Presentation on theme: "Indonesian Health Reform in a decentralized system"— Presentation transcript:
1Indonesian Health Reform in a decentralized system Laksono TrisnantoroCenter for Health Service ManagementGadjah Mada University
2Preface This paper is concerned with critical questions: Is there a reform in Indonesian health sector?Whether decentralization policy supports health care reform?
3Content Definition of Reform in Health Care Observations: Conclusion 1. Health Care Reform at national level under decentralized policy ( 1999 – 2007)2. Health Care Reform in 7 Provinces (2006),ConclusionWhat next?
4What Do We Mean by “Health System Reform”? (Bossert, 2007) Reform Definitionsustained, purposeful change to improve the efficiency, equity, and effectiveness of the health sectorWhat Do We Mean by “Health System Reform”? (Bossert, 2007)
5Health system reform:Not everything that changes, or causes change, is a health system reformPurposeful efforts to change the system to improve its performanceUsing 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 systemFlagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2
6What is the meaning of health system features? Depends on the definition:WHO: stewardship, provision, resources generation, etcKovner: the role of government in: regulation, provision of services, and financing the systemHarvard and WBI: use the “knobs” metaphora
7The “Control Knobs” from Harvard and WBI FinancingPaymentOrganizationRegulationPersuasion and Behaviour ChangeFlagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2
8Terminology 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 systemWill be used for analyzing Indonesian Health Sector through 2 observations:National levelProvincial level
9Observation 1: National Level Reform in FinanceReform in Organizing and Paying Human ResourcesReform in RegulationReform in health Promotion....Critical Question:Is there any reform inhealth finance?Human Resources?Is there any effort for linking these features of health reform?
10Reform in Health Finance Historical context of Indonesian Health FinanceMajor milestones in the 2000sWhat happened?
11Historical Perspective Colonial PeriodIndependence and the “Old Order”“New Order”Decentralized eraBefore 1945at present
12Colonial PeriodThe Dutch Indie was not administered as a welfare stateHealth services were provided for government employees, military personnel, and big company employees.Missionary hospitals and health services worked with limited coverage
131945 - 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.
141965-1998 The market economy was introduced The private sector growth rapidly, incl, for profit hospitals.There is a corporatization of medical services based on market forcesThere was no clear regulation of health market1997: Economic crisis induced the Social Safety Net incl. Health.
15currentDecentralization era since the stepdown of Suharto in 1998Direct Presidential and Governor/Major electionMore populist policies at national,provincial, and district levelPoor family has free health and hospital servicesPoor family scheme becomes political issue
16Historical FactsIndonesia is not a welfare state since the colonial eraIndonesia has market based economyIndonesian health system refers to American model using Safety Net, not the British one.Hospitals operate within market ideologyMedical Doctors (esp. specialists) operates based on the fundamental demand and supply principles.
22The market forces domination in Indonesia 4/7/2017
23Health Finance “Reform” Objective: to achieve Universal Health Coverage by National Social Security Law (UU SJSN)
24Indonesia’s Transition to Universal Coverage (National Social Security Law No.40/2004)PRESIDENTOrganization and ManagementNat Soc Sec CouncilBoardBoardBoardBoardBoardPT.JAMSOTEKPT.ASKEPT.TASPENPT.ASBRInchSSCarrierJAMSOTEKSS CarrierASKESSCarrierTASPENSSCarrierASBRISS CarrierINFORMALNatSoc SecurityCarriers5 yearsBranchBranchBranchBranchBranchBranchBranchBranchBranchNat Soc Security Council directs main policyNat Soc Security Carriers implement the program, not for profitSynchronization of multiple schemesEach single existing carrierfollows its own regulation- For profit entitiesSource: MOH: Ida Bagus Indra Gotama, Donald Pardede
25The program in 2005Ministry 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 , to US dollar for overseas scheme)There was a poor registration system for poor people at the beginning of the program
26The 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
27The Change in 2005 Contract to PT Askes Indonesia Subsidy to Providers (based on utilization)Government as PayerHospitalCommunityGovernment as payerHospitalCommunityPT Askes I
28Health Insurance situation (2005-2007) Source: Health PER, World Bank 2008
29In 2008: Many disputes between Ministry of Health and PT Askes IndonesiaA 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.
30The national health security program increased government budget How Pay for Health Care4/7/2017
31Is this an indicator of success in reforming Indonesian health finance?
32Since 2001, - the health program for the poor had improved the utilization of public hospital by the poor - Kakwani Index is improving
33But, There is still a geographical inequity Due to the access to Medical specialistsHospitalsAcross Indonesia
34Specialist distribution (KKI, 2008) Jakarta: 24% of specialists, serves around 4% community in a relatively small areaProvinces in Java: 49% of specialists, serves around 53% communityRest of Indonesia: 27% of specialists, serves around 43% community in a very large area
35Average Number of Public Hospital at a district Low economy in the communityHigh economy in the communityHigh Fiscal capacity in local government2.52Low fiscal capacity in local government0.50.31
36Average number of Private Hospital at a district Low economy in the communityHigh economy in the communityHigh Fiscal capacity in local government1.052.11Low fiscal capacity in local government0.51.91
37HipothesisHealth Finance provided by Jamkesmas will be used more by poor and near poor people in and around big citiesMost in Java IslandLeft the poor and near poor people in remote area or in the places where there is no medical service and specialists
38This hipothesis may explain why Indonesian Insurance Coverage Status in 2007 (based on social economy survey) looks not good.Source: SUSENAS 2007
39Therefore:Health finance reform should be linked (at least) with Human Resources ReformHow is the condition of health care reform in human resources?
40Reform in Human Resources This discussion focuses on specialist
41Indonesia is experiencing critical shortage of doctors, midwives and nurses Sumber: WHR 2006
42How many are really needed? Perception of 32 districts* AvailabilityGAP (%)Doctor98759339,9Specialist Doctor643053,1Dentist49729440,8Midwife4565295135,4Nurse4492329526,6Pharmacist894747,2Dietician65240438,0Public Health41531224,8Sanitarian73753028,11828254,9Epidemiologist21100,0Total13.7939.21633,2*) Bappenas Study in 2005
44As an illustration: Specialists Distribution (Pediatrics) Data: IDAI (Pediatrician Association, 2006)
45Obstetric and Gynecologist Typical graphic description of medical specialist distribution
46National Plan for “Reform” in Health Human Resource
47RPJP (Long Term Plan)Reduce disparity on health status and health careIncrease the number and improve distribution of health workersImprove access to health facilityReduce double burden of diseasesReduce misuse of narcotics and prohibited substances
48RPJM (Medium Term Plan) 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;Increase health education to the community since early age; andDistribute and increase the quality of primary health care.
49Health Resource Program 2004-2009 RPJM (Medium Term Plan)Health Resource ProgramObjectives : increase number, improve quality & distribution of health personnel, as well as improve health insurance for the poorMain Activities:1. Setup Plans for health personnel need;2. Improve skill and profesionalism through education and training3. Deploy of health personnel especially for health centers (and their networks) and hospitals;4. Carrier development5. Improve sustainable health insurance for the poor.
50RKP 2008 (Annual Plan)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 hospitalsImproving availability of medical and paramedical personnel, especially in remote and less developed areas4/7/2017
53Number of private hospitals is increasing more than government ones. Number of For-Profit Private-Hospital almost doubled in the last five yearsNumber of Non-For-Profit-Private Hospital almost remained the sameOwner030405060708For Profit Corporation495255607185Non-Profit (Foundation)530538539Non-Profit (NGOs)272829Total606617621626638653
54The increase of for-profit private hospital: Most happened in JavaIndicates the increasing role of private sector which can attract more medical specialists to JavaSome owned by medical specialistsDoctor culture is more influenced by private health service organizationWithout good payment and better work conidtion is more difficult for out of Java hospitals to attract doctors
55Market influence in specialist is increasing. 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 specialistsNo managed care culture
56Current Medical Practices: Specialists prefer to provide services in the middle and upper class using fee-for-serviceTry to set own feesNo standard income
57Link between Health Finance “Reform” and Human Resources Health finance “reform” does not consider medical doctor and specialist conditionNo 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
58What Do We Mean by “Health System Reform”? (Bossert, 2007) Does not meet the criteria of Health System ReformWhat Do We Mean by “Health System Reform”? (Bossert, 2007)Not everything that changes, or causes change, is a health system reformPurposeful 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 systemFlagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2
59Note: the National Reform in Health Finance Health finance reform is not will designed and executedThe SJSN Law is not yet effective due to the lack of Government Regulation for implementationUntil 2009 there is no GRThe current implementation of SJSN Law is more political rhetoric, not technical.
60Reform at Provincial Level Observation 2Reform at Provincial Level
61Based on DHS1 Project at 7 Provinces RiauRiau IslandBengkuluBaliNorth SulawesiSouth East SulawesiCentral Sulawesi
62The 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
63Total Reform Topics 1 2 5 9 3 7 4 6 33 12 10 8 54 Health Finance RiauRiau IslandBengkuluBaliNorth SlwsS EastSlwsCentralHealth Finance125Health service provision9374633Stewardship/regulationHuman ResourcesCommunity EmpowermentHealth System developmentTotal1210854
64Analysis All reformed-program was not designed as a big “R” reform Each reformed-program is independent each otherThe most popular topic: Health service ProvisionNo reform in public and private partnership
65Why there was no big “R” of health reform at provincial level? There was no clear definition of health care reformProvincial 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 governmentDecentralization policy is not effective to initiate reform
671. 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
682. 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 specialistsImproving 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)
693. 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 policyIt is not the right time for making reform (as it is still in a transitional phase).
70Notes: in the Decentralization Policy: The pendulum is swingingAct 22/99Act 32/04centralizationDe-centralization
712000-2007: The era of confusion and “strange” situation Change without significant changeChange 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
72After the stipulation of GR no 38 in 2007 (following Acts no 32/04): the legal basis for designing and implementing health reform gets new momentumAct 22/99Act 32/04centralizationDe-centralization
73Closing remark: What next? Is there any future of Indonesian Health Reformat National Level?at Provincial?at District?
742007 Moving Forward Pesimistic? No health reform Optimistic? There will be health reform at national, provincial and district levelCurrent activities in Indonesian Health Reform
75Activities 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
76Activities 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, andAusaid,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
77The Flagship Program combined training and consultation In-campus training (I)In-campus training (II)Off campus I: work assignment and consultationOff campus II: work assignment and consultationPreparation- FGD at each Prov/District- Acquiring data setPost-CourseConsultation and Workshop
78Health Sector Reform Cycle EThicsEvaluationPoliticsProblem identificationImplementationDiagnosticPolitical DecisionPolicy DevelopmentProgram ScheduleIn-campus training (I)In-campus training (II)Off campus I: work assignmentOff campus II: work assignmentPreparation- FGD at each Prov/District- Acquiring data setPost-CourseConsultation and Workshop
79Whether the activities will be effective to initiate and implement health reform? The SupportsThere are sufficient experiences during the transition period of decentralization ( )The legal basis is availableThe support of Ministry of Home Affair for health reform based in decentralization policy is big.The knowledge of health reform is supported by international expertsBut,The success depends on the leadership of Ministry of Health and Provincial/District/ City Health Leaders.