Thesis

Moving toward universal health coverage of Indonesia: where is the position?

Ahmad FuadyHealth Economics, Policy and Law

Erasmus University RotterdamThe Netherlands

2013

Introduction

• The WHO Director General, Margaret Chan: universal health coverage is “the single most powerful concept that public health has to offer”.

• The rights to health. The State must secure citizen’s rights to access health care services and any underlying determinants of health. Universal health coverage is one of attempts.

• Indonesia, accelerated health care reform since 1998.

• Does the health care reform comply with the rationale of providing the right to the highest attainable standard of health?

• Has the health care reform toward universal health coverage in Indonesia improved the fulfillment of the right to the highest attainable standard of health?

Theoretical framework

• Health is a fundamental human right.

• Article 12.1 of the International Covenant on Economic, Social and Cultural Rights: the rights to the enjoyment of the highest attainable standard of health.

• International and local legal instruments.

from economic and policy perspectives

Four interrelated and essential elements:1.Availability2.Accessibility

a. Non discriminationb. Physical accessibilityc. Economic accessibilityd. Information accessibility

3.Acceptability4.Quality

The role of policy actors in fulfilling the right to health

• The national and international policy makers, together with courts, non-governmental organisations, and other stakeholders : adopting and applying features of the right into policy actions.

• Legal recognition, followed by policy actions.

• The interaction among actors : favorable or unfavorable factor?

• Different patterns of interaction:

– Thailand, health system reform was part of large design to restructure the relationship between the State and civil society and democratization process.

– Philippines, health system reform was considered as business-as-usual and was not a monumental process.

– Indonesia?

Method

• Literature review of studies with time framework of 1998 to 2013.

• Sources :

– Indonesian databases.

– Scientific databases (Google Scholar, PubMed, and WebScience).

– International databases WHO, World Bank and the Joint Learning Network (JLN) for Universal Health Coverage.

– local and/or international case law.

• Comparing to neighboring countries: Thailand and Philippines.

• Analysis using guideline assessment of four important elements, adapted from Hunt (2006).

Indonesian health care reform: a brief history

Indonesian health care system

• A mixed public-private health care provision

– Public providers, dominate the services in rural area and primary to secondary-level health care services.

• Primary health centers (Puskesmas), operate in sub-district and village level.

• Supported Puskesmas (Pustu) for remote area.

• Public district-level hospitals.

– Private providers, concentrated in the urban area and are mostly for secondary and tertiary-level health care services.

• Poor referral system, in the implementation.

Indonesian health care reform: a brief history

Indonesian health care reform: a brief history

The policy actors and developed legal and policy instruments

• Central government, hierarchical control and authority to develop regulation

• Pressure and cause groups

Decentralization:a confounding issue

• Decentralization Act (2001): larger authority of local governments to manage and regulate their health and financial system.

• Much depends on temporary local elite interests rather than establishing sustainable system. For instance, case of Jembrana and Tabanan.

• The change of the governor and regent/mayor elections mode health insurance becomes one of the most popular issues.

• Some manage their local resources effectively while others do not (‘chaos’). The most recent case: ‘Jakarta Health Card’, promoted in 2012.

• Some problems in availability and quality of health care professionals and facilities.

WHERE IS THE POSITION?Impacts of health care reform on right to the highest attainable standard of health

Three dimensions of coverage

Increasing coverage of 41.7% (2005) to 63.2% (2012)

Comprehensive benefit package (2012)

No cost sharing (Jamkesmas)

Three dimensions of coverage

• Less coverage, compared to neighboring countries

• A low coverage to formal workers group

3%

Availability

Availability of (functioning) health care facilities.

• Increasing number of facilities, but remains insufficient.

• Puskesmas with inpatient service has grown mainly in the urban area while the remainings have shown a significant growth in the rural area. Puskesmas ‘without doctors’.

Pustu poor quality of care, do not operate regularly, and lack of drugs and diagnostic kits.

Availability

Availability of trained health care professionals and their salaries.

• Problem of data validity and reliability

• Lack of health care professionals

• Problem of deployment policy and unclear decentralization policy

• Without domestically competitive salary

Availability

Improving drugs availability in public health facilities

• 2010, essential medicine in the majority of public health services was below 80% while only 15% of health facilities had 80% of essential medicines.

• 2011, about 90.4% essential medicine has already been available more than 80% from required medicines throughout the public health facilities.

• Classical problem: discrepancy between urban and rural area.

Accessibility

• Physical constraints along with financial constraints because of transportation cost poor utilization of those existing public health facilities despite the free access.

• Access gap between rich and poor has remained high.

• Problems:

– Subsidy distribution is more pro-rich rather than pro-poor

– Leakage

– Considerable illegal fees, buying the card

– Illegal up-front payments

Acceptability

• …have to be respectful of medical ethics including the requirement of informed consent and confidentiality of personal health information, as well as culturally appropriate.

• Ethical violation increases. From 182 reported cases, MKDKI has decided that 29 (15.9%) doctors have been proven guilty, and their licenses have been revoked.

• Legal case of Mrs Darmoko vs Pondok Indah hospital unclear informed consent and incomplete information.

• Poor confidentiality in HIV/AIDS counseling work in Papua and ignorance of the local culture in training modules development.

Quality

• Health providers in outer Java-Bali have worse quality than those practicing in Java-Bali because of limited facilities.

• Private-solo practices worsen the quality of public health care service in a rural area.

The quality in terms of structural indicators has improved.

Conclusion

• Social movement has an important role.

• Decentralization policy has created both positive and negative impact. Political circumstances, elite interests, and local resources are the main determinants.

• The position:

Recommendation

General recommendation

• Examining local experiences and identifying lesson learned to improve the national program.

• Identifying local governments with good, moderate, and poor capacities. Those local governments with moderate and poor capacities should be supervised to manage their resources appropriately.

• Setting national target for local government.

Recommendation

Improving coverage

• No significant problem in the benefit package and proportion of cost sharing.

• Attracting employer and informal sectors to involve in national health insurance, particularly Jamsostek scheme. The low monthly premium of Rp 40,000-50,000 (USD 4.3-5.4) may be attractive

• Improving promotion and persuasion by both of the government and PT Askes. Ensuring that all eligible people enroll to the program.

Recommendation

Increasing availability

• Improving health care professional database. The MoH, KKI, and IMA have to develop a better method in registering and reviewing the health care professional.

• Mandatory placement for fresh graduated doctors in rural and remote area. Incentives?

– Sending health care professionals in teams.

– Better payment and facilities.

– Better local infrastructure, need further coordination..

• Setting national design and dividing the clear authorities between central and local government to build health care facilities.

• Advocating central government and the House of Representative to increase the proportion of the health budget .

Recommendation

Widening accessibility

• Preventing the leakages through active validation. Resource transfer from central to local government should be based on verified enrolment.

• Eliminating illegal upfront payment and rejection.

– The MoH, PHO and DHO : developing a mechanism of complaints, signing MoU with hospitals, and constructing adequate penalties for hospitals violating the memorandum.

– Hospital association: maintaining hospital performance and conducting equal supervision.

– Community: encouraging the well-implemented program and monitoring any potential violation in the grounds.

Recommendation

Making it more acceptable

• Introducing specific disease, such as HIV/AIDS and tuberculosis, into whole health program to reduce discrimination.

• Regarding to respect of medical ethics, the MKDKI and the IMA should develop preventive measures instead of merely accommodate people’s complaints of medical services. It would be overlapping with concerns to improve the quality of services explained further.

Recommendation

Improving quality

• Licensing and periodical review.

– The IMA: continuing national examination for physicians.

– The IBI and the PPNI: starting national exam for nurses and midwifes.

– The government: limiting the recruitment for new civil workers to those who have been certified and reviewed periodically.

• Moratorium of new development of health and medical schools

– The DGHE: accrediting all health and medical schools and strengthen the regulation, such as limiting enrolment for those poor-accredited schools or programs.

– The KKI, the IBI, and the PPNI: establishing competency and education standards.

Recommendation

Improving quality

• Piloting the project of performance-based payments in an urban setting.

• Considering the contracting system which focus on either primary care services or specific diseases.

– The MoH: developing good, measurable indicators and constructing the monitoring and evaluation systems.

Thank You