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Family Planning in the JKN

Presented at the FORNAS KKI, 26 Oct 2017

Dr. dr. Melania Hidayat, MPH
RH National Programme Officer
UNFPA Indonesia

Evolution of FP
in Indonesia

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Family Planning (FP)
WHO
FP allows people to attain their desired number of children & determine the spacing of
pregnancies.

ICPD 1994
The aim of FP programmes must be to enable couples and individuals to decide freely &
responsibly the number & spacing of their children & to have the information & means
to do so & to ensure informed choices & make available a full range of safe & effective
methods.

Indonesian Law no 52/2009
Family planning is an effort to manage birth spacing & ideal age for delivery, & manage
pregnancies, through promotion, protection, & assistance in accordance with
reproductive rights to establish quality families. 3

FP Programme in Indonesia
FP programme has been acknowledged as one of
the strongest programmes globally

A centrally controlled FP programme, with strong
political support from its initiation in late 60s to
late 90s resulted in
dramatic increase in contraceptive prevalence
decline in total fertility rate

It evolved following the national & global context:
Decentralization
Commitments to Universal Health Coverage
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Evolution of FP in Indonesia • 1970s to mid 1980s Policy focused on population control: reached rural areas with grassroots participation Promoted & successfully changed social norms: From Banyak Anak Banyak Rejeki to Keluarga Kecil Bahagia Sejahtera) & successfully promoted Dua Anak Cukup campaign • Early 1990s New policy emphasis on private sector services  KB Mandiri Successful demand creation Successful in mobilizing private sector  Blue Circle programme • ICPD Cairo 1994 Marked a paradigm change in FP Shifted focus to meeting the needs of individual women & men Quality of FP services 5 .

Evolution of FP … • 1997 – early 2000 • Indonesia faced economic crisis • Political reformation • Decentralization  challenges in: • adjustment from centralized FP to decentralized • ownership & political support from local governments • 2007  Enactment of Law & Govt regulation for FP revitalization • Local governments to establish FP institution & to allocate budget for FP • BKKBN to provide special allocation funds (DAK) • Jan 2014 .present The JKN era Rights-Based Family Planning Strategy 6 .

FP Status 7 .

in particular.Unfinished Agenda • Plateau in impact of FP programme from early 2000s • Contraceptive mix method is skewed to the injectables (away from long acting) • Significant Disparities : by geographical distribution & economic status • Relatively high discontinuation rate • Ensuring effective supply chain management for maintaining commodity security • Adolescent pregnancies continue to be an issue • Maintaining FP in the development agenda. in the current decentralized administration 8 .

9 over years remain relatively the same 1 10 0 0 1967 1971 1976 1980 1984 1987 1988 1991 1994 1997 2003 2007 2012 2015 2016 Source: Population Census 1980.6 2.7 decline in TFR 50 4. Total Fertility Rate & Contraceptive Prevalence Rate among married women 1964-2017 • 60s-90s: 70 6 5.4 57.1 54.4 3.6 2.9 47.3 59. SRPJMN 2016.3 Modern Method both CPR & TFP 3 2. 2002/3. 1997.6 2.2 56. IDHS 1991.6 2.9 3 2. 2000.4 • Gap between modern 2. 2012. 2007.7 57.4 increase in CPR & 5 4.7 52.1 43. SRPJMN 2017 .8 All Method 30 2. 1997. 1994.3 TFR 2 & traditional methods 20 16.6 • Dramatic 60 5.1 4 • 2000s: • Plateauing of 40 3.9 59.

3 13.1 11.4 81 77. PMA 2017 10 *among married women .6 14.Unmet Need.1 77.2 13.3 70.5 70 60. PMA 2016.4 60 54.7 .7 the stagnation .To understand the reasons for 50 49.5 59.9 59. PMA 2015.3 59.4 61.3 61.Innovative approaches / 40 actions is needed to address 30 unmet need that is relatively stagnant since 1994 20 17 18.4 57. CPR.1 79 78. Demand Satisfied among married women 1991 – 2017 90 81.4 14 13.4 10 0 1991 1994 1997 2002-03 2007 2012 2015 2016 2017 Unmet need mCPR % demand satisfied Source: IDHSs 2012.6 15.8 80 77 74.

2% 21.0% 14.6% 13.1% 6. SRPJMN 2017 • Increasing trend in use of injectables.0% Male sterilization 10.1% Pill 40.Contraceptive Method Mix 1991 – 2016 70.2% Implant 11.8% 31.9% 4.9% IUD 20.2% 4.3% Female sterilization 8.2% 15.0% 60.4% Condom 17. SRPJMN 2016.0% 32.0% IDHS 1991 IDHS 1994 IDHS 1997 IDHS 2002 IDHS 2007 IDHS 2012 PMA 2015 SRPJMN 2016 Source: IDHS 2012.8% 31.2% 13.0% 13.1% 10.2% 27.4% 15.0% 13.0% 13. low use of long acting reversible contraceptives (LARCs -IUDs & Implants) • Condom use remains very low 11 .2% 13.5% Traditional 50.9% 3.7% 31.8% 4.0% 0. PMA 2015.8% Injectable 30.

1% 5.0% 20.1% 1.2% 7.7% 1.9% 5.0% 4.0% 6.7% IUD 10.9% 6.6% 4.0% 17.0% 0.0% 3.4% 0.4% 0.0% 17.0% 5.0% 6.5% Pill 15. 2002-2003.3% Female Sterilization 5.5% 0. in particular for male condoms & pills • High reduction of IUDs discontinuation rate after 2003.2% 0.9% 1.Contraceptive Discontinuation Rate 1994-2016 Modern Method 25.6% Male Condom 13. 2012.6% 6.5% 3.0% 7.3% 15.3% 0.9% 2.4% 1.0% 4.3% 2.0% 0.0% 0.0% Implant 5.6% 18. 1997. SRPJMN 2016 • Discontinuation rate remains high. and implants after 2012 12 .7% 20.2% IDHS 1994 IDHS 1997 IDHS 2002-2003 IDHS 2007 IDHS 2012 SRPJMN 2016 Source: IDHS 1994.8% Injectables 4.3% 4.

Issues in Supply Chain Management: Contraceptives Stock out UNFPA Assessment. April 2013 Public SDPs Experienced Stock Outs • Availability: 27% of SDPs have 5 in April 2013 methods available 60% • Stock Out: 21% of SDPs experienced 53% stock outs of at least one contraceptive 50% JSI assessment. April 2016 42% 41% • Availability: 55% of SDPs have 5 40% methods available • Stock Out: 45% of SDPs experienced 32% stock outs of at least one contraceptive 30% 27% 20% 10% Stock out situation remains a concern 0% IUD Implants Injectables Pills Condom 13 .

57 Papua 2.06 North Sulawesi 2.74 East Java 1. Yogyakarta 1.39 • Highest: NTT (2.61 South East Sulawesi 2.12 West Java 2.49 North Maluku 2.6 North Sumatera 2.21 TFR by Provinces.28 • Lowest : Yogyakarta (1.59 West Sumatera 2.16 Disparities: Central Kalimantan Central Sulawesi 2.22 Bengkulu 2.23 2.09 South Sulawesi 2.34 2.5 1 1.5 3 .47 Riau 2.79 DKI Jakarta 1. Indonesia. 2015 Source: 2015 SUPAS (BPS Statistics Indonesia) Riau Islands 2.82 0 0.92 Central Java 2.67 East Nusa Tenggara 2.74%) INDONESIA 2.5 2 2.55 West Papua 2.82) Maluku 2.6 Aceh 2.13 2.22 Bangka Belitung 2.25 2.2 2.89 Bali 1.28 South Kalimantan West Nusa Tenggara 2.56 East Kalimantan 2.63 West Sulawesi 2.23 South Sumatera West Kalimantan 2.23 • National TFR: 2.12 Gorontalo Banten 2.28 per woman Jambi Lampung 2.

4 NUSA TENGGARA BARAT 60.4 CPR by Provinces.8 KEPULAUAN RIAU 49.4 SULAWESI UTARA 69.6 PAPUA 23.6 • Total mCPR (married women) 61.5 JAWA TENGAH 63.3 SULAWESI SELATAN 52. Indonesia.6 ACEH 50.6 SUMATERA UTARA 49.6% BANTEN 62.2 KALIMANTAN TENGAH SUMATERA SELATAN 68.3 • Highest: Lampung (70.1 INDONESIA 61.6 SULAWESI BARAT 51.3 SUMATERA BARAT 51.7 NUSA TENGGARA TIMUR 47 MALUKU 45.8 MALUKU UTARA 55.6 DI YOGYAKARTA 61.7 BANGKA BELITUNG 69. 2015 JAWA BARAT 65.3 KALIMANTAN UTARA 52.6 66.5 PAPUA BARAT 40.9 • Lowest : Papua (23. LAMPUNG 70.8 BALI 62.3 BENGKULU 69.2 69 Disparities: KALIMANTAN BARAT JAMBI 66.5 DKI JAKARTA 54.5 15 .8 Source: 2015 SUPAS (BPS Statistics Indonesia) JAWA TIMUR 65.7 GORONTALO 64.5%) SULAWESI TENGAH 60.3%) RIAU 57.3 SULAWESI TENGGARA 53.6 KALIMANTAN SELATAN 69.6 KALIMANTAN TIMUR 60.

Disparities: Unmet Need by Provinces IDHS 2012 • Total unmet need 11.4% • For spacing: 4.5 • For limiting: 6.8%) Source: IDHS 2012 16 .0%) • Highest: Papua (23.9 • More than half provinces have higher unmet need as compared to national figure • High disparities between regions: • Lowest : Jambi & Lampung (7.

Disparities: Unmet Need by Wealth Quintile • IDHS 1997 – 2012 • Highest unmet need & lowest CPR for modern method among lowest wealth quintile • PMA2020 – 2015 • Lowest unmet need among lowest wealth quintile (?) 17 .

Disparities : Unmet need for spacing and limiting by wealth quintiles Higher unmet need for limiting • Over years • Across all wealth quintiles Unmet need for spacing • Highest among those in lowest wealth quintile (IDHSs) 18 .

52 60.8 II BANGKA BELITUNG 2.73 56.9 IV SULAWESI TENGAH 2.2 I II • Q-III: Low CPR and low TFR MALUKU 3.42 67.3 73.97 53.11 67 48.4 IV IV to strengthen their FP programme KALIMANTAN TIMUR KALIMANTAN UTARA New 2.36 58.1 68.07 61.6 67.7 II SUMATERA UTARA 2.96 42 II PAPUA 2.5 16.32 64 IV 3 Provinces 7 Provinces DI YOGYAKARTA 2.75 60. BKKBN’s prioritization: FP Quadrants by Province PROVINCE TFR CPR KUADRAN Low CPR High CPR ACEH 2.7 II Source: Peta Kerja Bina Kesertaan KB Jalsus 2015 19 .43 New 62.3 II MALUKU UTARA 2.5 III JAWA TIMUR 2.79 51.92 51.37 65.6 New I • Q-II: low CPR and high TFR SULAWESI UTARA 2.47 2.7 I JAWA TENGAH 2.3 II I • More than half of the provinces (19) still yet KALIMANTAN TENGAH KALIMANTAN SELATAN 2.2 69.49 68.2 II • 7 provinces show good performance (Q-IV) NUSA TENGGARA TIMUR KALIMANTAN BARAT 3.5 III Low TFR Kuadran III Kuadran IV JAWA BARAT 2.68 3.8 II II 19 provinces 4 Provinces SUMATERA SELATAN 2.8 II LAMPUNG 2.57 2.02 58.3 53.32 62.3 II High TFR Kuadran II Kuadran I RIAU JAMBI 2.9 II PAPUA BARAT 2.38 71.4 51.9 II SUMATERA BARAT 2.2 IV BALI 2.7 II • To better understand the “anomalies” SULAWESI SELATAN SULAWESI TENGGARA 2.7 IV BANTEN 2.48 41.5 68.8 II BENGKULU 2.3 II II • Q-I: High CPR and high TFR GORONTALO SULAWESI BARAT 2.8 II KEPULAUAN RIAU 2.16 39.07 65.9 IV NUSA TENGGARA BARAT 2.69 49.18 49 III DKI JAKARTA 1.29 2.29 64.47 2.

2010 Population Census 20 . Indonesia. 1990.1 per 1000. 1990-2015 70 63 60 Nearly 1/3 of total population in Indonesia are youth (10-24 years) (20125 SUPAS) 50 47 44 2015 SUPAS 41 40 40 40 • ASFR 15-19 national estimate is 40.2015 SUPAS. showing a slight decline from the previous 30 five year.2005. less educated and poor teenagers 10 • Limited access to information and services on adolescent reproductive health 0 1990 1995 2000 2005 2010 2015 • There is a slow down of 15-19 fertility decline in the past ten years Source: 1995.Adolescent Fertility 15-19 Year Old Fertility Rate. • Proportion of teenagers who have started 20 childbearing is higher among urban. 2000.

FP in JKN 21 .

• Government covers all need of contraceptives (procurement & distribution of contraceptives). FP in JKN • JKN’s main objectives: • Provide health protection to all Indonesian people by 2019 • Remove financial barriers to access health services • Close the equity gap. FP methods. side effects. BPJS scheme covers the fee for services either through capitation or reimbursement modalities 22 . reaching the most disadvantaged (unreached. most remote) • Cross subsidy principle:  “Dengan Gotong Royong Semua Tertolong” • FP included in benefit package since initiation of BPJS scheme • FP under JKN • Covers all types of FP services: counseling.

99/2015. Law No. Presidential Decree No 19/2016 Article 21 & 22 3. MoH Decree No 52 Tahun 2016 Article 11 5. MoH Decree No 71 Tahun 2013 Article 19 4. 40/2004 2. No. MoH Decree No 64 Tahun 2016 6. 52/2016. MoH Decree No. SE Direktur Pelayanan Nomor 4/2017 7. non capitation & INA CBG • BKKBN :  Provides contraceptives for all members  Maintains supplying contraceptives for the clinics (facilities) registered in BKKBN’s system  Ensures services to those in the GALCITAS if they are not yet covered by BPJS 23 . No. 59/2014. Family Planning in JKN: Law and Regulations 1. 64/2016) • FP is included in benefit package • Services are provided through FKTP (PHC/facilities) & FKTL (secondary health care/facilities) • Services are provided through public facilities & private facilities that are registered in BPJS’s system • BPJS pays the services through capitation. No.

000 • Premiums were revised to better reflect the cost • Class 1: IDR 80.000 7 Tubectomy INA-CBG 24 .000 • Class 3: IDR 25.FP in JKN: Regulations on Premium & Tariff • Presidential regulation no 28/2016 on premiums BPJS – Tariff (fee for services) • Premiums are divided into 3 groups.  PBI (those receiving government subsidy) No Service Tariff  Mandiri (individuals)  Corporate 1 Pill/condom Capitation • Benefits are the same across different classification of membership 2 IUD Rp100.000 • Class 2: IDR 51.000 6 Mgmt complication Rp125.000  A debate on whether FP component has been well costed needs to be settled 5 Vasectomy Rp350.500 4 Injection Rp15.000 3 Implant Rp100.

Fakhrurrazi’s ppt (FP UHC policy discussion 29 May 2017) .Family Planning in JKN: Health Facilities and Health Providers First Line Health Facility (FKTP) FKTP 2017 • # FKTP is increasing but has not Target is :22. • The country still maintains 2 registration systems of FP facilities (BPJS & BKKBN) • FP elements need to be included in the BPJS’s credentialing of FKTP & FKTL • Only around 36% of midwives are under BPJS’s network *Source: BPJS Data per April 2017 25 Translated from dr.514 yet met the required target.

000 • Among 35 million current users.000 JKN has not yet covered FP for the 35.000 FP user Poor Govt subsidy for BPJS membership (PBI) FP user JKN 15.000 • Not all KPSs & KS1s received PBIs subsidy FP user PBI  Of 13. less than 50% of them use JKN’s scheme.000 5. 25.000 - 2012 2013 2014 2015 2016 2017 26 *Source: BKKBN Service Statistics .000.000. FP in JKN JKN Coverage and FP Users Under JKN 40.000 • KPS and KS1 (poor population according to FP user Total BKKBN’s definition) supposed to receive 20.000.5 million of lower wealth quintile users. the scheme covered less than 60% of them (8 million) 10.000.000.000.000.000.000 poor and disadvantaged: 30.

000 FP use among PBI 5.000 7.000 Injectable • Pattern of method Pill Implant mix among PBIs & 4.000.000.000 - PBI Non PBI PBI Non PBI PBI Non PBI 2015 2016 2017 27 Source: BKKBN 2015. Method Mix PBI & Non PBI 9.000 Tubectomy relatively similar Condom 2.000 IUD non PBIs is 3.000. 2017 .000.000 8.000 • Increasing trend of 6.000.000 Vasectomy 1.000. 2016.000.000.000.

Financing for FP in JKN 28 .

000 1.000 0 2012 2013 2014 2015 2016 2017 2018 2019 Source: BKKBN Resntra 2010-2014 & 205-2019 .FP in JKN Financing – BKKBN (IDR million) 7.000 allocation for contraceptive procurement 5.000 Budget allocation for contraceptive 2. but the 6.000 disproportionately increases 4.000 Allocation for FP programme is increasing over years.000 Total BKKBN Budget 3.

706.4 853.8 78.8 1.011.0 2015 9.7 13.1 300.0 948. Proyeksi Pembiayaan Pelayanan Kontrasepsi • 1.3T rupiahs for contraceptives *Source: Siswanto.7 3.3 9.345.5 831.327.5 2020 10.1 800.2 2.718.2 456.8 242.7 738.5 1. 2013 30 .0 370.8 1.077.192.7 1.5 354.23T rupiahs for the services dalam SJSN Bidang Kesehatan.2 4.7 2.9 291.3 4.7 2014 9.8 3.9 1.242.5 129.7 379.090.1 1.5 1.7 2.1 177.9 21.4 65.3 1.3 2019 10.7 1.1 458.4 1.854.6 499.1 2017 9.5 1.5 1.602.712.980. Financial Projection for FP* .8 2.9 404.6 6.5 3.3 197.8 2.450.6 2013 9.6 1.122.4 332.0 2.164.4 2.4 778.1 1.224.0 430.6 1.148.year 2012-2020 Poor Non Poor Year JKN Contraceptives BPJS’s fee Total Cost JKN Contracepti BPJS’s fee Total Cost Target for services for Poor Target ves for services for non Poor Total Cost (IDR Bill) (Million (IDR Bill) (IDR Bill) (IDR Bill) (Million (IDR Bill) (IDR Bill) (IDR Bill) couples) couples) 2012 8.0 1.2 311.8 4.3 627.5 540.383.7 215.339. Govt has to allocate annually around 2.122.194.508.262.9 1.4 728.250.607.664.3 21.5 17.2 1.8 887.3 1.415.3 822.7 2016 9.8 1.905.019.7 1.1 293.7 To maintain FP services under JKN.3 488.63T rupiah • 1.4 2018 10.995.

8% pay of those who access private facilities 31 kesehatan: Source: Siswanto.4% pay of those who access public facilities • 89.2% pay of those who access public health facilities • 47. 2016 .6% pay of those who access private health facilities • 88. Out of Pocket Payment for FP services under BPJS PMA2020 Round 1. 2016 BPJS’s members still pay OOP to receive FP service BPJS’s members OOP for FP services relatively the same • 47. Pelayanan KB melalui asuransi *Among married women in reproductive age Hasil analisa data PMA2020 round 1 dan 2.2015 PMA2020 Round2.

Out of Pocket Payment for FP services under BPJS By Wealth Quintiles PMA2020 Round 1 .9% who access public health facilities • 91.8% who access public facilities • 61.7% who access private facilities • 95. 2016 providers from providing FP services under the scheme 32 .8% who access private health facilities • Lowest wealth quintile pay OOP more than others for FP services *Source: Siswanto.2016 Lowest wealth quintile pay OOP for FP services: Lowest wealth quintile pay OOP for FP services • 58. Pelayanan KB melalui • Arrangement of fare-share of the fees among the providers discourages asuransi kesehatan: Hasil analisa data PMA2020 round 1 dan 2.2015 PMA2020 Round 2 .

Laksono’s ppt (FP UHC policy discussion 29 May 2017 . Is it a proper Insurance Coverage of FP thing? • Poorer women are likely to be covered by Jamkesda • Wealthier women by BPJS • Overall: • 26% covered by Jamkesda • 21% by BPJS 33 Cited from Prof.

1% (round 1) & 90% (round 2) WRA with lowest quintile pay to get access to any FP service • Among BPJS’s members higher percentage of lowest quintile compare to higher wealth quintiles pay to get FP services 34 kesehatan: Source: Siswanto. Pelayanan KB melalui asuransi *Among married women in reproductive age Hasil analisa data PMA2020 round 1 dan 2. 2016 .Payment for Family Planning Service Under JKN • 84.

Conclusions 35 .

• Common understanding on the benefits & the processes (of claims. • Services  Limited numbers of facilities & its networks: many midwives (& other private facilities) are not encouraged to provide FP services under the scheme  Issues around quality of services & FP competencies of health providers  QA system is not yet fully established  Private sector not yet effectively involved  Maintaining availability of the contraceptives: to expand the types of contraceptives. Ministry of Health. 36 providers & community . effective SCM • Financing  sustainability  Relatively low premium rate as compared to the broad (unlimited) benefits  challenges in maintaining financing • Integration of (at least) 3 different information systems (BKKBN.FP in JKN: Challenges • Utilization  equity  The scheme has not yet fully covered the poor  Those that are disadvantaged still have to pay out of pockets to access the services. to get the services. etc): managers. and BPJS).

FP in JKN: Opportunities • BPJS’s scheme provides opportunities for integration of: Standards & Services Information System • Strong private sectors (facilities/services)  Opportunities for expanding coverage to reach UHC • Midwives workforce are available across country  potential to cover FP needs of all people • Jamkesda integrated to JKN ??  more efficient financing 37 .

Strengthening FP in JKN 1. firm Strategic Policies in Financing to reduce in-equity  Increase budget for health infrastructure in less developed regions  Review the premium structure to close the equity gap • Clear arrangement under the scheme for outreach services to the GALCITAS • Attractive incentives for health providers who provide services for disadvantaged groups • Research to explain the drivers of OOP for FP among the disadvantaged • Local government to understand disadvantaged specific needs & design innovative approaches 38 . Address inequities in coverage and OOP payment • Clear.

including for financing the scheme 5. improve competencies of providers. standardize quality of services. e. recording and reporting 39 .Strengthening FP in JKN 2. standardize facilities. Integrated information system: registration. • Consider expansion of methods under the scheme 3. Improve quality of services • Map of health facilities & providers. integration of local government insurance to BPJS 4.g. certify providers. Monitoring: • Continuous monitoring of the implementation including identify bottlenecks and provide for financial risk protection immediate corrective actions • Regular review of policies. Efficiency and sustainability • Thorough costing exercise to determine actual cost for services • Explore different financing modalities for more efficient budgeting of the scheme. credentialing.

Terima kasih 40 .