Public fund for healthy and productive living

Asia Pacific Consortium for Public Health Meeting in Bandung Indonesia 22‐23 October 2015

Should the poor get freePublic fund for healthy and productive living

Should the poor get free health insurance while they smoke?

Wahyu Aning Tias & Mubasysyir HasanbasriGadjah Mada Universityj y

Contents• Why we write this• Why we write this

paper• Our content analysisy• Findings• Conclusion• Policy implication• Final notes

Asia Pacific Consortium for Public Health Meeting in Bandung Indonesia 22‐23 October 2015

Why we write this paper?

Public health problems: what?• When individuals have no 

control of those making them

The poor and the public health: why do social insurance serve as important public health toolcontrol of those making them 

ill and suffering• When there is epidemic 

causing social and economic

important public health tool• Poor bring diseases in 

community while they do not have access to health carecausing social and economic 

crisishave access to health care(cost). 

Smoking as public health About this paperSmoking as public health problems: value of public fund in health care cost.• When smoking related lung 

About this paper• This paper compare views on 

the policy of publicly paid health insurance for the poor g g

cancer absorb high cost of public fund.

pwho smoke.

Method: content analysis

Asia Pacific Consortium for Public Health Meeting in Bandung Indonesia 22‐23 October 2015

Method: content analysis

• National and local online news Kompas, Tempo, Detik, Republika, Vivanews , Liputan 6, okezone, Antara Bengkulu, Tribun Jabar, Suara Merdeka

• Selection criteria: media containing these indonesian words of “the poor”, “smoker”, “smoking”, “health insurance”, “universal precaution”, from 2013 to 2015

• Study focuses on 65 news, columns, and public opinions.p p

Four policy positions and their supporting stakeholders

Universal coverage with no discriminatary exclusion:

STobacco company:

Bagong Suyanto, DjokoSungkono, Abhisam

Demosa, Zulvan Kurniawan(Komisi Penyelamat Kretek)

p yFahmi Idris (BPJS), Zainal

Abidin (IDI)

Individual responsibility or P blic f nd ins rance forIndividual responsibility or taking private health

insurance:Nafsiah Mboi, Ahok, Ali

Gh f M kti T l Ab di

Public fund insurance for quit smoking:

Public fund for healthy and productive living

Ghufron Mukti, Tulus Abadi, Fauzi Bowo

p gWe support this

Four policy positions and their statements about them

Universal coverage with no discriminatary exclusion:

Tobacco company:“Tobacco products contribute more than 95 percent of the

“Poor smokers should not be punished, don’t treat the poor

with penalties” (Bagong Suyanto, poverty observer)

total excise Rp52,6 trillion earned by the country in the first semester 2013” Fachmi

Idris (Director of BPJS Kesehatan)Kesehatan)

Public fund insurance for quit smoking:

Individual responsibility or taking private health insurance:

“Is it fair that this man who willingly smokes 3 packs of cigarette a day

gets free treatment?” (Nafsiah Mboi,

smoking:“Now this paradigm must be changed.

Not how to provide care for patient, but how people do not become ill. So, no longer alleviate health financing, but rather how to encourage themgets free treatment? (Nafsiah Mboi,

Former Health Minister)but rather how to encourage them

healthier” (Jusuf Kalla, Vice President)

Scenario 1 Scenario 2 Scenario 3 Scenario “4”

Typopoor

Smoking Smoking Smoking Publicly paid insurance

ology or w

ho s

Lung cancerLung cancer Lung cancer Smoking 

cessation program

of positsm

oke insur

Publicly paid insurance Private insurance 

premium

Insurance premium paid by tobacco industry Quit smokinng

ion regand pu

rance

Health careHealth care Health care Healthy &

productive

gardingublicly

DieDie Die

g the paid

Strength and weakness of the four options

Option 1 Option 2 Option 3 Option 4

Waste of public  There is no private parties are willing Make poor people 

funds Should serve as a challenge for smokers to 

change, if they 

parties are willing to bear the cost healthy

Better used for something else

g , ywant to use public 

fundsSmoking is 

considered a luxury item that must be accounted for

Make poor people more productive

personally

To conclude: there are no good reasons to support freeTo conclude: there are no good reasons to support free insurance for the poor who smoke…• The need of prioritization in using public funds inThe need of prioritization in using public funds in country with low productivity and limited resources. 

• Potential better health outcome is more important: noPotential better health outcome is more important: no necessary escalating cost of care for unproductive living

• Promoting policy on individual responsibility on self‐Promoting policy on individual responsibility on selfinflicted illness and collective responsibility on public health problemshealth problems.

Final notesFinal notesWe argue that public money should be used in the way that promotes our health. If smoking status can not be p gthe reason for the revocation of rights of smokers for health insurance, this paper supports that health insurance is not seen as just a means to obtain health services. However, it should be used as a tool to fight self‐inflicted illness At least we suggest that BPJS provideinflicted illness. At least we suggest that BPJS provide smoking cessation program for those who smoke.

References Tandilittin H & Luetge C (2013) Civil Society and Tobacco Control in Indonesia:Tandilittin, H., & Luetge, C. (2013). Civil Society and Tobacco Control in Indonesia: The Last Resort. Open Ethics Journal, 7, 11‐18.Sharkey, K., & Gillam, L. (2010). Should patients with self‐inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate. Journal of medical ethics, 36(11), 661‐665.Persaud, R. (1995). Smokers' rights to health care. Journal of medical ethics,21(5),Persaud, R. (1995). Smokers  rights to health care. Journal of medical ethics,21(5), 281‐287.Björk, J., Lynøe, N., & Juth, N. (2015). Are smokers less deserving of expensive t t t? A d i d t ll d t i l th t b d ffi i l l BMCtreatment? A randomised controlled trial that goes beyond official values. BMC medical ethics, 16(1), 28.Veatch, R. M., & Steinfels, P. (1974). Case Studies in Bioethics: Who Should Pay for , , , ( ) ySmokers' Medical Care?. Hastings Center Report, 8‐10.

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