Indonesian Health Reform in a decentralized system

1. Indonesian Health Reform in a decentralized system Laksono Trisnantoro Center for Health Service Management Gadjah Mada University trisnantoro@yahoo.com

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. 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

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. 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. Study by Equitap Group

22. The market forces domination in Indonesia

23. Health Finance“Reform” in 2004 Objective: to achieveUniversal Health Coverageby National Social Security Law (UU SJSN)

24. 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

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. 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

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

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. The national health security program increased government budget How Pay for Health Care

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. Average Number of Public Hospital at a district

36. Average number of Private Hospital at a district

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. 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. Reform in Human Resources • This discussion focuses on specialist

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

42. How many are really needed?  Perception of 32 districts* *) Bappenas Study in 2005

43. Doctor Distribution in 2003-2004

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

45. Obstetric and Gynecologist Typical graphic description of medical specialist distribution

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

47. 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

48. 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.

49. 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.

50. 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