Sistem Asuransi Kesehatan di Maju dan Negara Berkembang

Ali Ghufron Mukti Magister Asuransi Kesehatan/JPKM Program Pasca Sarjana UGM

ISU-ISU SISTEM PELAYANAN KESEHATAN 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 Umumnya 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, 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 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 UU Asuransi Kesehatan Nasional penyelenggara PHIC Monopoli Paket rawat inap Cakupan 60% (wajib)

Health Insurance In Thailand

Medical Welfare Scheme (MWS) : cover indigence, health card for community leaders and health volunteer Civil Servant Medical Benefit Scheme(CSMBS) Compulsory Health Insurance : Social Security 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. Basic concepts of these scheme are public welfare for government workers; retrospective FFS payment, free choices of access without copayment. Beneficiaries include government workers and their families, estimated millions. Beneficiaries are free to choose public or private care but limited payment to private care.

Compulsory Health Insurance

The Workmen Compensation Scheme (WCS): cover sickness and injuries due to work-related. Contributions are paid by employers based on experience-rate. The Social Security Scheme (SSS) : started in for enterprises with and more workers and expanded to those with or more workers in . In , it aims to extend to those 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 % mainly in Bangkok and urban area. The Health Card project is a voluntary public subsidized health insurance scheme aiming to provide health insurance coverage 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, selfemployed, workers uncovered by SSS.

Health Insurance In Thailand

% public subsidized scheme; MWS, CSMBS % public subsidized scheme; VHC % public subsidized scheme: SSS unsubsidized scheme; 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 7.8 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) 7.8 1.1 7.1

11.3 1.4 5.5 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 IV.WCS V. VHCS VI. Private insurance The uninsured
Source: OECD 1994.

Hospital payment methods Public integrated model Global budget Public reimbursement of patients model Fee for services Public contract model Flat rate capitation 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

Model

Sources, responsible agency, mode of financing

Scheme MWS CSMBS SSS WC TA HC PI Source of finance Tax Tax Tax, employer, employee Employers Car owners Tax, premium Premium SSO M.Commerce MOPH Private insurer Fee-forservices Fee-forservices Mixed Fee-for-service Responsible agency MOPH M. Finance SSO Mode of financing Global budget Fee-forservices Capitation

Government budget subsidy

Scheme Budget /capita 363 2,106 519 250 Expense / capita > 363 > 2,106 1,558 534 Discrepa ncy index 1 5.8 1.4 0.69

Medical Welfare Scheme CSMBS Social Security Health Card Data in 1999

Perbandingan Pengeluaran Untuk Kesehatan dan Status Kesehatan Beberapa Negara ASIA
Negara Pengelu Pengelu Life GDP Per IMR aran aran Expectancy Kapita (1998)L/P Kes.(% Kes.(% 1998 Publik) GDP) (1995) (1995) 1.102 48 63/67 1,8 37 1.698 3.942 5.746 12.653 1.493 36 29 11 5 41 67/70 66/72 70/74 75/79 68/72 2,4 5,3 2,5 3,5 3,8 56 26 60 37 54

Indonesia Filipina Thailand Malaysia Singapore China

Sumber: WHO, 1999

Perbandingan Asuransi di Berbagai Negara

Isu Coverage Model USA
75% Multi payer

Canada German
100% 90%

Thai
80% Oligo payer Besar Rendah Murah

Filipina
60% Mono payer Besar Rendah Murah

Ind
15% Multi Payer Besar Tinggi Murah & Mahal

Mono payer Multi payer (Propinsi) Besar Rendah Murah Besar Tinggi Cukup

Peran Pmt Minimal Kompetisi Premi

Tinggi 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