University of Groningen
Moving forward to achieve universal health coverage in Indonesia
Wasir, Riswandy
DOI:
10.33612/diss.124431881
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Publication date: 2020
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Wasir, R. (2020). Moving forward to achieve universal health coverage in Indonesia. University of Groningen. https://doi.org/10.33612/diss.124431881
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SUMMARY
All countries in the United Nations (UN) has committed to achieving universal health coverage (UHC) as part of the sustainable development goals by 2030. The World Health Organization (WHO) states that UHC has been achieved by a country when all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. The WHO outlines that UHC is achieved by a country when out-of-pocket (OOP) expenditure falls below 20% of total healthcare expenditures. Furthermore, the WHO urged that government spending on healthcare should be at least 4% of a country‘s gross domestic product (GDP) to achieve UHC.
As a member of the UN, Indonesia is aiming to achieve UHC. This goal is increasingly supported with the Indonesian constitution or Undang-Undang Dasar 1945, article 28. Health is a basic right of every individual, and all citizens are entitled to health services including those living in poverty. At the beginning of 2014, the government of Indonesia officially announced its plan to achieve UHC by 2020 through a new national health insurance, which is known as Jaminan Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). This program is managed by a new health insurance program, which is called Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan). The JKN-KIS was the result of a merger of pre-existing social health insurance schemes. The fragmented health insurance schemes made health care spending and quality of healthcare services difficult to control.
Prior to the JKN-KIS implementation, there were several unresolved issues concerning medicine management, health financing system, and the epidemiological situation in Indonesia. In medicine management, the proportion of OOPs for medicines was high, accounting for over 50% of total health expenditures. Furthermore, medicine expenditure accounted for 67% of total health expenditure. With respect to health financing, the government of Indonesia experienced difficulties in increasing health expenditure at the national level. Instead of relying
on government healthcare financing, Indonesia was dominated by OOP expenditures. Regarding the epidemiological situation, the ageing population lead the proportional mortality due to non-communicable diseases almost doubled from 37% in 1990 to 73% in 2014. Of all non-communicable diseases, cardiovascular diseases (CVDs) are the leading cause of deaths and disability.
The main objective of this thesis was to evaluate the progress of the JKN-KIS in moving forward to achieve UHC in Indonesia. In particular, it set out to provide comprehensive findings on how the JKN-KIS has encountered three key challenges on medicine management, health financing, and epidemiological situation. In Chapter 1, we will briefly explain the concept of UHC according to the WHO. This is followed by an explanation of the Indonesia‘s health system transformation towards UHC, and the potential challenges for achieving UHC by 2020. Furthermore, the gaps in knowledge and the thesis objectives are presented.
In Chapter 2, we performed semi structured interviews to identify the problems of the e-Catalogue and the National Formulary (NF). These are the two new policy instruments that were introduced to regulate medicine pricing and reimbursement during the implementation of the JKN-KIS. Ideally, the e-Catalogue would help improve effectiveness, efficiency, and transparency on procuring medicine on healthcare facilities. While the NF would help ensure the availability of good quality, efficacious and affordable medicines. Therefore, these policies should help the JKN-KIS to control the medicine expenditure and reduce OOPs for medicines, which subsequently to achieve UHC. However, a year after the implementation, many public healthcare facilities only rarely used the e-catalogue for medicine procurement, and 40% of all medicines prescribed were not listed in the NF. We found that the major issue was the lack of harmonization between medicine listed in the e-Catalogue and the NF. Then, the most important reasons for prescribing medicines outside the NF was a lack of transparency and evidence base in the development of the NF.
In Chapter 3, we identified the barriers and facilitators of implementing health technology assessment (HTA) in the development of the e-Catalogue and the NF. The HTA committee was installed by the Indonesia‘s Ministry of Health several
months after the implementation of the JKN-KIS. Ideally, the committee would have provided the transparency and evidence base of the e-Catalogue and the NF in line with the guidelines of the JKN-KIS implementation. However, HTA has not been part of the development of the e-Catalogue and the NF. Several barriers of HTA implementation in the e-Catalogue and the NF were a lack of capacity, a lack of financial incentives, a lack of a clear framework and insufficient data. The first two barriers represent the most important obstacles. Reasons for the lack of capacity were that HTA is a new science in Indonesia, and only few HTA departments exist, formal training is not nationally provided, and an official association is missing in Indonesia. Furthermore, financial resources would be needed to pay the HTA experts, to organize HTA seminars, and conduct HTA research.
In Chapter 4, we assess health financing in Indonesia towards UHC. This is to understand whether Indonesia has organized its health financing system in line with the UHC targets. Trends of health financing prior to and after the implementation of the JKN-KIS are described. Furthermore, the projection of health financing schemes is also extended through 2030, as the year of sustainable development goals agenda. We found that the target for achieving UHC by 2020 will not be attained. The target for reducing household OOP schemes below 20 % may be reached by 2024. The target for reducing voluntary healthcare payment to less than 10% may be achieved by 2021. Importantly, the government schemes and compulsory contributory health financing schemes will remain far away from 4% of the GDP by 2020. Furthermore, we also found that in the first year of the JKN-KIS implementation, the expenditure of the BPJS-Kesehatan increased significantly from $2.0 billion (8.52% of THE) to US $4.0 billion (14.25% of THE). This resulted in the OOP schemes by household decreasing to US$ 1.5 billion (7% of THE). Increasing social health insurance expenditures and reducing OOP is the right progress for achieving UHC. However, we found that the revenues of the Kesehatan was insufficient for fulfilling their expenditure. This led the BPJS-Kesehatan to continuously develop a deficit since the first-year of implementation.
In Chapter 5, we estimate the long-term CVD burden and risk factors in Asian populations through a systematic review. The most important results for the
objective of the thesis was that the male sex, old age, and smooking status are the most prominent risk factors for long-term fatal CVD in the Asian population. In our systematic review we did not find studies from Indonesia in line with the inclusion criteria of our studies (cohort studies, Asian healthy above 18 years, free from CVDs, 10-year follow-up period). Notably, our inclusion criteria could obtain long-term incidence rate in the general population. Given the unavailability of information regarding long term risk factors of long-term fatal CVD in Indonesia, this result could be used as a reference to recognize that smoking is the modifying risk factor of CVDs. Therefore, this can be influenced through various interventions to reduce the mortality of CVDs in Indonesia and to reduce the financial burden of the BPJS-Kesehatan.
In Chapter 6, we present the general discussion of this thesis. We start with an overview of how the JKN-KIS has encountered the three key main challenges. Then, the future perspective will offer policy options to address the challenges and suggestions for further research needed for improving UHC. We will then explain how this thesis gives possible guidance to Indonesia and other countries. Finally, the conclusion of this thesis is that JKN-KIS is the cornerstone for Indonesia to achieve UHC in line with WHO targets. However, improving efficiency and raising financial resources for health are crucial for the JKN-KIS to address several challenges that are currently hampering the efforts being made to achieve UHC.
SAMENVATTING
De Verenigde Naties hebben toegezegd om in 2030 universele gezondheidsdekking (UHC) te bereiken als onderdeel van de doelstellingen voor duurzame ontwikkeling. De Wereldgezondheidsorganisatie (WHO) stelt dat UHC is bereikt in een land waar alle mensen en gemeenschappen gebruik kunnen maken van preventieve, genezende, revaliderende en palliatieve gezondheidsdiensten die zij nodig hebben, van voldoende kwaliteit zijn om doeltreffend te zijn, en er tegelijkertijd voor te zorgen dat het gebruik van deze diensten de gebruiker niet blootstelt aan financiële moeilijkheden. De WHO schetst dat UHC wordt bereikt door een land wanneer de eigen uitgaven (OOP) onder 20% van de totale uitgaven voor gezondheidszorg dalen. Bovendien drong de WHO erop aan dat de overheidsuitgaven voor gezondheidszorg ten minste 4% van het bruto binnenlands product bedragen om UHC te bereiken.
Als lid van de Verenigde Naties streeft Indonesië naar UHC. Dit doel wordt in toenemende mate ondersteund door de Indonesische grondwet of Undang-Undang Dasar 1945, artikel 28. Gezondheid is een basisrecht van elk individu en alle burgers hebben recht op gezondheidsdiensten, inclusief de armen. Begin 2014 kondigde de Indonesische regering officieel haar plan aan om UHC tegen 2020 te bereiken via een nieuwe nationale ziektekostenverzekering, die bekend staat als Jaminan Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). Dit programma wordt beheerd door een nieuw zorgverzekeringsprogramma, genaamd Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan). De JKN-KIS was het resultaat van een fusie van reeds bestaande sociale ziektekostenverzekeringen. Door de gefragmenteerde ziektekostenverzekeringen waren de uitgaven voor de gezondheidszorg en de kwaliteit van de gezondheidszorg moeilijk te controleren.
Voorafgaand aan de implementatie van JKN-KIS zijn er verschillende onopgeloste kwesties op het gebied van medicijnbeheer, gezondheidsfinanciering en epidemiologische situatie in Indonesië. Bij medicijnbeheer is het aandeel van OOP's voor geneesmiddelen hoog, tot meer dan 50% van de totale gezondheidsuitgaven. Bovendien waren de geneesmiddelenuitgaven goed voor 67% van de totale
gezondheidsuitgaven. Met betrekking tot gezondheidsfinanciering ondervond de regering van Indonesië moeilijkheden bij het verhogen van de gezondheidsuitgaven op nationaal niveau. In plaats van te vertrouwen op overheidsfinanciering voor de gezondheidszorg, werd Indonesië gedomineerd door OOP-uitgaven. Wat de epidemiologische situatie betreft, leidt een vergrijzende bevolking ertoe dat de proportionele sterfte als gevolg van niet-overdraagbare ziekten bijna is verdubbeld van 37% in 1990 tot 73% in 2014. Van alle niet-overdraagbare ziekten zijn hart- en vaatziekten de belangrijkste doodsoorzaak en oorzaak van invaliditeit.
Het hoofddoel van dit proefschrift is het evalueren van de voortgang van de JKN-KIS om UHC in Indonesië te bereiken. Met name om een uitgebreide beschrijving te geven over hoe de JKN KIS drie belangrijke uitdagingen op het gebied van medicijnbeheer, gezondheidsfinanciering en epidemiologische situatie is tegengekomen. In hoofdstuk 1 zullen we het concept van UHC kort uitleggen volgens de WHO. Gevolgd door uitleg over de transformatie van het Indonesische gezondheidssysteem naar UHC en de potentiële uitdagingen om UHC tegen 2020 te bereiken. Verder worden daar de kenniskloof en de doelstellingen van de diverse studies gepresenteerd.
In hoofdstuk 2 hebben we een semi-gestructureerd interview uitgevoerd om de problemen van de e-Catalogus en het Nationaal Formularium (NF) te identificeren. Dit zijn de twee nieuwe beleidsinstrumenten die de prijsstelling en vergoeding van geneesmiddelen regelen tijdens de implementatie van de JKN-KIS. In het ideale geval zou de e-catalogus de doeltreffendheid, efficiëntie en transparantie van de aankoop van medicijnen in zorginstellingen helpen verbeteren. OOk het NF zou bijdragen tot de beschikbaarheid van goede, effectieve en betaalbare geneesmiddelen. Daarom zou dit beleid de JKN-KIS moeten helpen om de uitgaven voor geneesmiddelen te beheersen en de OOP voor geneesmiddelen te verminderen, om uiteindelik UHC te bereiken. Een jaar na de implementatie gebruikten veel openbare zorginstellingen de e-catalogus echter slechts zelden voor het verkrijgen van medicijnen en 40% van alle voorgeschreven medicijnen was niet opgenomen in de NF. We ontdekten dat het belangrijkste probleem het gebrek aan harmonisatie was tussen de medicijnen die in de e-Catalogus en het NF staan Addendum
vermeld. De belangrijkste redenen voor het voorschrijven van geneesmiddelen buiten het NF waren dan ook een gebrek aan transparantie en evidence-base bij de ontwikkeling van het NF.
In Hoofdstuk 3 identificeerden we de belemmeringen en facilitator van het implementeren van health technology assessment (HTA) bij de ontwikkeling van de e-Catalog en het NF. De HTA-commissie werd enkele maanden na de implementatie van de JKN-KIS geïnstalleerd door het Indonesische ministerie van Volksgezondheid. Idealiter zou de commissie de transparantie en bewijsbasis van de e-Catalog en de NF hebben geleverd in overeenstemming met de richtlijnen van de implementatie van JKN-KIS. HTA heeft echter geen deel uitgemaakt van de ontwikkeling van de e-catalogus en de NF. Verschillende belemmeringen voor de implementatie van HTA in de e-catalogus en de NF waren een gebrek aan capaciteit, een gebrek aan financiële prikkels, een gebrek aan een duidelijk kader en onvoldoende gegevens. De eerste twee belemmeringen vormen de belangrijkste obstakels. Redenen voor het gebrek aan capaciteit waren dat HTA een nieuwe wetenschap is in Indonesië en dat er maar weinig HTA-afdelingen zijn, dat er geen nationale opleiding wordt gegeven en dat er in Indonesië een officiële vereniging ontbreekt. Bovendien zouden financiële middelen nodig zijn om de HTA-experts te betalen, HTA-seminars te organiseren en HTA-onderzoek uit te voeren.
In hoofdstuk 4 beoordelen we gezondheidsfinanciering in Indonesië richting UHC. Dit is om te begrijpen of Indonesië zijn systeem voor gezondheidsfinanciering heeft georganiseerd in overeenstemming met de UHC-doelstellingen. Trends van gezondheidsfinanciering voor en na de implementatie van de JKN-KIS worden beschreven. Bovendien wordt de prognose van financieringsregelingen voor de gezondheidszorg ook verlengd tot 2030, als agenda voor het jaar van doelstellingen voor duurzame ontwikkeling. We stelden vast dat de doelstelling om UHC tegen 2020 te halen niet gehaald zal worden. De doelstelling om de OOP-regelingen voor huishoudens onder de 20% te verminderen, kan tegen 2024 worden bereikt. De doelstelling om de vrijwillige betaling voor gezondheidszorg tot minder dan 10% te verminderen, kan tegen 2021 worden bereikt. Belangrijk is dat de overheidsregelingen en verplichte bijdragende Samenvatting
regelingen voor gezondheidsfinanciering nog steeds ver weg blijven van 4% van het BBP tegen 2020. Verder ontdekten we ook dat in het eerste jaar van de implementatie van JKN-KIS de uitgaven van de BPJS-Kesehatan stegen van $ 2,0 miljard (8,52% van totale uitgaven gezondheidszorg) tot $ 4,0 miljard (14,25%). Dit leidde ertoe dat de OOP-regelingen per huishouden afnamen tot US $ 1,5 miljard (7%). Het verhogen van de uitgaven voor sociale verzekeringen en het verminderen van OOP is de juiste koers voor het bereiken van UHC. We ontdekten echter dat de inkomsten van de BPJS-Kesehatan niet voldoende waren om hun uitgaven te dekken. Dit leidde ertoe dat de BPJS-Kesehatan sinds de implementatie in het eerste jaar voortdurend een tekort ontwikkelde.
In hoofdstuk 5 schatten we de CVD-belasting op lange termijn en risicofactoren in Aziatische populaties door middel van een systematische review. De belangrijkste resultaten waren dat mannelijk geslacht, oudere leeftijd en het huidige roken de meest prominente risicofactoren zijn voor fatale HVZ op lange termijn bij de Aziatische bevolking. In onze systematische review vonden we studies uit Indonesië niet in overeenstemming met de inclusiecriteria van onze studies (cohortstudies, Aziatisch gezond boven 18 jaar, vrij van HVZ, 10 jaar follow-up periode). Onze bevindingen ewaren dat op langer termijn een stijgende incidentie te verwachten is. Aangezien er geen informatie beschikbaar is over de risicofactoren op lange termijn van fatale HVZ in Indonesië, kan dit resultaat worden gebruikt als een referentie om te erkennen dat roken de wijzigende risicofactor van CVD's is. Dit kan worden beïnvloed door verschillende interventies om de mortaliteit van hart- en vaatziekten in Indonesië te verminderen en de financiële last van de BPJS-Kesehatan te verminderen.
In hoofdstuk 6 presenteren we de algemene discussie van dit proefschrift. We beginnen met het overzicht om te beschrijven hoe JKN-KIS de drie belangrijkste uitdagingen is tegengekomen. Vervolgens biedt het toekomstperspectief beleidsopties om de uitdagingen aan te gaan; en verder onderzoek nodig om UHC te verbeteren. Vervolgens leggen we uit hoe dit proefschrift mogelijk richting geeft aan Indonesië en andere landen. Ten slotte is de conclusie van dit proefschrift dat JKN-KIS de hoeksteen is voor Indonesië om UHC te bereiken in overeenstemming met Addendum
de WHO-doelen. Het verbeteren van de efficiëntie en het verhogen van financiële middelen voor de gezondheid zijn echter noodzakelijk voor de JKN-KIS om verschillende uitdagingen aan te pakken die momenteel de verwezenlijking van UHC belemmeren.
RINGKASAN
Negara yang tergabung dalam Perserikatan Bangsa-Bangsa (PBB) telah berkomitmen untuk mencapai cakupan kesehatan universal (UHC) sebagai bagian dari tujuan pembangunan berkelanjutan 2030. Organisasi kesehatan dunia (WHO) menyatakan bahwa UHC tercapai di suatu negara ketika semua masyarakatnya dapat mendapatkan pelayanan kesehatan berupa promotif, preventif, kuratif, rehabilitatif dan paliatif, dengan kualitas yang tinggi, tanpa membuat masyarakat terpapar kesulitan membayar ketika menerima pelayanan tersebut. WHO menjelaskan indikator UHC tercapai oleh suatu negara ketika pembiayaan kesehatan dari kantong masyarakat (OOP) turun di bawah 20% dari total pembiayaan kesehatan suatu negara. WHO juga mendesak setiap negara yang ingin mencapai UHC agar pembiayaan kesehatan dari pemerintah harus mencapai setidaknya 4% dari produk domestik bruto.
Sebagai anggota dari PBB, Indonesia bertujuan untuk mencapai UHC. Pencapaian target UHC semakin didukung oleh Undang-Undang Dasar 1945, pasal 28, yaitu kesehatan adalah hak dasar setiap individu, dan semua warga negara berhak atas layanan kesehatan termasuk orang miskin. Pada awal 2014, pemerintah Indonesia secara resmi mengumumkan rencana mereka untuk mencapai UHC sebelum tahun 2020 melalui asuransi kesehatan nasional baru, yang dikenal sebagai Jaminan Kesehatan Nasional-Kartu Indonesia Sehat (JKN-KIS). Program ini dikelola oleh program asuransi kesehatan baru, yang disebut Badan Penyelenggara Jaminan Sosial-Kesehatan (BPJS-Kesehatan). JKN-KIS adalah hasil dari penggabungan skema asuransi kesehatan sosial yang sudah ada sebelumnya. Skema asuransi kesehatan yang terfragmentasi membuat pengeluaran perawatan kesehatan dan kualitas layanan kesehatan sulit dikendalikan.
Sebelum pelaksanaan JKN-KIS, ada beberapa masalah kesehatan yang belum terselesaikan, yaitu pada manajemen obat-obatan, pembiayaan kesehatan, dan situasi epidemiologis di Indonesia. Dalam manajemen obat-obatan, proporsi OOP untuk obat-obatan tinggi, berkisar lebih dari 50% dari total pengeluaran kesehatan. Selanjutnya, pengeluaran obat-obatan mencapai 67% dari total pengeluaran
kesehatan. Mengenai pembiayaan kesehatan, pemerintah Indonesia mengalami kesulitan untuk meningkatkan pengeluaran kesehatan di tingkat nasional. Alih-alih mengandalkan pembiayaan kesehatan dari pemerintah, Indonesia didominasi oleh pembiayaan kesehatan dari masyarakat. Dalam hal situasi epidemiologis, angka harapan hidup yang meningkat menyebabkan proporsi orang meninggal karena penyakit tidak menular mencapai hampir dua kali lipat, yaitu dari 37% pada tahun 1990 menjadi 73% pada tahun 2014. Dari semua penyakit tidak menular, penyakit kardiovaskular adalah penyebab utama kematian dan kecacatan.
Tujuan tesis ini adalah untuk mengevaluasi perkembangan JKN-KIS dalam melangkah menuju pencapaian UHC di Indonesia. Terutama, untuk memberikan temuan komprehensif tentang bagaimana JKN KIS telah menghadapi tiga tantangan utama pada manajemen obat-obatan, pembiayaan kesehatan, dan situasi epidemiologis. Dalam bab 1, kami menjelaskan secara singkat mengenai konsep UHC menurut WHO. Kemudian, penjelasan tentang transformasi sistem kesehatan Indonesia menuju UHC, dan tantangan potensial mereka untuk mencapai UHC sebelum tahun 2020. Selanjutnya, gap terhadap pengetahuan dan tujuan tesis disajikan pada bab 1.
Dalam bab 2, kami melakukan wawancara semi terstruktur untuk mengidentifikasi masalah e-katalog dan formularium nasional (fornas). Ini adalah dua instrumen kebijakan baru yang mengatur penentuan harga dan penggantian biaya obat selama implementasi JKN-KIS. Idealnya, e-katalog membantu meningkatkan efektivitas, efisiensi, dan transparansi dalam pengadaan obat-obatan pada fasilitas kesehatan. Sementara fornas membantu memastikan ketersediaan obat-obatan yang berkualitas baik, manjur dan terjangkau. Oleh karena itu, kebijakan ini seharusnya membantu JKN-KIS untuk mengontrol pengeluaran obat-obatan dan mengurangi OOP untuk obat-obatan, sehingga dapat mencapai UHC. Namun, setahun setelah implementasi, banyak fasilitas kesehatan umum jarang menggunakan e-katalog untuk pengadaan obat-obatan, dan 40% dari semua obat yang diresepkan tidak terdaftar dalam fornas. Kami menemukan bahwa masalah utama adalah kurangnya harmonisasi antara obat-obatan yang tercantum dalam e-katalog dan fornas. Kemudian, alasan utama dokter ketika meresepkan obat-obatan Addendum
di luar fornas adalah kurangnya transparansi dan basis bukti dalam pengembangan fornas.
Dalam Bab 3, kami mengidentifikasi faktor penghambat dan pendukung penerapan penilaian teknologi kesehatan (HTA) dalam mengembangkan e-katalog dan fornas. Komite HTA ditunjuk oleh Menteri Kesehatan Indonesia beberapa bulan setelah implementasi JKN-KIS. Idealnya, komite HTA dapat menyediakan bukti ilmiah dan transparansi pengembangan e-katalog dan fornas sesuai dengan pedoman pelaksanaan JKN-KIS. Namun, HTA belum menjadi bagian dari pengembangan e-katalog dan fornas. Beberapa hambatan implementasi HTA dalam e-e-katalog dan fornas adalah kurangnya kapasitas, kurangnya insentif keuangan, kurangnya kerangka kerja yang jelas dan data yang tidak mencukupi. Dua hambatan pertama merupakan hambatan yang paling utama. Alasan kurangnya kapasitas karena HTA adalah ilmu baru di Indonesia, dan hanya sedikit departemen HTA yang tersedia, pelatihan formal tidak disediakan secara nasional, dan asosiasi resmi tidak ada di Indonesia. Selanjutnya, sumber daya keuangan akan diperlukan untuk membayar para ahli HTA, untuk mengatur seminar HTA, dan melakukan penelitian HTA.
Dalam bab 4, kami melakukan penilaian terhadap pembiayaan kesehatan UHC di Indonesia. Ini untuk memahami apakah Indonesia telah mengatur sistem pembiayaan kesehatannya sesuai dengan target UHC. Tren pembiayaan kesehatan sebelum dan sesudah implementasi JKN-KIS dijelaskan pada bab ini. Selain itu, proyeksi skema pembiayaan kesehatan juga dibuat hingga 2030, target tahun pencapaian tujuan pembangunan berkelanjutan. Kami menemukan bahwa target untuk mencapai UHC sebelum tahun 2020 tidak akan tercapai. Target untuk mengurangi skema OOP < 20% dapat dicapai pada tahun 2024. Target untuk mengurangi pembiayaan kesehatan privat < 10% dapat dicapai pada tahun 2021. Yang paling utama adalah skema pembiyaan kesehatan pemerintah masih akan jauh dari 4% PDB sebelum tahun 2020. Selanjutnya, kami juga menemukan bahwa pada tahun pertama implementasi JKN-KIS, pengeluaran BPJS-Kesehatan meningkat secara signifikan dari US $ 2,0 miliar (8,52% dari THE) menjadi US $ 4,0 miliar (14,25% dari THE). Hal ini menyebabkan skema OOP oleh rumah tangga menurun menjadi US $ 1,5 miliar (7% dari THE). Meningkatkan pengeluaran asuransi Ringkasan
kesehatan sosial dan mengurangi OOP adalah kemajuan yang tepat untuk mencapai UHC. Namun, kami menemukan bahwa pendapatan BPJS-Kesehatan tidak cukup memadai untuk memenuhi pengeluaran mereka. Hal ini membuat BPJS-Kesehatan terus mengembangkan defisit sejak implementasi tahun pertama.
Dalam Bab 5, kami memperkirakan beban penyakit kardiovaskular (CVD) jangka panjang dan faktor risiko pada populasi Asia melalui tinjauan sistematis. Hasil yang paling penting adalah bahwa jenis kelamin laki-laki, usia yang lebih tua, dan perokok adalah faktor risiko yang paling menonjol untuk CVD jangka panjang pada populasi Asia. Dalam tinjauan sistematis ini, kami tidak menemukan studi dari Indonesia sesuai dengan kriteria inklusi studi kami (studi kohort, orang Asia yang sehat di atas 18 tahun, bebas dari CVD, 10 tahun masa tindak lanjut). Khususnya, kriteria inklusi kami dapat memperoleh tingkat insiden jangka panjang pada populasi umum. Mengingat tidak tersedianya informasi mengenai faktor risiko jangka panjang dari CVD fatal jangka panjang di Indonesia, hasil ini dapat digunakan sebagai referensi untuk mengetahui bahwa perokok adalah faktor risiko CVD yang dapat dirubah. Oleh karena itu, ini dapat dipengaruhi melalui berbagai intervensi untuk mengurangi angka kematian akibat CVD di Indonesia dan untuk mengurangi beban keuangan BPJS-Kesehatan.
Dalam bab 6, kami menyajikan diskusi umum dari tesis ini. Kami mulai dengan ikhtisar untuk menggambarkan bagaimana JKN-KIS telah menghadapi tiga tantangan utama utama. Kemudian, pada perspektif masa depan, kami akan menawarkan opsi kebijakan untuk mengatasi tantangan, dan penelitian lebih lanjut diperlukan untuk meningkatkan UHC. Kemudian kami akan menjelaskan bagaimana tesis ini memberikan panduan yang memungkinkan untuk Indonesia dan negara-negara lain. Akhirnya, kesimpulan dari tesis ini adalah bahwa JKN-KIS adalah landasan bagi Indonesia untuk mencapai UHC yang sejalan dengan target WHO. Namun, meningkatkan efisiensi dan meningkatkan sumber daya keuangan untuk kesehatan adalah keharusan bagi JKN-KIS untuk mengatasi beberapa tantangan yang saat ini menghambat pencapaian UHC di Indonesia.
Acknowledgement
“Feed two birds with one seed”, this proverb might describe me during the period I was pursuing my PhD, marrying my love, and raising my kids in the last four years. Therefore, I would like to send my greatest gratitude to Allah, the Almighty, who mercifully bestows upon me health, strength, determination, and patience to encounter these monumental occasions in the same period. I really enjoyed experiencing these remarkable moments simultaneously because of precious support from many parties. Hence, I would like to sincerely express my gratitude in these pages to all people and institutions for their contributions during my tremendous journey.
To start, I would like to pay my special regards to my supervisors, and
co-supervisors. Mostly, I would like to thank you for your flexibility and for allowing
me to develop my research ideas. I realize my research, especially in data collection, was costly, time consuming, and ambitious. But, your financial assistance, followed by your comprehensive supervision, made my goals achievable.
Prof. Erik Buskens, you are the one who contributed in all stages of my PhD
trajectory. I am really grateful because you always provided me the opportunity to confide both my academic and personal matters. Your intelligent advice, and especially wise encouragements you delivered to me during our weekly meetings always increased my confidence. Most importantly, I was always glad to receive your feedback on manuscripts, cover letters for the journals, and so on. Sentences will change like written by a highly professional writer. One unforgettable moment was when preparing my oral presentation for attending ISPOR 2018 conference. I am indebted since you helped me to create a professional slide set and speech. Lastly, I sincerely appreciate the availability of your time for me, even though you recently were in mourning for your father's death.
Prof. Maarten Postma, you are the first person that I encountered in Groningen. I
remember when nominated as a DIKTI scholarship awardee. Then, I was required to to submit a letter of acceptance as soon as possible. In three days, you helped me to obtain it. Furthermore, my fortune was that you gave me another desk in PTEE instead of just the one in Epidemiology. This allowed me to meet with other forgoing Indonesians, expecting they could help me to avoid becoming homesick and familiarize me with the Dutch culture. Most importantly, I am glad to your creative solutions in dealing with my academic and personal matters. So, thank you very much for giving me a chance as your PhD student, helping me to get started on PhD, and always providing me meaningful ways to accomplish my PhD journey.
Dr. Wim Goettsch, I remember the first time we met at the Dutch National Health
Care Institute in Diemen. You provided me an important reference to develop a framework for my first and second research project. You also connected me to Amr Makady, to help me analyze the qualitative data and run the qualitative study tool. So, thank you for collaborating on my two studies and for accepting to be my co-promoter in your busy time. Collaborating with the special advisor HTA at the
Dutch National Health care Institute will be certainly worthwhile, and great for my future networking.
Dr. Talitha Feenstra, the first two years of my PhD journey were the most difficult
period. Lucky me to have you as my daily supervisor in these days. You passionately explained me several basic research skills, such as searching references in PubMed, writing reports to the supervisors, and scheduling my research project. Your strict and intensive supervision helped me to be a disciplined and independent researcher for the next two years of my PhD period. So, thank you very much for the valuable technical skills that you provided to me.
I would like to express my profound gratitude to my research collaborators: Prof.
Ali Ghufron Mukti, Silvy Irawati, Jurjen Van der Schans, and Amr Makady,
for their analytical assistances, and meaningful feedback on my manuscripts. I would also thank the assessment committee: Prof. Menno Reijneveld, Prof.
Katja Taxis, and Prof. Aukje Mantel for providing me their valuable time,
particularly during the COVID 19 pandemic to read and appraise my thesis.
I am also truly thankful to the staff of the Epidemiology Department: Erwin, Aukje,
Lizette, and Gerben, and the staff of PTEE unit in the Pharmacy Department: Jannie, Bert, and, Hugo, for their practical and technical support.
I also thank my friends and colleagues in the PTEE unit: Prof. Bob Wilffert, Prof.
Eelko Hak, Abraham, Mas Adjie, Mbak Afifah, Kak Akbar, Christian, Mas Didik, Eva, Kak Ira, Mas Ivan, Jurjen, Mas Khairul, Linda, Mbak Lusi, Mbak Neily, Nynke, Pepijn, Pieter, Qi, Simon, Mbak Sofa, Mbak Sylvi, Taichi, Tanja,
Mbak Tia, Kak Ury, Yuan; in the Patient-Centered HTA Unit: Paul, Thea, Henk,
Maarten, Karin, Sander, Koen, Ariuntuya, Ahmed, Kaying; and in the
Epidemiology Department: Omar, Pato, Reinder, Katri; you all brightened my PhD journey through scientific talks in our group meetings, and spontaneous conversation on any occasion.
I would like to express my deepest thanks to Kak Ury for provoking me to pursue my PhD at the University of Groningen, teaching me life skills, portraying me the Dutch academic atmosphere, and sharing your badminton techniques to me.
I would like to send my sincere thanks to Kak Akbar for being a big brother to me in Groningen and allowing me to have chitchat every time. Most importantly, your wife Andis, and son Abdullah, have become close friends for my wife and children. I and my family are now counting down the days for a lot of wonderful moments we will create in Makassar.
My deepest gratitude also goes to Pak Asmoro and family as well as Kak Habibie and family for accompanying my wife while delivering my second kids in the UMCG Hospital. At that time I was also expected to deliver my presentation in the study group meeting and then pick my family up at the airport thereafter.
Being a thousand miles from home to pursue my PhD and build my new sweet household feels easier with all friendship from the Indonesian student association in Groningen and the Groningen Indonesian Moslem community. Therefore, I would like to sincerely thanks them all who made Groningen become my second home. Budhe Nunung-Pakde Zaid, Oom Herman-Budhe Arie, Oom Weno-Uwak Asiyah, Oom Archie-Tante Mary. Mas Didik Setiawan and family, Mas Amak and family, Mas Zaki Almuzakki and Family, Mas Surya and Family, Mas Ali Syariati and Family, Mas Mega and Family, Mas Joko and family, Mas Azkario, Mbak May, Mbak Dina, Mas Adhyatmika and family, Mas Kuswanto and Family, Bli Kadek and Family, Mas Zainal and Family, Mas Azis and family, Mbak Nur Qomariah, Mas Fajar and family, Mas Khairul and family, Mas Ivan and family, Mas Yudi and Family, Mbak Nuriel, Mas Ristiono and family, Mas Didin and family, Mas
Latief and family, Mas Krisna and family, Mas Hegar and family, Mas Azkamuji
and family, Mas Luthfi, Mas Guntur, Mas Yoga, Mas Ade and family, Mas Agung and family, Mas Fika and family, Mas Chalis and family, Mas Afif, Mas Bhimo, Mbak Inda and Family, Mas Umar Djalins, Mas Ajie Mahar, Mas Fean, Mas
Lana and family, Mas Ali Abdurrahman and family, Adzkia, Ibu Neno Purba, Fathki, Stephanie, Yessaya, Kinanti, Inez, Sarah, Afra, Laras, Mas Rifki, Kang Angga, Mas Romy and family, Kang Deny and all my Indonesian friends who
could not be listed in this acknowledgement.
I also credit my house landlord, Mr. Sulaiman Surie for providing me a house for living with my family which is close to the UMCG. This helps me to be flexible to do my work and check my little family during lunchtime.
I would also like to express my deepest gratitude to those who have provided me motivation and their sincere prayers for my PhD life: Bapak Anies Rasyid
Baswedan (Governor of DKI Jakarta), Bapak Prof. Nurdin Abdullah (Governor of
South Sulawesi), Bapak Syahrul Yasin Limpo (Indonesia‘s Minister of Agriculture), Bapak Agus Arifin Nu'mang (ex-vice governor of South Sulawesi), Bapak Aksa Mahmud, Bapak AGH Sanusi Baco, and all people attending at my salvation event to start my PhD trajectory.
Finally, I wish to express my deepest gratitude to my beloved family for giving me extraordinary motivation. The unforgettable moments when you all repeatedly drove me to the airport accompanied by your heartfelt tears. These moments continuously crossed to my mind in all my activities in Groningen. Hence, I dedicate this thesis to all of you and hopefully, this answers all your prayers and wishes.
To my parents (Bapak and Mama): Prof. Wasir Thalib and Ummu Kalsum, as well as my parent in law (Papa and Ibu): Prof. Sidin Ali and Hafsah Usman, I consider myself nothing without you. Thank you so much for your endless love, sincere unceasing prayer, moral and financial support to me. Most importantly, I pay my deepest gratitude for helping me to take care of my wife, son, and daughter in the last year of my PhD. So that I only pay attention to my PhD journey without any obstacle in the way.
To my siblings: Kak Rika Fatimah Wasir, Kak Rizqurrachman Wasir, Rina
Wahyuni Wasir; my brother and sister in law: Kak Ikrar Sakti Yusuf, Kak Wahida Masrah, Andi Agung Yasser, My nephews, and nieces: Iffat, Dzakiyah, Adzkia, Fakhri, Farzan, Rafassya, Radeva. My wife‘s siblings (also in law): Kak Risna Sari, Kak Irwan Rais, Kak Tri hastiti Fiskawarni, Kak Zulhajji Hamid;
and my wife‘s nephews, and nieces: Sadam, Zaky, Fildzah, Fairah, I am very pleased for your time to take care of Bapak and Mama, as well as Papa and Ibu when I was not in Indonesia.
To my beloved wife, Fadilah Aulia Rahma, accepting me as your husband in the first year of my PhD, and, subsequently, living with me in Groningen was a remarkable moment in my life. As a youngest and carefree child of Papa and Ibu, with a strong determination to be a doctor, I never thought you would actualy leave your comfort zone and your ideals. Most importantly, you were willing to give birth to our kids in Groningen, without being accompanied by extended family, as is common in Indonesia. Amazingly, in addition to fulltime caring for our two kids, you provided me delicious foods and tidied my clothes up every day to ensure my nutrition and appearance during my research work. So, thank you very much for devoting your quality time, and your career to allow me to pursue my PhD, and raising our kids. I owe you everything. Therefore, I dedicate this thesis and of course the rest of my life to you.
To my kids, Muhammad Mikail Davian Riswandy and Mikhayla Maritza
Riswandy, your smiles and funny reactions always relieve my stress and booster my
spirit to write my manuscripts. Importantly, you both foster my self-awareness to make the best use of time during Pursuing my PhD. So, thank you for providing quality time for me during my PhD Journey and for expressing to me that I should obtain value in every single activity. I apologize for leaving you both for a while in Indonesia. Surely, we will have our quality time again.
Ministry of research and higher education, thank you for providing me a DIKTI
scholarship. Without your funding I would not have been able to develop my scientific competence and discoveries in four years.
Last but not least, I am grateful to all people who contributed to my PhD projects that cannot be listed one by one in this acknowledgment. Thank you very much!
Groningen, April 2020 Riswandy Wasir
PHD PORTOFOLIO
Personalia
Name : Riswandy Wasir
Gender : Male
Place and Date of Birth : Makassar, 12 January 1988 Nationality : Indonesian
E-mail : riswandy.wasir@yahoo.com
Department of PhD : Epidemiology, University Medical Center Groningen PhD Period : December 2015-Mei 2020 (4 years, 6 months) Promotors : Prof. Dr. Erik Buskens
Prof. Dr. Maarten Postma Co-Promotors : Dr. Wim Goettsch
List of Publications
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2018). Use of medicine policies for universal health coverage in Indonesia. Value in Health, 21(3), S1, October, 2018. DOI: https://doi.org/10.1016/j.jval.2018.09.004
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2018). Barriers to and facilitators of the application of health technology assessment in medicine pricing and reimbursement policies in Indonesia. Value in
Health, Volume 21, S184, October, 2018. DOI:
https://doi.org/10.1016/j.jval.2018.09.1099
S Irawati S, R Wasir R, Schimdt AF, Islam A, Feenstra T, Buskens E, Wilfert B, E Hak (2019). Long term risk of incidence of cardiovascular events in Asian Populations. Systematic review and Meta-Analysis of Population-Based Cohort Studies. Current Medical research and opinion, 35(2), 291-299. DOI: https://doi.org/10.1080/03007995.2018.1491149
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Buskens E, Feenstra T
(2019). Use of medicine pricining and reimbursement policies for universal health coverage in Indonesia. PloS ONE, 14(2), [e0212328]. February, 2019 DOI: https://doi.org/10.1371/journal.pone.0212328
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2019). The implementation of HTA in medicine pricing and reimbursement policies in Indonesia: Insight from multiple stakeholders. PloS ONE, 14(11), [e022565626]. November, 2019 DOI: https://doi.org/10.1371/journal.pone.0225626
Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E (2019).
Implementation of universal health coverage in Indonesia. Value in Health, 22(3), S782, November, 2019. DOI: https://doi.org/10.1016/j.jval.2019.09.2024
Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Trends and projection of
health financing for universal health coverage in Indonesia. (Submitted)
Irawati S, Wasir R, Bahar MA, Hak E, Wilffert, B, Taxis K, Postma MJ, Buskens E, The burden of cardiovascular disease and trend of claim reimbursement for statin prescription in Indonesia after the implementation of the National Health Insurance (Jaminan Kesehatan Nasional, JKN) 2014-2016 (In preparation)
Wasir R, Postma MJ, van der Schans J, Buskens E. Health and economic
implications of national treatment coverage for cardiovascular disease in Indonesia: an estimation of the return on investment on statin (In preparation)
Scientific Conferenes
Wasir R, Feenstra T, Postma MJ, Goettsch W, Buskens E. The role of a health
technology assessment in medicine policy to enable universal health coverage in low middle-income countries: Indonesia as a reference case. The 3rd InaHEA conference, July 28-30th, 2016, Yogyakarta, Indonesia. (Poster presentation).
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2018). Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia. International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, New Perspective for improving 21st Century health system. 10-14 November 2018, Barcelona, Spain. (Oral Presentation)
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2018). Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia. International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, Student research spotlight. 10-14 November 2018, Barcelona, Spain. New Perspective for improving 21st Century health system. 10-14 November 2018, Barcelona, Spain. (Poster Presentation)
Wasir R, Irawati S, Makady A, Postma MJ, Goettsch W, Feenstra T, Buskens E
(2018). Barriers to and facilitators of the application of health technology assessment in medicine pricing and reimbursement policies in Indonesia. International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, New Perspective for improving 21st Century health system. 10-14 November 2018, Barcelona, Spain. (Poster Presentation)
Wasir R. Experience on the first event of ISPOR student research spotlight.
Webinar Presidents Teleconference. November 2018. (Panelists)
Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Trend and
Projection on financial protection for universal health coverage in Indonesia. The Addendum
13th Post Graduate Forum on Health System and Health Policy. Medical specialist within the Health System in Asia: A perspective on production and utilization. 19-20 July 2019, Yogyakarta, Indonesia. (Poster Presentation)
Wasir R, Postma MJ, van der Schans J, Mukti AG, Buskens E. Implementation of
universal health coverage in Indonesia. International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2019. Digital transformation of Healthcare. 2-6 November 2019, Copenhagen, Denmark. (Poster Presentation)
Awards Nominations
Top outcomes research at International Society for Pharmacoeconomics and
Outcomes Research (ISPOR) Europe 2018, New Perspective for improving 21st Century health system. 10-14 November 2018, Barcelona, Spain
Top-3 Poster Prize at the 13th Post Graduate Forum on Health System and Health Policy. Medical specialist within the Health System in Asia: A perspective on production and utilization. 19-20 July 2019, Yogyakarta, Indonesia
PhD level courses taken
Courses Year Workload
Academic Writing 2016 2 ECTS
PhD Introductory Event 2016 1 ECTS
Pharmacoeconomics 2016 5 ECTS
Qualitative Data Collection and Analysis 2016 5 ECTS
Ethics of Research and Scientific Integrity for Researchers 2017 2,5 ECTS
Managing your PhD 2017 2 ECTS
Presentation Skills 2018 2 ECTS
Publishing in English 2018 2 ECTS
Budget Impact Analysis I: A 6-Step Approach at ISPOR Europe, Barcelona, Spain
2018 5 hours Budget Impact Analysis II: Application and Design Issues at
ISPOR Europe, Barcelona, Spain
2018 5 hours Introduction to Modelling at ISPOR Europe, Copenhagen,
Denmark
2019 5 hours Statistical Methods for Health Economics and Outcomes
Research at ISPOR Europe, Copenhagen, Denmark
2019 5 hours Bayesian Analysis: Overview and Applications at ISPOR
Europe, Copenhagen, Denmark
2019 10 hours PhD Portofolio
About the Author
Riswandy Wasir was born on January 12th, 1988 in Makassar, South Sulawesi, Indonesia. He is the third son of four children from Ayahanda Prof. Dr. H. M. Wasir Thalib, MS and Ibunda Dra. Hj. Ummu Kalsum Ali Tadjo. His primary, secondary and tertiary school was obtained in Makassar, which are respectively in SD Negeri Kompleks IKIP, SMP Negeri 6 and SMA Negeri 3. He obtained a Bachelor of Pharmacy at Universitas Muslim Indonesia (UMI), a Pharmacist certificate at Universitas Islam Indonesia (UII) and a Master of Public Health at the University of Gadjah Mada (UGM). In December 2015, He started his PhD trajectory at the unit of Patient-Centered Health Technology Assessment (HTA), Epidemiology Department, University Medical Center of Groningen (UMCG), University of Groningen, Groningen, the Netherlands under the supervision of Prof. Dr. Erik Buskens, Prof. Dr. Maarten Postma and Dr. Wim Goettsch. His PhD project focused on the health policy strategies to enable countries (in particular Indonesia) to achieve universal health coverage as part of the sustainable development goals. His study is funded by the Ministry of Research, Technology and Higher Education of the Republic of Indonesia under the scheme of DIKTI scholarship. During his PhD trajectory, he has published his studies in international peer-reviewed journals and also actively presented his studies at international conferences. One of his studies was nominated for top outcomes research at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, in Barcelona, Spain. He was also awarded a top-3 poster prize at the 13th Post Graduate Forum on Health System and Health Policy, in Yogyakarta, Indonesia. Currently, he continues his career as a lecturer and researcher at the Sekolah Tinggi Ilmu Farmasi (STIFA) Makassar, Makassar, South Sulawesi, Indonesia. His research interests are in the areas of universal health coverage and health policy, particularly in policies in medicine management. He married his beloved wife Fadilah Aulia Rahma, a youngest and carefree child of Prof. Dr. H. M. Sidn Ali, M.Pd and Dra. Hj. Hafsah Usman, M.Pd. The marriage of Riswandy and Fadilah has been blessed with two beloved children, Muhammad Mikail Davian Riswandy and Mikhayla Maritza Riswandy. Their kids were both born in Groningen in the period of pursuing a PhD of Riswandy Wasir.
Tentang Penulis
Riswandy Wasir lahir pada 12 Januari 1988 di Makassar, Sulawesi Selatan, Indonesia. Dia adalah putra ketiga dari empat bersaudara dari pasangan Ayahanda Prof. Dr. H. M. Wasir Thalib, MS dan Ibunda Dra. Hj. Ummu Kalsum Ali Tadjo. Sekolah dasar, menengah pertama dan menengah atas diperoleh di Makassar, yang masing-masing di SD Negeri Kompleks IKIP, SMP Negeri 6 dan SMA Negeri 3. Ia memperoleh gelar Sarjana Farmasi di Universitas Muslim Indonesia (UMI), sertifikat Apoteker di Universitas Islam Indonesia (UII) dan Magister Kesehatan Masyarakat di Universitas Gadjah Mada (UGM). Pada Desember 2015, dia memulai perjalanan PhD-nya di Unit Patient-Centered Health Technology Assessment (HTA), Epidemiology Department, University Medical Center of Groningen (UMCG), University of Groningen, Groningen, Belanda di bawah pengawasan Prof. Dr. Erik Buskens, Prof. Dr. Maarten Postma dan Dr. Wim Goettsch. Proyek PhD-nya berfokus pada strategi kebijakan kesehatan untuk memungkinkan negara, khususnya Indonesia, untuk mencapai cakupan kesehatan universal (Universal Health Coverage, UHC), yang merupakan bagian dari tujuan pembangunan berkelanjutan. Studinya didanai oleh Kementerian Riset, Teknologi, dan Pendidikan Tinggi, Republik Indonesia di bawah skema beasiswa DIKTI. Selama perjalanan PhD, dia telah menerbitkan beberapa artikel di jurnal internasional bereputasi tinggi dan juga aktif mempresentasikan penelitiannya di konferensi internasional. Salah satu penelitianya dinobatkan sebagai penelitian dengan luaran terbaik pada International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Europe 2018, di Barcelona, Spanyol. Dia juga dianugerahi sebagai presenter poster terbaik ke 3 di Post Graduate Forum on Health System and Health Policy ke 13, di Yogyakarta, Indonesia. Saat ini, dia melanjutkan karirnya sebagai dosen dan peneliti di Sekolah Tinggi Ilmu Farmasi (STIFA) Makassar, Makassar, Sulawesi Selatan, Indonesia. Minat penelitiannya adalah di bidang universal health coverage dan kebijakan kesehatan, terutama dalam kebijakan manajemen obat-obatan. Dia menikahi gadis pujaan hatinya Fadilah Aulia Rahma, putri bungsu yang riang dari Prof. Dr. H. M. Sidn Ali, M.Pd dan Dra. Hj. Hafsah Usman, M.Pd. Pernikahan Riswandy dan Fadilah telah dikaruniai dua anak kesayangan, Muhammad Mikail Davian Riswandy dan Mikhayla Maritza Riswandy. Anak-anak mereka berdua lahir di Groningen ketika Riswandy Wasir sedang mengejar gelar PhDnya.
Research Institute SHARE
This thesis is published within the Research Institute SHARE (Science in Healthy Ageing and healthcaRE) of the University Medical Center Groningen / University of Groningen.
Further information regarding the institute and its research can be obtained from our internet site: http://www.share.umcg.nl/
More recent theses can be found in the list below. (supervisors are between brackets)
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2019 Nijholt W
Gaining insight in factors associated with successful ageing: body composition, nutrition, and cognition
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