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Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University

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Presentation on theme: "Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University"— Presentation transcript:

1 Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University

2 Preface This paper is concerned with critical questions: Is there a reform in Indonesian health sector? Whether decentralization policy supports health care reform?

3 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?

4 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 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:

6 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 7 The “Control Knobs” from Harvard and WBI Financing Payment Organization Regulation Persuasion and Behaviour Change

8 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

9 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?

10 Reform in Health Finance Historical context of Indonesian Health Finance Major milestones in the 2000s What happened?

11 Historical Perspective Colonial Period Independence and the “Old Order” “New Order” Decentralized era Before 1945 1945 - 1965 1965 - 1999 1999 - at present

12 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

13 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.

14 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.

15 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

16 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.

17 Indonesian health finance situation in 2001

18 12/17/201418 Study by Equitap Group

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22 12/17/201422 The market forces domination in Indonesia

23 Health Finance “Reform” in 2004 Objective: to achieve Universal Health Coverage by National Social Security Law (UU SJSN)

24 24 Organization and Management - Each single existing carrier follows its own regulation - For profit entities PT. A S K E S Branch PT. T A S P E N Branch PT. A S A B R I Branch PT. J A M S O S T E K Branc h PRESIDENT 5 years nch SS Carrier A S K E S Branch SS Carrier T A S P E N Branch SS Carrier A S A B R I Branch SS Carrier J A M S O S T E K Branch Nat Soc Sec Council SS Carrier I N F O R M A L Board Nat Soc Security Carriers Board - 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 (National Social Security Law No.40/2004) Branch Source: MOH: Ida Bagus Indra Gotama, Donald Pardede

25 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

26 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

27 The Change in 2005 Government as Payer Hospital Commu nity Government as payer Hospital Communit y PT Askes I Subsidy to Providers (based on utilization) Contract to PT Askes Indonesia

28 28 Source: Health PER, World Bank 2008 Health Insurance situation (2005-2007)

29 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.

30 12/17/201430 How Pay for Health Care The national health security program increased government budget

31 Is this an indicator of success in reforming Indonesian health finance?

32 Since 2001, - the health program for the poor had improved the utilization of public hospital by the poor - Kakwani Index is improving

33 But, There is still a geographical inequity Due to the access to Medical specialists Hospitals Across Indonesia

34 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 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 2.52 Low fiscal capacity in local government 0.50.31

36 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 1.052.11 Low fiscal capacity in local government 0.51.91

37 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 38 This hipothesis may explain why Indonesian Insurance Coverage Status in 2007 (based on social economy survey) looks not good. Source: SUSENAS 2007

39 Therefore: Health finance reform should be linked (at least) with Human Resources Reform How is the condition of health care reform in human resources?

40 Re form in Human Resources This discussion focuses on specialist

41 41 Indonesia is experiencing critical shortage of doctors, midwives and nurses Sumber: WHR 2006

42 42 How many are really needed?  Perception of 32 districts* NeedAvailabilityGAP (%) Doctor 98759339,9 Specialist Doctor 643053,1 Dentist 49729440,8 Midwife 4565295135,4 Nurse 4492329526,6 Pharmacist 894747,2 Dietician 65240438,0 Public Health 41531224,8 Sanitarian 73753028,1 Public Health 18282 54,9 Epidemiologist 210 100,0 Total 13.7939.216 33,2 *) Bappenas Study in 2005

43 43 Doctor Distribution in 2003-2004

44 As an illustration: Specialists Distribution (Pediatrics) Data: IDAI (Pediatrician Association, 2006)

45 Typical graphic description of medical specialist distribution Obstetric and Gynecologist

46 46 National Plan for “Reform” in Health Human Resource

47 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 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 49 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. RPJM (Medium Term Plan)

50 12/17/201450 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 51 The Facts in 2008

52 Specialist distribution (KKI, 2008) ProvinceNumber%CumulativePeople servedRatio DKI Jakarta 2.89023,92% 8.814.000,001 : 3049 Jawa Timur 1.98016,39%40,30% 35.843.200,001 : 18102 Jawa Barat 1.88115,57%55,87% 40.445.400,001 : 21502 Jawa Tengah 1.23110,19%66,06% 32.119.400,001 : 26092 Sumatera Utara 6175,11%71,17% 12.760.700,001 : 20681 D.I.Jogjakarta 4854,01%75,18% 3.343.000,001 : 6892 Sulawesi Selatan 4343,59%78,77% 8.698.800,001 : 20043 Banten 3522,91%81,69% 9.836.100,001 : 27943 Bali 3502,90%84,58% 3.466.800,001 : 9905 Sumatera Selatan 2161,79%86,37% 6.976.100,001 : 32296 Kalimantan Timur 2031,68%88,05% 2.960.800,001 : 14585 Sulawesi Utara 1731,43%89,48% 2.196.700,001 : 12697 Sumatera Barat 1671,38%90,86% 4.453.700,001 : 26668 Propinsi Lainnya 1.1049,14%100,00% 52.990.200,001 : 47998 12083100,00% 224.904.900,001 : 18613

53 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 030405060708 For Profit Corporation 49 52 55 60 71 85 Non-Profit (Foundation) 530 538 539 Non-Profit (NGOs) 27 28 29 Total 606 617 621 626 638 653

54 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

55 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

56 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

57 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 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

59 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.

60 Observation 2 Reform at Provincial Level

61 Based on DHS1 Project at 7 Provinces Riau Riau Island Bengkulu Bali North Sulawesi South East Sulawesi Central Sulawesi

62 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

63 Reform Topics RiauRiau Island Beng kulu BaliNort h Slws S East Slws Cent ral Slws Health Finance 11215 Health service provision 923742633 Stewardship/regulation 11 Human Resources 123 Community Empowerment 22127 Health System development 12115 Total 12371085954

64 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

65 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

66 Conclusion

67 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

68 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)

69 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).

70 Notes: in the Decentralization Policy: The pendulum is swinging centralization De-centralization Act 22/99 Act 32/04

71 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

72 centralization De-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

73 Closing remark: What next? Is there any future of Indonesian Health Reform at National Level? at Provincial? at District?

74 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

75 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

76 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

77 The Flagship Program combined training and consultation In- campus training (I) In-campus training (II) Off campus I: work assignme nt and consultati on Off campus II: work assignme nt and consultati on Preparation- FGD at each Prov/ District - Acquiring data set Post-Course Consultation and Workshop

78 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 assignme nt Off campus II: work assignme nt Preparation- FGD at each Prov/ District - Acquiring data set Post-Course Consultation and Workshop

79 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.

80 Thank-you

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