Jakarta Globe – IRIN, January 14, 2014
 |
| Malaria continues to remain a serious health concern in Indonesia (IRIN Photo) |
The rollout
of universal health coverage in Indonesia has been greeted with public
enthusiasm, but health experts warn that inadequate funding could undermine the
quality of care.
The
government aims to have every Indonesian covered by health insurance by 2019
under a new scheme called Jaminan Kesehatan Nasional (JKN), with nearly 20
trillion rupiah (US$1.6 billion) allocated to cover premiums for the poor in
2014.
Around 65
percent of the country’s 240 million people, including 86 million categorized
as poor, are covered by some form of regional or national health program and
are automatically entitled to comprehensive coverage under the JKN, which has
replaced the previous health schemes.
“This is a
great program. It should mean that people will no longer be denied treatment
because they don’t have money,” said Wawan Mulyawan, a neurosurgeon and medical
insurance consultant who works at a private hospital in Jakarta, the capital.
The World
Bank estimates the insurance scheme will
cost $13-$16 billion each year once fully implemented, while Jakarta has said
it will double its spending on health to 16 trillion rupiah ($1.64 billion) in
2014 to cover the poor and “near poor”.
Challenges
and concerns
The rollout
began on 1 January 2014, but implementation has not gone smoothly, with many
workers at referral hospitals poorly informed about the program’s details.
“Hospitals
are afraid they will lose money by not being reimbursed like in the past, while
health workers are afraid they will make mistakes,” Mulyawan conceded. “As a
result, quality of treatment has been compromised because it doesn’t follow
clinical pathways set by the hospitals.”
Under the
previous national insurance for the poor, hospitals, both state and private,
complained the government delayed payments for more than a year, and some
hospitals refused patients unless they made partial payment in advance.
However, the government says it has learned from its mistakes.
“We are
strengthening the primary care system across the country by improving
infrastructure and adding more health workers,” Deputy Health Minister Ali
Ghufran told IRIN.
Indonesia
has 25 health workers per 10,000 people, which meets the World Health Organization’s
minimum of 23, but they tend to be concentrated in urban centers, leaving parts
of the archipelago without an adequate number of health personnel.
More than
1,700 state and private hospitals are participating in JKN, with over 9,000
state-funded community clinics, known as Puskesmas, serving as the backbone of
primary care, Ghufran said.
The
government plans to build 150 new hospitals in 2014, and says all hospitals
will be required to serve JKN patients by 2019.
People’s
welfare minister Agung Laksono said the challenges facing the health system in
implementing universal coverage include a poorly functioning referral system,
poor quality services at primary and referral levels, and high treatment costs.
Patient
safety is also a concern, as not all hospitals are accredited, he said. Only
around 65 percent of Indonesia’s hospitals are accredited, with the majority of
them being state-run.
Problematic
payments
“Indonesia
is undergoing a transition in disease epidemiology, marked by the still high
prevalence of communicable diseases, and yet at the same time degenerative and
non-communicable diseases such as cardiovascular diseases and cancer are on the
increase,” he said.
The rate of
mortality from non-communicable diseases rose from 41.7 percent in 1995 to 59.5
percent in 2007 — an increase of 42 percent — the latest figure available from
the Health Ministry.
According
to the Health Ministry’s Basic Health Survey, the prevalence of diabetes was
2.1 percent in 2013, compared to 1.1 percent in 2007. Hypertension was
prevalent among 31.7 percent of the population, up from 25.8 percent in 2007.
A report released in 2013 by Novo Nordisk, a global healthcare company, says 7.6 million
people in Indonesia are living with diabetes, with millions more are at risk.
By 2030,
the number of people with diabetes in
Indonesia is projected to top 11.8 million, a 6 percent annual growth that by
far exceeds the country’s overall population growth.
Muhammad
Imran, whose elderly father was receiving treatment for diabetes and high blood
pressure as an outpatient under a previous insurance plan, said the Central
Army Hospital had been inundated with patients referred by primary healthcare
clinics.
“My father
had to wait for hours to be seen by a doctor,” he said. “After that we had to
queue again for hours at the pharmacy. This is ridiculous.”
While the
government pays 19,225 Indonesian rupiah per month for treatment in a
third-class hospital ward for each poor citizen, individuals can also purchase
one of three insurance options: 25,500 rupiah per month for third-class
treatment, 42,500 rupiah for second-class and 59,000 rupiah for first-class.
The
110,000-member Indonesian Medical Association says the amount the government is
paying for the poor is too low, and has warned that this could compromise the
quality of healthcare.
What about
the doctors?
“There will
inevitably be problems. Doctors will not be adequately paid and they won’t be
able to provide the maximum quality of care,” said association chairman Zainal
Abidin.
Indonesian
President Susilo Bambang Yudhoyono said he was aware of the potential problem,
and the government would issue an additional regulation providing financial
incentives for doctors and other medical workers. The premium paid for the poor
would also gradually be increased.
“An
evaluation will be conducted after three months, and [again after] six months,
to ensure that its implementation will be better in the future,” the president
said.
The JKN
specifies that government doctors and dentists working at public clinics
(Pukesmas) be paid according to “capitation”, meaning that healthcare providers
are paid a set amount for each enrolled person assigned to them during a period
of time (usually a month), whether or not that person seeks treatment.
Under the
program, doctors and health facilities at the primary care level, both public
and private, will have to treat all persons assigned to them, regardless of
whether patients come to them for treatment or not.
But Abidin
said the amount a primary care provider or family doctor receives for each
enrolled person assigned to them — 8,000 rupiah, about 68 US cents — is too
low.
For
example, public and private clinics or family doctors will receive 40 million
rupiah ($3,328) for 5,000 enrolled citizens in advance per month, regardless of
how much they spend on treating those patients, and whether or not they seek
care.
According
to a 2013 paper by Australia’s Nossal Institute for Global Health, there were
potential inequalities in implementing universal health coverage in Indonesia.
Experience
with the previous national health scheme, Jamkesmas, had shown that despite
nominal comprehensive coverage for the poor, patients had difficulty accessing
certain services, and sometimes had to pay for medicines not available at the
facility, particularly in rural areas.
“Poor
quality and unequal distribution of government health facilities have been
issues with which the ministry of health has been struggling with for some
decades, without much progress. Significant further government investment in
health infrastructure and workforce will be needed,” the paper said.
The Health
Ministry says Indonesia needs more than 12,000 new doctors to meet its goal of
40 per 100,000 people. The country has 88,000 doctors, with a ratio of 33
doctors per 100,000 people, and its universities produce 7,000 doctors
annually, the ministry noted.
“The
majority of doctors are civil servants. If there’s a surge in patients while…
[the doctor] has to juggle working in two or three places to make a decent
living, you can imagine the stress,” said Mulyawan, the neurosurgeon and
insurance expert.
The unequal
distribution of health workers would not be a problem if they were adequately
paid wherever they work, he said. “Most doctors choose to work in cities
because that’s where the money is.”
No comments:
Post a Comment