.56 Farmasi dan alat

penunjang siap 24 jam

208 60.1 233 77.3 74 67.6 90 60.0 80 55.0

7 Ruang Pemulihan siap 24 jam

208 49.0 233 68.7 74 44.6 90 40.0 80 35.0

8 Unit Pelayanan darah 24 jam

208 43.3 233 37.8 74 47.3 90 44.4 80 36.3

9 Tim PONEK Esensial

208 38.5 233 57.1 74 24.3 90 34.4 80 42.5

18/12/2012 Determinan Kematian Maternal_kajian Litbangkes 7

KESIMPULANPada kajian ini diperoleh uncorredcted ratio kematian ibu.Pada kajian ini perlu dikoreksi dengan completeness sebesar0,4352; sehingga urutan MMR dari tertinggi sebagai berikut : Region Sulawesi (459/ 100.000 kelahiran hidup) Region IBT (434/100.000 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

600

800

1000

1200

1400

Po

pu

latio

n (

x 1

,000

)

Population - 67 millionTotal fertility rate: 1.6 (2009)

Life expectancy at birth:74 Years

0

200

400

600

0 20 40 60 80 100 Age

Po

pu

latio

n

Pop 2007 POP 2020

Source: Health Care Reform Project (2008)

74 Years

Under 5 Mortality: 14/ 1000 live births

Maternal mortality: 48/100,000 live births

9

How Pay for Health CareThe national health security program increased government budget

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 CoverageDecreasePoverty from Health Care Spending

Source: Limwattananon (2010): analysis of Socioeconomic Survey (various years)

2000280,000

Households

200888,000

Households

14

Distribution of Patients by Treatment Outcome

0%

20%

40%

60%

80%

100%

2003-4 2008-9 2003-4 2008-9 2003-4 2008-9

Hypertension Diabetic Hypercholesterol

No diag No trearment Uncontrol Control

ImproveHealth Outcome

Source: National Health Examination Survey 2003-2004 and 2008-2009

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

QUALITYHospital Accreditation

Voluntary program which is conducted by the Institute of Hospital Quality Improvement and Accreditation

Accredited Hospitals

100

150

200

250

Nu

mb

er o

f h

osp

ital

This Thai accreditation process is demanding from both public and private hospitals

0

50

100

1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Nu

mb

er o

f h

osp

ital

Hospitals

18

Coverage of health facilitiesMainly under Ministry of Public Health (MOPH)

• Provinces (76) exclude Bangkok

– General/Regional hospitals 100%• Districts

– Community hospitals nearly 100%

Health Care Delivery Development

– Community hospitals nearly 100%• Subdistrict or Tambon

– Municipal health centres (214)– Tambon Health centres (9,738) nearly 100%

19

4

5

6

7

8

9%

in

com

e sp

ent

on

hea

lth

1992

2000

2002

2004

Dec

linin

g of

gapEQUITY

Income Spending on Health by Income Groups

Before UC

0

1

2

3

4

Decile

1

Decile

2

Decile

3

Decile

4

Decile

5

Decile

6

Decile

7

Decile

8

Decile

9

Decile

10

Income Deciles

% in

com

e sp

ent

on

hea

lth

20042006

Dec

linin

g of

gap

Poorest Richest

After UC

Source: Socio-Economic Survey 1992 - 2006 conducted by NSO.20

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 08Owner

03 04 05 06 07 08

For Profit Corporation

49 52 55 60 71 85

Non-Profit(Foundation)

530 538 538 538 539 539

Non-Profit (NGOs)

27 27 28 28 28 29

Total

606 617 621 626 638 653

Specialist distribution (KKI, 2008)

Jakarta: 24% of specialists, serves around 4% community in a relatively small area

• Provinces in Java: 49% of specialists, serves • 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 Number % Cumulative People served Ratio

DKI Jakarta 2.890 23,92% 23,92% 8.814.000,00 1 : 3049

Jawa Timur 1.980 16,39% 40,30% 35.843.200,00 1 : 18102

Jawa Barat 1.881 15,57% 55,87% 40.445.400,00 1 : 21502

Jawa Tengah 1.231 10,19% 66,06% 32.119.400,00 1 : 26092

Sumatera Utara 617 5,11% 71,17% 12.760.700,00 1 : 20681

D.I.Jogjakarta 485 4,01% 75,18% 3.343.000,00 1 : 6892D.I.Jogjakarta 485 4,01% 75,18% 3.343.000,00 1 : 6892

Sulawesi Selatan 434 3,59% 78,77% 8.698.800,00 1 : 20043

Banten 352 2,91% 81,69% 9.836.100,00 1 : 27943

Bali 350 2,90% 84,58% 3.466.800,00 1 : 9905

Sumatera Selatan 216 1,79% 86,37% 6.976.100,00 1 : 32296

Kalimantan Timur 203 1,68% 88,05% 2.960.800,00 1 : 14585

Sulawesi Utara 173 1,43% 89,48% 2.196.700,00 1 : 12697

Sumatera Barat 167 1,38% 90,86% 4.453.700,00 1 : 26668

Propinsi Lainnya 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)

Jumlah Dokter Spesialis Obsetri dan Ginekologi

11

20

11

13

16

18

22

17

27

29

29

56

46

40

46

101

141

154

168

240

12

13

13

14

15

17

21

23

25

27

28

34

39

42

48

71

136

153

163

287

Sulteng

NAD

Jambi

Kalbar

Kepri

Kalsel

Kalt im

Lampung

Banten

Riau

DIY

Sumbar

Sumsel

Sulsel

Bali

Sumut

Jabar

Jateng

Jat im

DKI

Obstetric and Gynecologist

4

4

3

1

4

6

10

7

5

6

8

12

7

11

1

2

3

3

4

5

7

8

8

8

9

10

11

0 50 100 150 200 250 300 350

M alut

Papua Barat

Gorontalo

Sulbar

Babel

Bengkulu

Papua

NTT

Sultra

M aluku

NTB

Sulut

Kalteng

Sulteng

2006 2008

Typical graphic description of medical specialist distribution

Historical Facts , to answerwhy there is inequitable distribution of health

workforce and hospital

Indonesia is not a welfare state since the colonial era

Hospitals operate within market ideologyMedical Doctors (esp.colonial era

Indonesia has market based economy

Medical Doctors (esp.specialists) operates based on the fundamental demand and supply principles.

Adverse Effects of 30-baht UCin Thailand

Demanding huge governmental budgetExodus of doctors from government-run hospitals to

private sectorprivate sectorDouble standards of medication and treatmentWhen 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 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 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 (micro-economics)

Culture has been the forgotten resource for health care reform in Thailand.

Culture of volunteer workers & culture of care in community should be promotedcommunity should be promoted

Government supports: knowledge, training, setting standards of activities and programs at the grass-roots 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 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 10Membuat kesepakatan dengan Fasilitas

kesehatan mengenai besar pembayaranfasilitas kesehatan yg mengacu padafasilitas kesehatan yg mengacu padastandar tarif yg ditetapkan pemerintah

Membuat atau menghentikan kontrakkerja dengan fasilitas kesehatan

SUTOTO PERSI 40

Standar Tarif harus dalam hargakeekonomian, ada up dating. !!!

PERPRES 12 TH 2013 TTG JAMINAN KESEHATAN

Pasal 35 (1) Pemerintah dan Pemerintah Daerah bertanggung

jawab atas ketersediaan Fasilitas Kesehatan danpenyelenggaraan pelayanan kesehatan untukpenyelenggaraan pelayanan kesehatan untukpelaksanaan program Jaminan Kesehatan.

(2) Pemerintah dan Pemerintah Daerah dapatmemberikan kesempatan kepada swasta untuk berperanserta memenuhi ketersediaan Fasilitas Kesehatan danpenyelenggaraan pelayanan kesehatan.

41

PERPRES 12 TTG JAMINAN KESEHATANPasal 24

Peserta yang menginginkan kelas perawatanyang lebih tinggi dari pada haknya, dapatyang lebih tinggi dari pada haknya, dapatmeningkatkan haknya dengan mengikutiasuransi kesehatan tambahan, atau membayarsendiri selisih antara biaya yang dijamin olehBPJS Kesehatan dengan biaya yang harus dibayarakibat peningkatan kelas perawatan.

42

Supasit PannarunothaiCenter 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 ThailandThe Constitution

The Decentralization Act 2001Universal health coverage

Equity Efficiency

Social accountabilityQuality

Benchmarks of Fairness Phase I Scoring of Provincial Health Reforms

Benchmarks Phayao* Yasothon1 Intersectoral public health 1.8 2.02 Financial barriers to equitable access 2.6 2.23 Non-financial barriers to access 2.7 2.04 Comprehensiveness of benefits and tiering 1.4 2.14 Comprehensiveness of benefits and tiering 1.4 2.15 Equitable health financing 1.5 1.56 Efficacy, efficiency and quality of health care 2.1 2.07 Administrative efficiency 1.8 1.58 Democracy, accountability and empowerment 3.8 1.99 Patient and provider autonomy 1.6 0.8

Overall score 2.1 1.8Score from -5 to +5 with zero representing status quoThe overall score was made by implicit weightingPannarunothai and Srithamrongsawat (2000)

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.development.

If combining with more objective data, the benchmarks should provide more accurate directions for developments.

Mettanando BhikkhuB.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 mountainAccumulation of Knowledge

Health Reform

Social Movement Political Linkage

Source: Dr. Prewase Wasi

49

Volunteer Recruitment

6 million Thai people registered with the Ministry of Culture as “Volunteers”

Volunteering at the grass-roots 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.

Chalermpol CHAMCHAN

“Impacts and Constraints of Universal Coverage (UC) in Thailand’s Public Health

System”

24 June 2009 At Faculty of Economics, TU

Chalermpol CHAMCHAN

Doctor of Area Studies, Graduate School of Asian and African Area Studies (ASAFAS), Kyoto University

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 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

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

2. Linking consequences:

SNS and KBKJ strategies

From Secondary level hospitals to Tertiary level hospital

Over-referring of In-Patient cases

55

Backward from

Tertiary level hospitals to Secondary level hospitals Infeasible reallocations of health personnel from

provincial cities to rural districts

3. Secondary Constraints

provincial cities to rural districts

Secondary care level hospital to PCUs Infeasible strengthening primary care network

56

Workloads and Poor performances of

service provisions at the primary care level

Workloads and Poor

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

Primary Constraints at Facilities in Secondary

Infeasible to strengthen Primary

care network

Consequences of Failures at primary

care level

Consequences of Failures at primary

care level

Consequences of Failures at primary

care level

June At Faculty of Economics, TU 57

Workloads and Poor performances of service

provisions at the secondary care level

Workloads and Poor performances of service provisions at the primary

care level

Facilities in Secondary Care Level +

Impacts of the UC implementation

Primary Constraints at Facilities in Tertiary Care

Level +Impacts of the UC

implementation

1) Primary Constraints

Infeasible Reallocation of health personnel in

the province

3) Secondary Constraints

Consequences of Over-referring of In-Patient cases

2) Linking Consequences

Consequences of Over-referring of In-Patient cases

Consequences of Over-referring of In-Patient cases

2) Linking Consequences2) Linking Consequences

“…where shortages (and inequitable distributions) of health workforces are still prevalence in many areas and sufficient budget funding are not yet 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

Thailand’s health system has achieved intermediate goal but not yet the final one of the UC policy.

(1) Assuring universal

and comprehens

(2) Ensuring adequate

and

(3) Increasing

the effectivenes

ConclusionsConclusions

‘Universal inclusion’ is to be achieved, but “Universal access” is still not ensured that it is equitable to

all insured population UC system is insufficiently provided with health resources,

and as a result ineffectively functioning and vulnerable59

ive health insurance coverage.

comprehensive health insurance coverage.

equitable access to needed health

service.

and equitable access to needed health

service.

s and sustainability of health

system

effectiveness and

sustainability of health

system

Source: Docteur et al. 2003Source: Docteur et al. 2003

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

Policy SuggestionsPolicy Suggestions

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