PRIVATE SECTOR HEALTH CARE IN INDONESIA - Health Systems ...

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Cahya Kawaluyan Hospital has adapted the government DRG system but modified it to suit their needs.Various hospital packages including hospital service tariffs are readily available for patients to haveinformed decisions. It also helps insurance companies in their premium setting based on realisticprojections.Cahya Kawaluyan Hospital accepts Jamkesmas and Gakin patients. Per regulation, they also reserve 25-30percent of their beds for charity cases. Most of their patient load occupies the Class III section of the hospital.Twenty-five percent of the hospital’s business is from private insurers. Less than 10 percent of their patientsare Jamkesmas and Gakin combined. Based on their experience, administration of the Jamkesmas is faster asthere is a hospital verifier who adjudicates the claim and readily approves the amount to be paid. Jamkesmas,however, is less preferred than Gakin because Jamkesmas often approves only 30 percent of the claim. Thehospital cannot charge the remaining 70 percent to the patient. The experience with Gakin is thatreimbursement of benefit takes four to five months upon receipt of claim by the District Health Office. Gakinis still preferred over Jamkesmas because the hospital is only required to cover on its account 20 percent of thecharges and bills the balance to the District Health Office. The patient is requested to pay the excess beforeresorting to the District Health Office. It is unclear on whether or not the District Health Office pays thehospital regardless of how much is claimed in excess of the 20 percent of total charges incurred by the patient.There was information received that there are several Consumer Groups in West Java but none was focusedon health at this time. Yayasan Bina Konsumen (Indonesia) is one group focusing on agrarian issues. Thegroup has an extensive network all over the country. Although focus was not on health, certain cases onhealth were elevated to the group’s Office of the Chairman. Clearly, it can be surmised that there is lack ofcommunication between patient and providers in terms of health outcomes and informed decisions. Afacilitator role of the Consumer Group may help mediate as patients usually are afraid to complain or seekfurther information. Bina Kosumen has a national directory of the various offices located nationwide. Itdistributes IEC materials on health and other issues to its constituents.2.20 General Observations• Lack of government stewardship over the whole health system.Currently, the government seems its main role in running public sector facilities. Theprivate health sector still remains an after-thought. The District Health Offices only see theirrole as licensing private facilities and they only take an interest if there is a case of malpracticein the private sector. All of the data points to the fact that the private sector delivery isdominate. For example, only six percent of births in West Java occur in public facilities, so ifmaternal health is a priority for the province, then working with the private sector is key tosuccess.• Understanding the private sector requires understanding dual practice.Although the private sector is dominate, it is not a “pure” private sector since most of thephysicians and midwives practicing in the private sector are, in fact, governmentemployees who work in the public sector in the morning and private sector in theafternoon. Almost 90 percent of the midwives in West Java are in dual practice and there arevery few in “pure” private practice; generally the pure private providers are retired publicemployees. The most striking examples of dual practice were in the top hospitals in Bandung,where only a small percentage of the doctors in the hospital were employed by the hospital; thevast majority are “guest” doctors who work in the public sector.92
Understanding the interaction between the public and private sector is key to regulatingthe private sector. There is also an inherent conflict of interest, since health professionals havean interest in ensuring that quality of care in the public sector is low in order to attract patientsto their private practice.• Health insurance exists in name only; Askes, Jamkesmas and Gakin are publicprograms that do not really use insurance principles.Jamkesmas is supposed to provide a comprehensive benefit package to the poor for amere Rp 5,000 per month. This small amount of money can only, in fact, pay for a veryrestricted benefit package if the insurance program had to pay the true costs/prices for theprovision of care. There is little attention to actual insurance principles such as estimatedutilization to set the premiums. There is also little attention to demand management such asdeductibles and co-payments. If these programs are to function as insurance, then they need tobased on more actuarially sound principles.• Professional and hospital associations are not playing a sufficient role in assuringthe quality standard services.• Civil society organizations particularly faith-based groups, such asMuhammadiyah and catholic Perdhaki) could play a much greater role in publichealth.Faith-based organizations have an extensive network of health care providers. They alsohave great social assets because of community involvement. They are an ideal venue forDirectly Observed Treatment Short-course (DOTS) for tuberculosis, since this depends oncommunity involvement. Given that the current system depends almost exclusively on thePuskesmas and a few patients want to go to the Puskesmas on a regular basis, there is widescope for greater involvement of faith-based organizations in implementing DOTS and otherpriority public health interventions including HIV/AIDS and maternal and child health.2.21 Recommendations2.21.1 Assist Districts and Provinces to use the payment methods of the new social insuranceschemes (Jamkesmas + Gakin) to improve maternal and child healthCurrently, the government is not harnessing the power of these new social insurance schemes to driveimprovements in the quality of care for services particularly MCH services. Unlike the insuranceschemes of the past like Askes which only paid for services in the public sector, these new schemes payboth public and private providers. However, the current reimbursement rates are much lower than theprivate sector prices and this creates a strong dis-incentive to not participate.In the case of maternal health services, the payment rates are below market rates, but not so far belowmarket rates that reform is infeasible. With small increases in the payment rates, they could create athriving market for maternal health services that could drive significant improvements in the quality ofcare in the public and private sector and also align incentives with clinical practice. As discussed earlier,a good example is the current payment for post-partum hemorrhage, one of the major causes of maternaldeath. Currently, once a midwife refers the case to the hospital, she no longer receives payment. Thisproblem could easily be solved by created a separate code for post-partum hemorrhage. This could allow93
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PRIVATE SECTOR HEALTHCARE IN INDONE
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PRIVATE SECTOR HEALTH CAREIN INDONE
Page 8 and 9:
7. Rationalizing Use of Medications
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ABBREVIATIONSANCAskesAskeskinAusAID
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THEUSAIDVATWHOTotal health expendit
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EXECUTIVE SUMMARYAs documented in I
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By using their power to select whic
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higher reimbursement for complex de
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2. BACKGROUND2.1 GENERAL BACKGROUND
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While decentralization of the healt
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FIGURE 1: TOTAL EXPENDITURES ON HEA
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poor, which only allows use of publ
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Lack of overall investment in healt
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• Pharmacists and drugsellers - A
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4.2 ASSESSMENT APPROACHData collect
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practice, however, limited resource
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Dinas to the hospital detailing the
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Unlike Muhammadiyah and NU faciliti
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TABLE 3: POPULATION COVERAGE BY HEA
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customary fees. At the same time, i
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7. RATIONALIZING USE OFMEDICATIONS7
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too few medicines to meet the publi
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8. PHARMACISTS ANDDRUGSELLERS AS PA
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district provides TB drugs to priva
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9. ROLE OF PROFESSIONALASSOCIATIONS
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IMA is involved in any allegations
Page 63 and 64: 10. CONCLUSIONS ANDRECOMMENDATIONSI
Page 65: If Indonesia is to achieve its prio
Page 68 and 69: • Supporting the mapping of all f
Page 71 and 72: ANNEX A: ASSESSMENT GUIDEIndonesia
Page 73 and 74: Key Informants at Provincial LevelK
Page 75: Key InformantsoooIBI, and memberrep
Page 78 and 79: Assessment Question Approach/Backgr
Page 80 and 81: Indicator Number Data Source and No
Page 82 and 83: 1.3.4 DinKes Experience with Privat
Page 84 and 85: The team interviewed a manager 16 a
Page 86 and 87: They have used many different healt
Page 88 and 89: In Yogyakarta Province, there are 1
Page 90 and 91: graduates to work immediately in 24
Page 92 and 93: Muhammadiyah is a 226 bed hospital
Page 94 and 95: Dinas Yogyakarta31. Mardiningsih, S
Page 96 and 97: 2.1 Provincial InformationThe popul
Page 98 and 99: How can services provided at privat
Page 100 and 101: The Provincial Health Office meets
Page 102 and 103: from multiple sources: 40 percent f
Page 104 and 105: 2.9 Licensing and Oversight of Phar
Page 106 and 107: As per IMA Propinsi, they meet with
Page 108 and 109: It was mentioned that the budget fo
Page 110 and 111: • Private midwives are willing to
Page 112 and 113: etween PKBI and the District Health
Page 116 and 117: the midwife to charge a slightly hi
Page 118 and 119: Involving Physicians in DOTS. A sig
Page 120 and 121: Ikatan Bidan Indonesia (IBI) West J
Page 122 and 123: Indicator DKI West Jakarta Data Sou
Page 124 and 125: visited an average of over 60 perce
Page 126 and 127: 3.9 Potential role of professional
Page 128 and 129: members who pay membership fees. Th
Page 130 and 131: emainder paying out of pocket. Reve
Page 132 and 133: 3.20 Indonesian Pharmacists Associa
Page 134 and 135: OtherApotek Gitamara, Jl. Kemanggis
Page 136 and 137: 13. Government of Indonesia, World
Page 138: 41. Thrabany, Hasbullah, et al. 200
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