Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University [email protected]
Apr 01, 2015
Indonesian Health Reform in a decentralized system
Laksono TrisnantoroCenter for Health Service Management
Gadjah Mada [email protected]
Preface
This paper is concerned with critical questions:• Is there a reform in Indonesian health sector?• Whether decentralization policy supports
health care reform?
ContentDefinition of Reform in Health CareObservations:- 1. Health Care Reform at national level under
decentralized policy ( 1999 – 2007)- 2. Health Care Reform in 7 Provinces (2006),
ConclusionWhat next?
Reform Definition• sustained, purposeful
change to improve the efficiency, equity, and effectiveness of the health sector
What Do We Mean by “Health System Reform”? (Bossert, 2007)
5
• Not everything that changes, or causes change, is a health system reform
• Purposeful efforts to change the system to improve its performance
Using an interesting understanding of:• “little r” reforms; Small changes to one or a few
features of the system• “Big R” reforms; Large changes to more than one
feature of the system
Health system reform:
What is the meaning of health system features?
• Depends on the definition: • WHO: stewardship, provision,
resources generation, etc• Kovner: the role of government
in: regulation, provision of services, and financing the system
• Harvard and WBI: use the “knobs” metaphora
7
The “Control Knobs” from Harvard and WBI
• Financing• Payment• Organization• Regulation• Persuasion and Behaviour Change
Terminology
• reform• Reform
• “little r” reforms; Small changes to one or a few features of the system
• “Big R” reforms; Large changes to more than one feature of the system
Will be used for analyzing Indonesian Health Sector through 2 observations:
• National level• Provincial level
Observation 1: National Level
• Reform in Finance• Reform in
Organizing and Paying Human Resources
• Reform in Regulation
• Reform in health Promotion
• ....
Critical Question:Is there any reform in • health finance? • Human Resources?Is there any effort for linking these
features of health reform?
Reform in Health Finance
• Historical context of Indonesian Health Finance
• Major milestones in the 2000s• What happened?
Historical Perspective
• Colonial Period• Independence and the
“Old Order”• “New Order”• Decentralized era
Before 1945
1945 - 1965
1965 - 1999
1999 - at present
Colonial Period
• The Dutch Indie was not administered as a welfare state
• Health services were provided for government employees, military personnel, and big company employees.
• Missionary hospitals and health services worked with limited coverage
1945 - 1965
• The period of market forces suppression• There was no clear national health financing
policy.• There was an Act on poor family health
services in early 1950s, but poorly implemented.
• Health insurance and social security is limited for government employees, military personnel, and big company employees.
1965-1998
• The market economy was introduced• The private sector growth rapidly, incl, for
profit hospitals.• There is a corporatization of medical services
based on market forces• There was no clear regulation of health
market • 1997: Economic crisis induced the Social
Safety Net incl. Health.
1999 - current
• Decentralization era since the stepdown of Suharto in 1998
• Direct Presidential and Governor/Major election
• More populist policies at national,provincial, and district level
• Poor family has free health and hospital services
• Poor family scheme becomes political issue
Historical Facts
• Indonesia is not a welfare state since the colonial era
• Indonesia has market based economy
• Indonesian health system refers to American model using Safety Net, not the British one.
• Hospitals operate within market ideology
• Medical Doctors (esp. specialists) operates based on the fundamental demand and supply principles.
Indonesian health finance situation in 2001
04/11/23 18
Study by Equitap Group
04/11/23 19
04/11/23 20
04/11/23 21
04/11/23 22
The market forces domination in Indonesia
Health Finance “Reform” in 2004
Objective: to achieve Universal Health Coverage by National Social Security Law
(UU SJSN)
24
Organization and Management
- Each single existing carrier follows its own regulation - For profit entities
PT.
ASKES
Branch
PT.
TASPEN
Branch
PT.
ASABRI
Branch
PT.
JAM SOSTEK
Branch
Branch
PRESIDENT
5 years
nch
SS Carrier
ASKES
Branch
SSCarrier
TASPEN
Branch
SS Carrier
ASABRI
Branch
SSCarrier
JAM SOSTEK
Branch
Nat Soc Sec Council
SS Carrier
INFORMAL
Board
NatSoc
SecurityCarriers
BoardBoardBoardBoard
- Nat Soc Security Council directs main policy- Nat Soc Security Carriers implement the program, not for profit- Synchronization of multiple schemes
Indonesia’s Transition to Universal Coverage Indonesia’s Transition to Universal Coverage (National Social Security Law No.40/2004)(National Social Security Law No.40/2004)
Branch
Source: MOH: Ida Bagus Indra Gotama, Donald Pardede
The program in 2005
• Ministry of Health introduced Askeskin (Health Insurance for the Poor)
• The budget was calculated based on 5 thousand rupiah per month per individu.
(commercial health insurance: from 25.000 - 250.000, to US dollar for overseas scheme)
• There was a poor registration system for poor people at the beginning of the program
The Contract to PT Askes Indonesia(2005-2007)
• Ministry of Health under the new Minister contracted PT Askes Indonesia for managing the Askeskin scheme for poor family.
• This was a radical change from the previous policy, which channel the central budget directly to the hospitals and encourage local government health office to develop health insurance scheme.
• There was no pilot study
The Change in 2005
Government as Payer
Hospital
Community
Government as payer
Hospital
Community
PT Askes I
Subsidy to Providers (based on utilization)
Contract to PT Askes Indonesia
28
Source: Health PER, World Bank 2008
Health Insurance situation (2005-2007)
In 20082006-2007: Many disputes between Ministry of
Health and PT Askes Indonesia• A new change in 2008: Askeskin program was
renamed to Jamkesmas.• The coverage is not only the poor but also near poor
(more coverage).• The budget is channelled directly to Hospital and
Health Centers using managed care concept (incl. DRG)
• Increasing budget.
04/11/23 30
How Pay for Health CareThe national health security program increased government budget
Is this an indicator of success in reforming Indonesian health finance?
Since 2001, - the health program for the poor had improved the utilization of public hospital by the poor - Kakwani Index is improving
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
KI 2001 KI 2004
Tahun
Kakw
ani In
dex Hospital Inpatient
Care
HospitalOutpatient Care
Non-hospitalInpatient Care
Non-hospitalOutpatient Care
All Public HealthCare
But,
• There is still a geographical inequity
Due to the access to• Medical specialists• HospitalsAcross Indonesia
Specialist distribution (KKI, 2008)
• Jakarta: 24% of specialists, serves around 4% community in a relatively small area
• Provinces in Java: 49% of specialists, serves around 53% community
• Rest of Indonesia: 27% of specialists, serves around 43% community in a very large area
35
Average Number of Public Hospital at a district
Low economy in the community
High economy in the community
High Fiscal capacity in local government
2.5 2
Low fiscal capacity in local government
0.5 0.31
36
Average number of Private Hospital at a district
Low economy in the community
High economy in the community
High Fiscal capacity in local government
1.05 2.11
Low fiscal capacity in local government
0.5 1.91
Hipothesis
• Health Finance provided by Jamkesmas will be used more by poor and near poor people in and around big cities
• Most in Java Island• Left the poor and near poor people in remote
area or in the places where there is no medical service and specialists
38
This hipothesis may explain why Indonesian Insurance Coverage Status in 2007 (based on social economy survey)
looks not good.
73,3
14,4
62,4 2,9 1
Unisured
JAMKESMAS
ASKES
JAMSOSTEK
Other
JPKM
Source: SUSENAS 2007
Therefore:
• Health finance reform should be linked (at least) with Human Resources Reform
• How is the condition of health care reform in human resources?
Reform in Human Resources
• This discussion focuses on specialist
41
Indonesia is experiencing critical shortage of doctors, midwives and nurses
Sumber: WHR 2006
42
How many are really needed? Perception of 32 districts*
Need Availability GAP (%)Doctor 987 593 39,9
Specialist Doctor 64 30 53,1
Dentist 497 294 40,8
Midwife 4565 2951 35,4
Nurse 4492 3295 26,6
Pharmacist 89 47 47,2
Dietician 652 404 38,0
Public Health 415 312 24,8
Sanitarian 737 530 28,1
Public Health 182 82 54,9
Epidemiologist 21 0 100,0
Total 13.793 9.216 33,2
*) Bappenas Study in 2005
43
Doctor Distribution in 2003-2004
0
500
1000
1500
2000
2500
NA
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As an illustration:Specialists Distribution (Pediatrics)
Data: IDAI (Pediatrician Association, 2006)
J umlah Dokter Spesialis Obsetri dan Ginekologi
4
4
3
1
4
6
10
7
5
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141
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240
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15
17
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25
27
28
34
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42
48
71
136
153
163
287
0 50 100 150 200 250 300 350
Malut
Papua Barat
Gorontalo
Sulbar
Babel
Bengkulu
Papua
NTT
Sultra
Maluku
NTB
Sulut
Kalteng
Sulteng
NAD
J ambi
Kalbar
Kepri
Kalsel
Kaltim
Lampung
Banten
Riau
DIY
Sumbar
Sumsel
Sulsel
Bali
Sumut
J abar
J ateng
J atim
DKI
2006 2008
Typical graphic description of medical specialist distribution
Obstetric and Gynecologist
46
National Plan for “Reform” in Health Human Resource
47
Reduce disparity on health status and health care Increase the number and improve distribution of health
workers Improve access to health facility Reduce double burden of diseases Reduce misuse of narcotics and prohibited substances
RPJP (Long Term Plan)
48
1. Increase the number, network and quality of health centers; 2. Increase the quality and the number of health personnel; 3. Develop health insurance system especially for the poor; 4. Increase dissemination of environmental health and healthy
life style; 5. Increase health education to the community since early age;
and 6. Distribute and increase the quality of primary health care.
RPJM (Medium Term Plan)
49
Health Resource Program 2004-2009Objectives : increase number, improve quality & distribution of health
personnel, as well as improve health insurance for the poor
Main Activities:1. Setup Plans for health personnel need; 2. Improve skill and profesionalism through education and training 3. Deploy of health personnel especially for health centers (and their
networks) and hospitals; 4. Carrier development5. Improve sustainable health insurance for the poor.
RPJM (Medium Term Plan)
04/11/23 50
1. Improvement of equity, accessibility, and quality of health services especially for the poor, through provision of free of charge access of the poor to health center and hospitals
2. Improving availability of medical and paramedical personnel, especially in remote and less developed areas
RKP 2008 (Annual Plan)
51
The Facts in 2008
Specialist distribution (KKI, 2008)
Province Number % Cumulative People served Ratio
DKI Jakarta
2.890 23,92% 23,92% 8.814.000,00 1 : 3049
Jawa Timur 1.980 16,39% 40,30% 35.843.200,00 1 : 18102
Jawa Barat 1.881 15,57% 55,87% 40.445.400,00 1 : 21502
Jawa Tengah 1.231 10,19% 66,06% 32.119.400,00 1 : 26092
Sumatera Utara 617 5,11% 71,17% 12.760.700,00 1 : 20681
D.I.Jogjakarta 485 4,01% 75,18% 3.343.000,00 1 : 6892
Sulawesi Selatan 434 3,59% 78,77% 8.698.800,00 1 : 20043
Banten 352 2,91% 81,69% 9.836.100,00 1 : 27943
Bali 350 2,90% 84,58% 3.466.800,00 1 : 9905
Sumatera Selatan 216 1,79% 86,37% 6.976.100,00 1 : 32296
Kalimantan Timur 203 1,68% 88,05% 2.960.800,00 1 : 14585
Sulawesi Utara 173 1,43% 89,48% 2.196.700,00 1 : 12697
Sumatera Barat 167 1,38% 90,86% 4.453.700,00 1 : 26668
Propinsi Lainnya 1.104 9,14% 100,00% 52.990.200,00 1 : 47998
12083 100,00% 224.904.900,00 1 : 18613
Number of private hospitals is increasing more than government ones.
• Number of For-Profit Private-Hospital almost doubled in the last five years
• Number of Non-For-Profit-Private Hospital almost remained the same
Owner
03 04 05 06 07 08
For Profit Corporation
49 52 55 60 71 85
Non-Profit (Foundation)
530 538 538 538 539 539
Non-Profit (NGOs)
27 27 28 28 28 29
Total
606 617 621 626 638 653
The increase of for-profit private hospital:
• Most happened in Java• Indicates the increasing
role of private sector which can attract more medical specialists to Java
• Some owned by medical specialists
• Doctor culture is more influenced by private health service organization
• Without good payment and better work conidtion is more difficult for out of Java hospitals to attract doctors
Medical Specialis Culture Facts in 2008(done by various cultural studies in medical specialists)
• There is not any significant change in medical specialist behavior.
• Market influence in specialist is increasing.• Jamkesmas (health insurance) program is
difficult to compete with fee for service system for doctor and medical specialists
• No managed care culture
Current Medical Practices:
Specialists prefer to provide services in the middle and upper class using fee-for-service
Try to set own fees
No standard income
Link between Health Finance “Reform” and Human Resources
• Health finance “reform” does not consider medical doctor and specialist condition
• No attention in reforming the doctor payment. The fee for medical doctor from Jamkesmas is too low or not clear.
• Human resources “reform” is not clear and weak in practice.
Does not meet the criteria of Health System Reform
58
What Do We Mean by “Health System Reform”? (Bossert, 2007)
• Not everything that changes, or causes change, is a health system reform
• Purposeful efforts to change the system to improve its performance
• “little r” reforms; Small changes to one or a few features of the system
• “Big R” reforms; Large changes to more than one feature of the system
Does not meet the criteria of Health System Reform
Note: the National Reform in Health Finance
• Health finance reform is not will designed and executed
• The SJSN Law is not yet effective due to the lack of Government Regulation for implementation
• Until 2009 there is no GR
• The current implementation of SJSN Law is more political rhetoric, not technical.
Observation 2
• Reform at Provincial Level
Based on DHS1 Project at 7 Provinces
• Riau• Riau Island• Bengkulu• Bali• North Sulawesi• South East Sulawesi• Central Sulawesi
The Question:• Is there any reform
with big R at provincial level?
• A close observation into 54 DHS1 projects which are called as reform activties in 7 provinces
Reform Topics Riau Riau Island
Bengkulu
Bali North Slws
S EastSlws
CentralSlws
Health Finance 1 1 2 1 5
Health service provision 9 2 3 7 4 2 6 33
Stewardship/regulation 1 1
Human Resources 1 2 3
Community Empowerment
2 2 1 2 7
Health System development
1 2 1 1 5
Total 12 3 7 10 8 5 9 54
Analysis
• All reformed-program was not designed as a big “R” reform
• Each reformed-program is independent each other
• The most popular topic: Health service Provision
• No reform in public and private partnership
Why there was no big “R” of health reform at provincial level?
There was no clear definition of health care reform
• Provincial Government followed the change of national program and it is called reform.
• Technical change in the program is also called reform.
• No clear design of health care reform from the central government
Decentralization policy is not effective to initiate reform
•Conclusion
1. Health Reform is not well prepared at national and provincial level.
• Reform is associated with political issue during the Suharto (ex president) stepdown period (1999).
• Ministry of Health did not have intention to reform the health sector after decentralization policy (2000 – 2007)
• There is no formal health reform document
2. Health reform with small “r”only: not interrelated as prescribed by experts.
At national health finance reform was designed without any intention to link to the reform in:
• Paying medical specialists• Improving the organization of health service
(developing health service network across country)
• Changing the behavior of people (e.g smoking prevalence increases among the poor people)
3. Decentralization policy has little effect on the reform at provincial and district level
Why?• The Government
Regulation No. 25/2000 (based on Act 22/99) on government function at different level was unclear in its concepts and implementation until replaced by PP 38/2007 (based on Act 32/04).
• The period of 2000 – 2007 is still in the transition of decentralization policy
• It is not the right time for making reform (as it is still in a transitional phase).
Notes: in the Decentralization Policy:
The pendulum is swinging
centralizationDe-centralization
Act 22/99
Act 32/04
2000-2007: The era of confusion and “strange” situation
• Change without significant change
• Change in the Laws and Regulation but not significant change in the process and the improvement of health status indicators.
Indonesian health sector is a decentralized sector but experiencing:
• a more “centralized” financing system (06-07).
• Not coordinated change.
Will be discussed in Nossal Institute, University of Melbourne, Thursday 20th of May 2009
centralizationDe-centralization
Act 22/99
Act 32/04
After the stipulation of GR no 38 in 2007 (following Acts no 32/04):
• the legal basis for designing and implementing health reform gets new momentum
Closing remark: What next?
Is there any future of Indonesian Health Reform• at National Level?• at Provincial? • at District?
Moving Forward
• 2007 • Pesimistic? No health reform
• Optimistic? There will be health reform at national, provincial and district level
• Current activities in Indonesian Health Reform
Activities at central level
• Ministry of Health established a small group on how to initiate health reform (started 2008)
• But, this small group is not fully supported by top officers in the MoH
Activities at provincial and district level (small scale)
• Gadjah Mada University in collaboration with MoH, local governments, supported by:
• the World Bank Institute, • Harvard School of Public Health, and • Ausaid, develops the capacity of planning and
executing health care reform through the Flagship Program in Health Care Reform and Sustainable Financing (started in 2008)
• The experiment is implemented in 5 Provinces and 5 districts/cities
The Flagship Program combined training and consultation
In-campus training (I)
In-campus training (II)
Off campus I: work assignment and consultation
Off campus II: work assignment and consultation
Preparation- FGD at each Prov/District - Acquiring data set
Post-CourseConsultation and Workshop
78
Problem identification
Political Decision
EThics
Politics
Implementation
Policy Development
Diagnostic
Evaluation
Health Sector Reform Cycle
Program Schedule
In-campus training (I)
In-campus training (II)
Off campus I: work assignment
Off campus II: work assignment
Preparation- FGD at each Prov/District - Acquiring data set
Post-CourseConsultation and Workshop
Whether the activities will be effective to initiate and implement health reform?
The Supports• There are sufficient experiences
during the transition period of decentralization (2000-2007)
• The legal basis is available• The support of Ministry of Home
Affair for health reform based in decentralization policy is big.
• The knowledge of health reform is supported by international experts
But, • The success
depends on the leadership of Ministry of Health and Provincial/District/ City Health Leaders.
Thank-you