Dr. Surya Chandra Surapati; Chairperson of BKKBN

Pak Nofrijal, Principal Secretary of BKKBN

Pak Sanjoyo, Deputy for Research and Development

Dr. KalsumKomaryani, Head of P2JK

Dr. Fakhrurozi,  BPJS

Pak Anung, Director General of Family Health – Ministry of Health

Pak Ismi, Ministry of Health, Centre for Health Financing

Representatives from Bappenas, PMK, Ministry of Home Affairs, YCCP

Our experts: Prof Siswanto, Prof Laksono, and Prof Hasbullah

Ladies and Gentlemen,

AsalamAlakum
 

On behalf of UNFPA, I am absolutely delighted to be part of this discussion on Family Planning in Universal Health Coverage. I am very pleased to welcome all of you to this very important and timely discussion on FP in UHC. The topic is very relevant to our work, to the global and national commitments, specifically the SDGs and FP2020, but most importantly to the specific needs of the Indonesian people, particularly for the welfare of women and families.

We should be proud of the Indonesian Social Insurance Scheme policy, which has shown Government’s commitments to give social protection to all of its people. The scheme has generouslycovered almost all health benefits,with relatively low premiums.

Since it was launched in early 2014, we have noted how the Government has made the efforts to make efficient use of its health system to adjust to the JKN (social health insurance) scheme, and vice versa. Despite the pro and cons of its policies and implementation, many Indonesian people have benefitted from the scheme. The JKN has saved many lives and treated many more illness/morbidity.

Having said that, I believe that we are also aware of the challenges the country is facing, in particular for the family planning element. After 3 years of implementation of the National Health Insurance scheme, gaps remain. Many policies and programme instruments are still yet to be strengthened or completed; and issues around implementation still need to be addressed.

I appreciate Pak Surya, Pak Nofand BKKBN’s team for their initiative in organizing this discussion, whichwill allow us to get the latest updates on the policies, progress of the implementation, review the challenges and anticipate opportunities for improvement. With all the experts and the key stakeholders in the room I believe we can identify the gaps and recommend alternatives for solutions.

In this discussion on family planning in Universal Health Coverage, there is an assumption that a rights based approach central as universal means everyone.

As the Representative of UNFPA, I feel it is my duty to reiterate the human rights principles of family planning to ensure that there is a full understanding of a rights based approach within the context of Universal Health Coverage. The International Conference on Population and Development, ICPD, was extremely explicit on the fundamental right to decide freely and for themselves whether, when and how many children to have. This has been embodied as a cornerstone in the National Rights based Family Planning Strategy.

At the risk of being provocative, I would like to highlight the 10 dimensions of a rights based family planning programme.

1. Agency and autonomy – this really talks about choosing voluntarily, free of discrimination, coercion and violence family planning. In the newspaper – Jakarta Post -today, I noticed an article in Yogjakarta which discussed the incentivizing of vasectomy for 1 million rupiah as a strategy to increase FP. This is reminiscent of the Indira Gandhi era of coercion and payment of vasectomies that put her into serious trouble for not using a rights approach.
2. Availability, accessibility and acceptability. In these three dimensions we are talking about services and commodities being available, accessible and acceptable to every person. Are we honoring this if we don’t provide availability of contraceptives to unmarried persons? Do migrants have access to FP services? Do poor – rural and urban have same access to UHC FP services as the wealthy? I hope in this discussion we can have more discussion around this issue as the basic ideology for UHC was ensuring the poorest received care. If we are supposed to have a full range of commodities what about emergency contraception availability? What about when stockouts happen are we well addressing availability?
3. Quality. Quality counselling is vital for an informed choice. Are condoms and other contraceptives WHO prequalified or equivalent in quality?
4. Empowerment.In the broader picture beyond UHC, comprehensive sexuality education includes empowerment of girls, thus laying the foundation for adolescents needs which UHC should be protecting and providing services for.
5. Equity and discrimination. When private midwives provide 70 percent of the FP services in Indonesia, do they have same options for being providers of UHC, especially in rural areas where the poorer may live?
6. Informed choice. In postpartum FP, all methods should be advised about and are we giving equal coverage and allowing women to use their method of choice or are we pushing long term FP in post partum period.
7. Transparency and accountability. What research is being done by BPJS related to JKN in terms of monitoring availability and quality and coverage, including by wealth quintile regarding use of FP services in NHI?
8. Voice and participation. How does the private sector participate in the JKN?

In my very humble observation on the FP in UHC in this country, I would highlight at least 4 points/questions that we may need to discuss:

1. Do we have solid analysis for financing the whole benefit of FP services under the UHC scheme?According to the policy, the Government will cover all the needs of its people, which is around 3-4 times higher than the cost in the past when the Govt only covered the needs for the poor. How will the country finance the services and especially the contraceptivesto cover all the needs of the people? How sustainable is the current scheme? An integrated and harmonized information system is required to ensurebasic data feeds into programming and policy changes. BPJS had 121 million members in 2014 but now in 2017 there are 171 million members. Have we adequately used population figures and projections to analyse services required and delivered throughout the country?
2. What is the best policy for engaging private sector which is already strong in this country? How can the scheme in the long run be strengthened and how can the scheme attract the private sector? In 20 provinces, analysis shows that there are 40,000 private midwives but only 15 percent are participating in JKN for various reasons.
3. How can we reach the hard to reach population, while the scheme only recognize static service delivery points? Does the “mobile service” have a place in the scheme? Significant inequity exists. Papua percent of demand satisfied is 48 percent while in Jakarta it is 85%.  Is there analysis exploring lowest wealth quintile accessing FP through UHC? What are the recommendations that are required to improve access for the poor in terms of capitation, noncapitation, tariffs, payment reimbursement and processing?
4. How can we reduce the missed opportunities of meeting the demand through the provision of post-partum FP?  Does the FP services post partum get health care providers to be less inclined to promote FP since reimbursement is only having an interval of timing for which it is applicable?

I believe there are many more issues that will be raised by the panelists and the discussants, which I would like to follow.Let me stop here, but before I conclude, let me take this opportunity to reiterate UNFPA’s commitment to support the Government of Indonesia to achieve Universal Health Coverage through a strong National Health Insurance Scheme.

Thank you.