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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?

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indonesian health reform in a decentralized system

Indonesian Health Reform in a decentralized system

Laksono Trisnantoro

Center for Health Service Management

Gadjah Mada University

[email protected]

preface
Preface

This paper is concerned with critical questions:

  • Is there a reform in Indonesian health sector?
  • Whether decentralization policy supports health care reform?
content
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
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
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
what is the meaning of health system features
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
t he control knobs from harvard and wbi
The “Control Knobs” from Harvard and WBI
  • Financing
  • Payment
  • Organization
  • Regulation
  • Persuasion and Behaviour Change
terminology
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
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
Reform in Health Finance
  • Historical context of Indonesian Health Finance
  • Major milestones in the 2000s
  • What happened?
historical perspective
Historical Perspective
  • Colonial Period
  • Independence and the “Old Order”
  • “New Order”
  • Decentralized era

Before 1945

1945 - 1965

1965 - 1999

1999 - at present

colonial period
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
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 199 8
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
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
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.
slide23

Health Finance“Reform”

in 2004

Objective: to achieveUniversal Health Coverageby National Social Security Law (UU SJSN)

slide24

5 years

Branch

Branch

Branch

Branch

Branch

Branch

Branch

Branch

Branch

Branch

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

PT.

J

A

M

S

O

S

T

E

K

PT.

A

S

K

E

S

PT.

T

A

S

P

E

N

PT.

A

S

A

B

R

I

nch

SS

Carrier

J

A

M

S

O

S

T

E

K

SS Carrier

A

S

K

E

S

SS

Carrier

T

A

S

P

E

N

SS Carrier

I

N

F

O

R

M

A

L

SS

Carrier

A

S

A

B

R

I

Nat

Soc Security

Carriers

  • Nat Soc Security Council directs main policy
  • Nat Soc Security Carriers implement the program, not for profit
  • Synchronization of multiple schemes
  • Each single existing carrier
  • follows its own regulation
  • - For profit entities

Source: MOH: Ida Bagus Indra Gotama, Donald Pardede

the program in 2005
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
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

Hospital

Hospital

Community

Community

Government as Payer

Government as payer

The Change in 2005

Contract to PT Askes Indonesia

Subsidy to Providers (based on utilization)

PT Askes I

health insurance situation 2005 2007
Health Insurance situation (2005-2007)

Source: Health PER, World Bank 2008

in 2008
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.

slide32
Since 2001, - the health program for the poor had improved the utilization of public hospital by the poor - Kakwani Index is improving
slide33
But,
  • There is still a geographical inequity

Due to the access to

  • Medical specialists
  • Hospitals

Across Indonesia

specialist distribution kki 2008
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
hipothesis
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
slide38
This hipothesis may explain why Indonesian Insurance Coverage Status in 2007 (based on social economy survey) looks not good.

Source: SUSENAS 2007

therefore
Therefore:
  • Health finance reform should be linked (at least) with Human Resources Reform
  • How is the condition of health care reform in human resources?
re form in human resources
Reform in Human Resources
  • This discussion focuses on specialist
as an illustration specialists distribution pediatrics
As an illustration:Specialists Distribution (Pediatrics)

Data: IDAI (Pediatrician Association, 2006)

slide45

Obstetric and Gynecologist

Typical graphic description of medical specialist distribution

slide47

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
slide48

RPJM (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; and
  • Distribute and increase the quality of primary health care.
health resource program 2004 2009
Health Resource Program 2004-2009

RPJM (Medium Term Plan)

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 profesionalismthrough 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.

rkp 2008 annual plan
RKP 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 hospitals
  • Improving availability of medical and paramedical personnel, especially in remote and less developed areas
slide53

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
the increase of for profit private hospital
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 cultur e facts in 2008 done by various cultural studies in medical specialists
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
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

link between health finance reform and human resources
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

what do we mean by health system reform bossert 2007
What Do We Mean by “Health System Reform”?(Bossert, 2007)

Does not meet the criteria of 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
  • “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
note the national reform in health finance
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.
observation 2
Observation 2
  • Reform at Provincial Level
based on dhs1 project at 7 provinces
Based on DHS1 Project at 7 Provinces
  • Riau
  • Riau Island
  • Bengkulu
  • Bali
  • North Sulawesi
  • South East Sulawesi
  • Central Sulawesi
the question
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
analysis
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
w hy there was no big r of health reform at provincial level
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

1 health reform is not well prepared at national and provincial level
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
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
3. Decentralization policy has little effect on the reform at provincial and district level

Why?

  • The Government RegulationNo. 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
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.

2000-2007: The era of confusion and “strange” situation

Will be discussed in Nossal Institute, University of Melbourne, Thursday 20th of May 2009

slide72

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
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

Moving Forward
  • Current activities in Indonesian Health Reform
activities at central level
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
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
the flagship program combined training and consultation

In-campus training (I)

In-campus training (II)

Post-Course

Consultation and Workshop

Preparation- FGD at each Prov/

District

- Acquiring data set

Off campus II: work assignment and consultation

Off campus I: work assignment and consultation

The Flagship Program combined training and consultation
health sector reform cycle

In-campus training (I)

In-campus training (II)

Preparation- FGD at each Prov/

District

- Acquiring data set

Post-Course

Consultation and Workshop

Off campus II: work assignment

Off campus I: work assignment

Health Sector Reform Cycle

EThics

Evaluation

Politics

Problem identification

Implementation

Diagnostic

Political Decision

Policy Development

Program Schedule

whether the activities will be effective to initiate and implement health reform
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.
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