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

2
 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
4
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
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 particular, in the current
decentralized administration

8
 Total Fertility Rate &
Contraceptive Prevalence Rate among married women
1964-2017
• 60s-90s:
70 6

5.6 • Dramatic
60 5.2 56.7 57.4 57.9
59.3 59.4 increase in CPR &
5
4.7 52.1
54.7 decline in TFR
50
4.1 43.9
47.1
4
• 2000s:
• Plateauing of
40 3.4 3.3 Modern Method both CPR & TFP
3 2.9
3
2.8 All Method
30 2.6 2.6 2.6 2.6
2.4
• Gap between modern
2.3 TFR
2
& traditional methods
20 16.9 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, 2000;

IDHS 1991, 1994, 1997, 1997, 2002/3, 2007, 2012;
SRPJMN 2016; SRPJMN 2017
Unmet Need, CPR, Demand Satisfied among married women
1991 – 2017
90
81.4 81
77.1 77.1 79 78.8
80 77
74.3
70.5
70
60.3 61.4 61.9
59.5 59.3 59.4
57.4
60
54.7 - To understand the reasons for
50
49.7 the stagnation
- Innovative approaches /
40
actions is needed to address
30
unmet need that is relatively
stagnant since 1994
20 17 18.6
15.3 13.6 14.4 14
13.2 13.1 11.4
10

0
1991 1994 1997 2002-03 2007 2012 2015 2016 2017

Unmet need mCPR % demand satisfied

Source: IDHSs 2012; PMA 2015; PMA 2016; PMA 2017 10
*among married women
Contraceptive Method Mix
1991 – 2016
70.0%

60.0%

13.5% Traditional
50.0% 13.2% 13.2% 13.6% 13.4%
15.4% Condom
17.1% Pill
40.0%
14.8%
Injectable
30.0% 32.2%
15.2% 21.2% 27.8% 31.8% 31.2% Implant
11.7% 31.9%
IUD
20.0%
Male sterilization
10.0% 13.1% 10.3% Female sterilization
8.1% 6.2% 4.9% 3.9% 4.8% 4.0%
0.0%
IDHS 1991 IDHS 1994 IDHS 1997 IDHS 2002 IDHS 2007 IDHS 2012 PMA 2015 SRPJMN 2016

Source: IDHS 2012; PMA 2015; SRPJMN 2016; SRPJMN 2017

• Increasing trend in use of injectables; low use of long acting reversible contraceptives
(LARCs -IUDs & Implants)
• Condom use remains very low 11
Contraceptive Discontinuation Rate 1994-2016
Modern Method
25.0%

20.7%
20.0%
17.6% 18.0% 17.9%
5.3%
15.5% Pill
15.0% 4.6% 6.0% 6.6% Male Condom
13.3%
4.8%
Injectables
4.2% 7.7%
IUD
10.0% 6.9%
6.0% 5.0% Implant
5.3%
Female Sterilization
5.1%
5.0%
4.0% 3.6% 4.0% 7.5%
3.3%
2.4%
1.5% 0.9%
2.1% 1.7% 1.2%
0.9% 1.3%
0.0% 0.0% 0.4% 0.4% 0.0%
0.2%
IDHS 1994 IDHS 1997 IDHS 2002-2003 IDHS 2007 IDHS 2012 SRPJMN 2016

Source: IDHS 1994, 1997, 2002-2003, 2012; SRPJMN 2016

• Discontinuation rate remains high, in particular for male condoms & pills
• High reduction of IUDs discontinuation rate after 2003; and implants after 2012
12
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
 Yogyakarta 1.74
East Java 1.79
DKI Jakarta 1.89
Bali 1.92
Central Java 2.06
North Sulawesi 2.09
South Sulawesi 2.12
West Java 2.12
Gorontalo
Banten
2.13
2.16
Disparities:
Central Kalimantan
Central Sulawesi
2.2
2.21
TFR by Provinces, Indonesia, 2015
Source: 2015 SUPAS (BPS Statistics Indonesia)
Riau Islands 2.22
Bengkulu 2.22
Bangka Belitung 2.23
South Sumatera
West Kalimantan
2.23
2.23
• National TFR: 2.28 per woman
Jambi
Lampung
2.25
2.28 • Lowest : Yogyakarta (1.74%)
INDONESIA 2.28
South Kalimantan
West Nusa Tenggara
2.34
2.39
• Highest: NTT (2.82)
Maluku 2.47
Riau 2.49
North Maluku 2.55
West Papua 2.56
East Kalimantan 2.57
Papua 2.59
West Sumatera 2.6
Aceh 2.6
North Sumatera 2.61
South East Sulawesi 2.63
West Sulawesi 2.67
East Nusa Tenggara 2.82

0 0.5 1 1.5 2 2.5 3

 LAMPUNG 70.3

BENGKULU 69.7

BANGKA BELITUNG 69.6

KALIMANTAN SELATAN 69.4

SULAWESI UTARA 69.2

KALIMANTAN TENGAH
SUMATERA SELATAN 68.2
69
Disparities:
KALIMANTAN BARAT
JAMBI
66.6

66.4
CPR by Provinces, Indonesia, 2015
JAWA BARAT 65.8
Source: 2015 SUPAS (BPS Statistics Indonesia)
JAWA TIMUR 65.7

GORONTALO 64.5

JAWA TENGAH 63.8

BALI 62.6

• Total mCPR (married women) 61.6%

BANTEN 62.1

INDONESIA 61.6

DI YOGYAKARTA 61.4

NUSA TENGGARA BARAT 60.9 • Lowest : Papua (23.5%)

SULAWESI TENGAH 60.6

KALIMANTAN TIMUR 60.3 • Highest: Lampung (70.3%)

RIAU 57.8

MALUKU UTARA 55.5

DKI JAKARTA 54.3

SULAWESI TENGGARA 53.3

KALIMANTAN UTARA 52.3

SULAWESI SELATAN 52.3

SUMATERA BARAT 51.6

SULAWESI BARAT 51.6

ACEH 50.6

SUMATERA UTARA 49.8

KEPULAUAN RIAU 49.7

NUSA TENGGARA TIMUR 47

MALUKU 45.5

PAPUA BARAT 40.6

PAPUA 23.5
15
 Disparities:
Unmet Need by Provinces
IDHS 2012
• Total unmet need 11.4%
• For spacing: 4.5
• For limiting: 6.9

• More than half provinces have

higher unmet need as compared to
national figure

• High disparities between regions:

• Lowest : Jambi & Lampung (7.0%)
• Highest: Papua (23.8%)

Source: IDHS 2012

16
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
 BKKBN’s prioritization: FP Quadrants by Province
PROVINCE TFR CPR KUADRAN
Low CPR High CPR
ACEH 2.4 51.7 II
SUMATERA UTARA 2.69 49.9 II
SUMATERA BARAT 2.79 51.3 II
High TFR Kuadran II Kuadran I RIAU
JAMBI
2.57
2.36
58.1
68.8
II
II
19 provinces 4 Provinces SUMATERA SELATAN 2.42 67.8 II
BENGKULU 2.38 71.8 II
LAMPUNG 2.5 68.8 II
BANGKA BELITUNG 2.49 68.8 II
KEPULAUAN RIAU 2.18 49 III
DKI JAKARTA 1.73 56.5 III
Low TFR Kuadran III Kuadran IV JAWA BARAT 2.37 65.7 I
JAWA TENGAH 2.32 64 IV
3 Provinces 7 Provinces DI YOGYAKARTA 2.02 58.5 III
JAWA TIMUR 2.07 65.7 IV
BANTEN 2.32 62.2 IV
BALI 2.07 61.9 IV
NUSA TENGGARA BARAT 2.52 60.2 II

• 7 provinces show good performance (Q-IV) NUSA TENGGARA TIMUR

KALIMANTAN BARAT
3.47
2.48
41.6
67.3
II
I

• More than half of the provinces (19) still yet KALIMANTAN TENGAH
KALIMANTAN SELATAN
2.29
2.3
73.2
69.4
IV
IV
to strengthen their FP programme KALIMANTAN TIMUR
KALIMANTAN UTARA New
2.43
New
62.6
New
I

• Q-II: low CPR and high TFR SULAWESI UTARA 2.29 64.9 IV
SULAWESI TENGAH 2.75 60.7 II
• To better understand the “anomalies” SULAWESI SELATAN
SULAWESI TENGGARA
2.47
2.92
51.3
53.3
II
II
• Q-I: High CPR and high TFR GORONTALO
SULAWESI BARAT
2.68
3.11
67
48.2
I
II
• Q-III: Low CPR and low TFR MALUKU 3.16 39.3 II
MALUKU UTARA 2.97 53.9 II
PAPUA BARAT 2.96 42 II
PAPUA 2.5 16.7 II

Source: Peta Kerja Bina Kesertaan KB Jalsus 2015 19

Adolescent Fertility

15-19 Year Old Fertility Rate, Indonesia, 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 40.1 per
1000, showing a slight decline from the previous
30 five year.
• Proportion of teenagers who have started
20 childbearing is higher among urban, 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: 1995,2005,2015 SUPAS; 1990, 2000, 2010 Population Census

20
FP in JKN

21
 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; 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, FP methods, side effects.
• Government covers all need of contraceptives (procurement & distribution of
contraceptives); BPJS scheme covers the fee for services either through capitation or
reimbursement modalities
22
 Family Planning in JKN: Law and Regulations
1. Law No. 40/2004
2. Presidential Decree No 19/2016 Article 21 & 22
3. MoH Decree No 71 Tahun 2013 Article 19
4. MoH Decree No 52 Tahun 2016 Article 11
5. MoH Decree No 64 Tahun 2016
6. SE Direktur Pelayanan Nomor 4/2017
7. MoH Decree No. 59/2014; No. 99/2015; No. 52/2016; No. 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, 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
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
• Premiums were revised to better reflect the cost
• Class 1: IDR 80,000
• Class 2: IDR 51,000 3 Implant Rp100,000
• Class 3: IDR 25,500
4 Injection Rp15,000
 A debate on whether FP component has been well
costed needs to be settled
5 Vasectomy Rp350,000

6 Mgmt complication Rp125,000

7 Tubectomy INA-CBG
24
Family Planning in JKN:
Health Facilities and Health Providers

First Line Health Facility (FKTP) FKTP 2017
Target is :22,514
• # FKTP is increasing but has not
yet met the required target.
• 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. Fakhrurrazi’s ppt (FP UHC policy discussion 29 May 2017)
 FP in JKN
JKN Coverage and FP Users Under JKN
40,000,000

JKN has not yet covered FP for the 35,000,000

poor and disadvantaged: 30,000,000

• Among 35 million current users, less than
50% of them use JKN’s scheme. 25,000,000
• KPS and KS1 (poor population according to FP user Total
BKKBN’s definition) supposed to receive 20,000,000 FP user Poor
Govt subsidy for BPJS membership (PBI) FP user JKN
15,000,000
• Not all KPSs & KS1s received PBIs subsidy FP user PBI
 Of 13.5 million of lower wealth quintile users, the
scheme covered less than 60% of them (8 million) 10,000,000

5,000,000

-
2012 2013 2014 2015 2016 2017
26
*Source: BKKBN Service Statistics
 Method Mix PBI & Non PBI
9,000,000

8,000,000

7,000,000 • Increasing trend of

6,000,000
FP use among PBI
5,000,000
Injectable
• Pattern of method
Pill
Implant
mix among PBIs &
4,000,000
IUD non PBIs is
3,000,000 Tubectomy relatively similar
Condom
2,000,000 Vasectomy

1,000,000

-
PBI Non PBI PBI Non PBI PBI Non PBI

2015 2016 2017

27
Source: BKKBN 2015, 2016, 2017
Financing for FP in JKN

28
FP in JKN
Financing – BKKBN (IDR million)
7,000 Allocation for FP programme is
increasing over years, but the
6,000 allocation for contraceptive
procurement
5,000 disproportionately increases

4,000 Total BKKBN Budget

3,000 Budget allocation for

contraceptive
2,000

1,000

0
2012 2013 2014 2015 2016 2017 2018 2019
Source: BKKBN Resntra 2010-2014 & 205-2019
 Financial Projection for FP* - 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 8.9 291.4 728.3 1,019.7 2.4 65.1 177.8 242.9 1,262.6
2013 9.2 311.4 778.6 1,090.0 2.8 78.7 215.1 293.7 1,383.7
2014 9.4 332.5 831.8 1,164.3 4.5 129.0 370.6 499.7 1,664.0
2015 9.5 354.8 887.7 1,242.6 6.3 197.5 540.7 738.1 1,980.7
2016 9.7 379.0 948.4 1,327.3 9.1 300.3 822.5 1,122.8 2,450.1
2017 9.9 404.2 1,011.5 1,415.7 13.2 456.3 1,250.5 1,706.7 3,122.4
2018 10.0 430.6 1,077.9 1,508.5 17.3 627.0 1,718.8 2,345.8 3,854.3
2019 10.1 458.8 1,148.5 1,607.3 21.1 800.4 2,194.7 2,995.2 4,602.5
2020 10.3 488.8 1,224.1 1,712.9 21.4 853.2 2,339.5 3,192.8 4,905.7

*Source: Siswanto, Proyeksi Pembiayaan
Pelayanan Kontrasepsi
dalam SJSN Bidang Kesehatan, 2013
To maintain FP services under JKN, Govt has to allocate annually around 2.63T rupiah
• 1.3T rupiahs for contraceptives
• 1.23T rupiahs for the services
30
 Out of Pocket Payment for FP services under BPJS
PMA2020 Round 1,2015 PMA2020 Round2, 2016

BPJS’s members still pay OOP to receive FP service BPJS’s members OOP for FP services relatively the same
• 47.2% pay of those who access public health facilities • 47.4% pay of those who access public facilities
• 89.6% pay of those who access private health facilities • 88.8% pay of those who access private facilities

31 kesehatan:
Source: Siswanto, Pelayanan KB melalui asuransi
*Among married women in reproductive age
Hasil analisa data PMA2020 round 1 dan 2, 2016
Out of Pocket Payment for FP services under BPJS
By Wealth Quintiles
PMA2020 Round 1 - 2015 PMA2020 Round 2 - 2016

Lowest wealth quintile pay OOP for FP services: Lowest wealth quintile pay OOP for FP services
• 58.8% who access public facilities • 61.9% who access public health facilities
• 91.7% who access private facilities • 95.8% who access private health facilities

*Source: Siswanto, Pelayanan KB melalui
asuransi kesehatan: Hasil analisa data
PMA2020 round 1 dan 2, 2016
• Lowest wealth quintile pay OOP more than others for FP services
• Arrangement of fare-share of the fees among the providers discourages
providers from providing FP services under the scheme
32
 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. Laksono’s ppt (FP UHC policy discussion 29 May 2017
Payment for Family Planning Service Under JKN

• 84.1% (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
Conclusions

35
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.

• 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, 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, Ministry of Health, and BPJS).

• Common understanding on the benefits & the processes (of claims, to get the services, etc): managers,
36
providers & community
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. Address inequities in coverage and OOP payment
• Clear, 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
Strengthening FP in JKN
2. Improve quality of services
• Map of health facilities & providers; standardize quality of services, improve competencies of
providers, standardize facilities, certify providers.
• Consider expansion of methods under the scheme
3. Efficiency and sustainability
• Thorough costing exercise to determine actual cost for services
• Explore different financing modalities for more efficient budgeting of the scheme; e.g.
integration of local government insurance to BPJS
4. Monitoring:
• Continuous monitoring of the implementation including identify bottlenecks and provide
for financial risk protection immediate corrective actions
• Regular review of policies, including for financing the scheme
5. Integrated information system: registration, credentialing, recording and
reporting
39
Terima kasih

40