Ali Ghufron Mukti Magister Asuransi Kesehatan/JPKM

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Sistem Asuransi Kesehatan di

Maju dan Negara Berkembang

Ali Ghufron Mukti

Magister Asuransi Kesehatan/JPKM Program Pasca Sarjana UGM Program Pasca Sarjana UGM

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ISU

ISU--ISU SISTEM PELAYANAN

ISU SISTEM PELAYANAN

KESEHATAN DI BERBAGAI NEGARA

• PEMERATAAN PENINGKATAN BIAYA • PENINGKATAN BIAYA PEL.KES • EFISIENSI • KUALITAS • AKUNTABILITAS& SUSTAINABILITAS SUSTAINABILITAS (Neg.berkembang)

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Sistem Asuransi di

Negara

• USA • Kanada • Jerman • Jerman • Filipina • Thailand • Indonesia

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Sistem Asuransi

Kesehatan di Amerika

• Multipayer Umumnya komersial dan y y

lebih percaya pada mekanisme pasar

• 38 Juta tidak terasuransi, 85% diantaranya kelompok perkerja. diantaranya kelompok perkerja. • Medicare

• Medicaid • Medicaid

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Sistem Asuransi

Kesehatan di Kanada

• Tidak seperti Inggris, tidak seperti gg

Amerika

• Dana pemerintah Pusat diberikan ke Dana pemerintah Pusat diberikan ke badan publik independen yg

berorientasi nirlaba dan bertg jawab berorientasi nirlaba dan bertg jawab pada PEMDA PROPINSI (50:50)

sekarang block grant sekarang block grant • Mulai dari rawat inap

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Sistem Asuransi

Kesehatan di Jerman

• Multi payery

• Di laksanakan oleh Bapel swasta • Sifat sosial Nirlaba hanya sedikit • Sifat sosial Nirlaba hanya sedikit

komersial

• Asuransi kesehatan kontrak dengan • Asuransi kesehatan kontrak dengan

asosiasi dokter asosiasi dokter yang mengatur ke dokter

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Sistem Asuransi di

Filipina

Di mulai 1997 dg UUg

Asuransi Kesehatan Nasional Asuransi Kesehatan Nasional penyelenggara PHIC

Monopoli

Paket rawat inap

Cakupan 60% (wajib) Ca upa 60% ( aj b)

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Health Insurance In

Thailand

• Medical Welfare Scheme (MWS) : cover indigence,

h lth d f it l d d h lth

health card for community leaders and health volunteer

• Civil Servant Medical Benefit Scheme(CSMBS) • Compulsory Health Insurance : Social Security p y y

Scheme(SSS), Workmen Compensation Scheme (WCS), and Traffic Accident Insurance (TA).

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• Voluntary Health Insurance : Private Insurance (PI), Voluntary Health Card (VHC).

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The Civil Servants Medical Benefit Scheme The Civil Servants Medical Benefit Scheme

• Objective : fringe benefits for government workers and to compensate their low salaries

and to compensate their low salaries.

• Basic concepts of these scheme are public welfare

f k i FFS

for government workers; retrospective FFS payment, free choices of access without

co-t payment.

• Beneficiaries include government workers and their families, estimated 7 millions.

• Beneficiaries are free to choose public or private p p care but limited payment to private care.

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Compulsory Health Insurance

• The Workmen Compensation Scheme (WCS): cover sickness and injuries due to work related cover sickness and injuries due to work-related. Contributions are paid by employers based on experience rate

experience-rate.

• The Social Security Scheme (SSS) : started in

1991 f t i ith 20 d k

1991 for enterprises with 20 and more workers and expanded to those with 10 or more workers in 1993 I 2001 it i t t d t th 1

1993. In 2001, it aims to extend to those 1 or more workers.

• The Traffic Accident Insurance (TA) : compulsory for all car owners.

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Voluntary Health Insurance

• Private Insurance pays only limited role, estimation of covered people 1% mainly in estimation of covered people 1% mainly in Bangkok and urban area.

• The Health Card project is a voluntary • The Health Card project is a voluntary

public subsidized health insurance scheme aiming to provide health insurance coverage g p 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 g farmer fishermen self

in rural area e.g. farmer, fishermen, self-employed, workers uncovered by SSS.

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Health Insurance In

Thailand

• 100% public subsidized

100% public subsidized

scheme; MWS, CSMBS

• 75% public subsidized scheme;

VHC

• 25% public subsidized scheme:

SSS

• unsubsidized scheme; WCS

• unsubsidized scheme; WCS,

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Trends and Coverage

Scheme 1991 1996 1999 1996* 1999* I. Medical Welfare Schemes 12.7 12.3 12.4 29.5 (32 1)22.5 Schemes (32.1) 2. Government employee scheme • CSMBS 13 2 11 3 7 8 11 3 7 8 • CSMBS 13.2 11.3 7.8 11.3 7.8 • State Enterprise 2.1 1.4 1.1 1.4 1.1 3. Social Security including

WCS and employer welfare 0 5.5 7.1 5.5 7.1 WCS and employer welfare

4. Voluntary insurance

• Voluntary Health Card 1.4 13.2 28.2 13.2 28.2 (18.6) ( ) • Private insurance 3.1 1.2 1.4 1.2 1.4 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.

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Financing Model and provider

payment methods

Schemes Model Hospital

payment p y

methods

I. MWS Public integrated model Global budget II. CSMBS Public reimbursement of patients model Fee for services III SSS P bli t t d l Fl t t it ti III. SSS Public contract model Flat rate capitation IV.WCS Public reimbursement of patients model Fee for service

V. VHCS Voluntary integrated model Global budget VI Private Voluntary reimbursement of patients Fee for service VI. Private

insurance Voluntary reimbursement of patientsmodel Fee for service The uninsured Voluntary out of pocket model Fee for service

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Sources, responsible agency, mode of

financing

Scheme Source of finance Responsible Mode of Scheme Source of finance Responsible

agency

Mode of financing

MWS Tax MOPH Global budget

CSMBS Tax M. Finance

Fee-for-services SSS Tax, employer, SSO Capitation

employee

WC Employers SSO

Fee-for-services TA Car owners M.Commerce

Fee-for-services

HC Tax premium MOPH Mixed

HC Tax, premium MOPH Mixed

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Government budget subsidy

Scheme Budget

/capita Expense/ capita Discrepancy index index Medical Welfare Scheme 363 > 363 1 CSMBS 2,106 > 2,106 5.8 Social Security 519 1,558 1.4 Health Card 250 534 0.69 Data in 1999 Data in 1999

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Perbandingan Pengeluaran Untuk Kesehatan dan Perbandingan Pengeluaran Untuk Kesehatan dan

Status Kesehatan Beberapa Negara ASIA Status Kesehatan Beberapa Negara ASIApp gg

Negara GDP g Per IMR Life Pengelu Pengelu Kapita 1998 Expectancy (1998)L/P g aran Kes.(% GDP) g aran Kes.(% Publik) GDP) (1995) Publik) (1995) Indonesia 1.102 48 63/67 1,8 37 Fili i 1 698 36 67/70 2 4 56 Filipina 1.698 36 67/70 2,4 56 Thailand 3.942 29 66/72 5,3 26 Malaysia 5 746 11 70/74 2 5 60 Malaysia 5.746 11 70/74 2,5 60 Singapore 12.653 5 75/79 3,5 37 China 1.493 41 68/72 3,8 54 China 1.493 41 68/72 3,8 54 Sumber: WHO, 1999

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Perbandingan Asuransi di

Berbagai Negara

Isu USA Canada German Thai Filipina Ind

Coverage 75% 100% 90% 80% 60% 15%

M d l M lti M M lti Oli M M lti

Model Multi

payer Mono payer(Propinsi) Multi payer payerOligo Monopayer PayerMulti

Peran Pmt Minimal Besar Besar Besar Besar Besar

Kompetisi Tinggi Rendah Tinggi Rendah Rendah Tinggi

Premi Mahal Murah Cukup Murah Murah Murah &

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Kesimpulan

• Umumnya Sifat asuransi kesehatan not-for 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