Transcript Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University [email protected].

Indonesian Health Reform
in a decentralized system
Laksono Trisnantoro
Center for Health Service Management
Gadjah Mada University
[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?
Content
Definition of Reform in Health Care
Observations:
- 1. Health Care Reform at national level under
decentralized policy ( 1999 – 2007)
- 2. Health Care Reform in 7 Provinces (2006),
Conclusion
What 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)
Health system reform:
• 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
5
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
The “Control Knobs” from
Harvard and WBI
•
•
•
•
•
Financing
Payment
Organization
Regulation
Persuasion and Behaviour Change
7
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
Before 1945
1945 - 1965
1965 - 1999
1999 - at
present
• Colonial Period
• Independence and the
“Old Order”
• “New Order”
• Decentralized era
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
Study by Equitap Group
11/6/2015
18
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19
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20
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21
The market forces domination in Indonesia
11/6/2015
22
Health Finance “Reform”
in 2004
Objective: to achieve Universal Health
Coverage by National Social Security Law
(UU SJSN)
Indonesia’s Transition to Universal Coverage
(National Social Security Law No.40/2004)
PRESIDENT
Organization and Management
Nat Soc Sec Council
Board
Board
Board
Board
Board
SS Carrier
SS
Carrier
SS
Carrier
SS
Carrier
T
A
S
P
E
N
A
S
A
B
R
I
I
N
F
O
R
M
A
L
PT.
J
A
M
S
O
S
T
E
K
PT.
PT.
T
A
S
P
E
N
A
S
A
B
R
I
SS
Carrier
PT.
A
S
K
E
S
J
A
M
S
O
S
T
E
K
5
years
Branc
Branch
Branch
Branch
A
S
K
E
S
nch
Nat
Soc
Security
Carriers
Branch
h
Branch
- Each
single existing carrier
follows its own regulation
- For profit entities
Source: MOH: Ida Bagus Indra Gotama, Donald Pardede
- Nat
Branch
Branch
Branch
Branch
Soc Security Council directs main policy
- Nat Soc Security Carriers implement the program, not for profit
24
- Synchronization of multiple schemes
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
Subsidy to Providers
(based on utilization)
Contract to PT Askes
Indonesia
PT Askes I
Hospital
Hospital
Commu
nity
Government as
Payer
Communit
y
Government
as payer
Health Insurance situation
(2005-2007)
Current Health Insurance Systems in Indonesia
JAMSOSTEK
Private Insurers
TYPES:
Social Security.
Social
HMO
Commercial Health
Insurance
COVERAGE, Millions
of People
3
5
ASKES, HMOs
P.T. ASKES
(14)
ASKESKIN
(76)
HMOs &
Comm.
Financing
(2)
Military Health
Services
Free Health Services
92
106 Million (approximately 48% of population) targeted
Source: Health PER, World Bank 2008
2
28
In 2008
2006-2007: 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.
The national health security program increased government budget
How Pay for Health Care
11/6/2015
30
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
0.2
0.1
Kakwani Index
Hospital Inpatient
Care
0
KI 2001
KI 2004
Hospital
Outpatient Care
-0.1
Non-hospital
Inpatient Care
-0.2
Non-hospital
Outpatient Care
All Public Health
Care
-0.3
-0.4
Tahun
But,
• There is still a
geographical inequity
Due to the access to
• Medical specialists
• Hospitals
Across 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
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
35
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
36
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
This hipothesis may explain why
Indonesian Insurance Coverage Status in
2007 (based on social economy survey)
looks not good.
1
2,4 2,9
6
Unisured
JAMKESMAS
ASKES
JAMSOSTEK
Other
JPKM
14,4
73,3
Source: SUSENAS 2007
38
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
Indonesia is experiencing critical shortage of doctors,
midwives and nurses
Sumber: WHR 2006
41
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
13.793
9.216
33,2
Total
*) Bappenas Study in 2005
42
Doctor Distribution in 2003-2004
43
As an illustration:
Specialists Distribution (Pediatrics)
Data: IDAI (Pediatrician Association,
2006)
Obstetric and Gynecologist
Jumlah Dokter Spesialis Obsetri dan Ginekologi
DKI
240
287
163168
Jatim
153
154
Jateng
136141
Jabar
71
Sumut
101
48
46
Bali
42
40
39 46
Sulsel
Sumsel
34
Sumbar
56
28
29
27
29
25
27
17 23
21
22
17
18
15
16
14
13
DIY
Riau
Banten
Lampung
Kaltim
Kalsel
Kepri
Kalbar
13
11
13
Jambi
NAD
20
12
11
7 11
10
12
9
8
68
Sulteng
Kalteng
Sulut
NTB
M aluku
Sultra
8
5
78
7
NTT
Papua
10
56
4
4
13
Bengkulu
Babel
Sulbar
3
3
24
1
4
Gorontalo
Papua Barat
M alut
0
50
100
150
200
2006
250
300
2008
Typical graphic description of medical specialist
distribution
350
National Plan for “Reform” in
Health Human Resource
46
RPJP (Long Term Plan)





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
47
RPJM (Medium Term Plan)
1.
2.
3.
4.
Increase the number, network and quality of health centers;
Increase the quality and the number of health personnel;
Develop health insurance system especially for the poor;
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.
48
RPJM (Medium Term Plan)
Health Resource Program 2004-2009
Objectives : 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 development
5. Improve sustainable health insurance for the poor.
49
RKP 2008 (Annual Plan)
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
11/6/2015
50
The Facts in 2008
51
Specialist distribution (KKI, 2008)
Province
DKI Jakarta
Jawa Timur
Jawa Barat
Jawa Tengah
Sumatera Utara
D.I.Jogjakarta
Sulawesi Selatan
Banten
Bali
Sumatera Selatan
Kalimantan Timur
Sulawesi Utara
Sumatera Barat
Propinsi Lainnya
Number
%
Cumulative
People served
Ratio
2.890
23,92%
23,92%
8.814.000,00
1 : 3049
1.980
16,39%
40,30%
35.843.200,00
1 : 18102
1.881
15,57%
55,87%
40.445.400,00
1 : 21502
1.231
10,19%
66,06%
32.119.400,00
1 : 26092
617
5,11%
71,17%
12.760.700,00
1 : 20681
485
4,01%
75,18%
3.343.000,00
1 : 6892
434
3,59%
78,77%
8.698.800,00
1 : 20043
352
2,91%
81,69%
9.836.100,00
1 : 27943
350
2,90%
84,58%
3.466.800,00
1 : 9905
216
1,79%
86,37%
6.976.100,00
1 : 32296
203
1,68%
88,05%
2.960.800,00
1 : 14585
173
1,43%
89,48%
2.196.700,00
1 : 12697
167
1,38%
90,86%
4.453.700,00
1 : 26668
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
03
04
05
06
07
08
For Profit
Corporation
49
52
55
60
71
85
Non-Profit
(Foundation)
530
538
538
538
539
539
27
27
28
28
28
29
606
617
621
626
638
653
Owner
Non-Profit
(NGOs)
Total
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 feefor-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
Does not meet the criteria of
Health System Reform
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
58
Note: the National Reform in
Health Finance
• Health finance reform is • The current
not will designed and
implementation of SJSN
executed
Law is more political
rhetoric, not technical.
• The SJSN Law is not yet
effective due to the lack
of Government
Regulation for
implementation
• Until 2009 there is no
GR
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
Health Finance
Health service provision
9
Riau
Island
Beng
kulu
Bali
1
1
2
2
3
7
Nort
h
Slws
S
East
Slws
1
4
2
Stewardship/regulation
Human Resources
1
Community
Empowerment
2
Health System
development
1
Total
12
5
6
33
1
1
2
2
3
Cent
ral
Slws
2
1
7
10
3
1
2
1
8
5
7
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
Act
22/99
Act
32/04
centralization
De-centralization
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
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
Act
22/99
Act
32/04
centralization
De-centralization
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
• the World Bank Institute,
experiment is
• Harvard School of Public Health, and
implemented
• Ausaid,
in 5 Provinces
develops the capacity of planning and
and 5
executing health care reform through the
districts/cities
Flagship Program in Health Care Reform
and Sustainable Financing (started in
2008)
The Flagship Program combined
training and consultation
PreparationFGD at each
Prov/
District
- Acquiring
data set
InIn-campus
campus
training
training
(II)
Off
(I)
Off
campus
campus I:
II: work
work
assignme
assignme
nt and
nt and
consultati
consultati
on
on
Post-Course
Consultation
and
Workshop
Health Sector
Reform Cycle
EThics
Politics
Evaluation
Problem identification
Implementation
Diagnostic
Political Decision
Program
Schedule
PreparationFGD at each
Prov/
District
- Acquiring
data set
Policy Development
Incampus
training
(I)
In-campus
training
(II)
Off
campus I:
work
assignme
nt
Off
campus
II: work
assignme
nt
Post-Course
Consultation
and
Workshop
78
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