Laksono Trisnantoro
Center for Health Service Management
Gadjah Mada University trisnantoro@yahoo.com

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

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?

• sustained, purposeful change to improve the efficiency, equity, and effectiveness of the health sector
(Bossert, 2007)

• 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
5

• 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

• Financing
• Payment
• Organization
• Regulation
• Persuasion and Behaviour Change
7

r
R
• “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

• 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?

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

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

• 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

• 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.

• 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.

• 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

• 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.

4/11/2020
Study by Equitap Group
18

4/11/2020 19

4/11/2020 20

4/11/2020 21

The market forces domination in Indonesia
4/11/2020 22

Objective: to achieve Universal Health
Coverage by National Social Security Law
(UU SJSN)

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.
T
E
K
J
A
M
S
O
S
PT.
A
S
K
E
S
PT.
P
E
N
T
A
S
PT.
A
S
A
B
R
I
SS
Carrier
S
T
E
K
J
A
M
S
O
SS Carrier
A
S
K
E
S
SS
Carrier
T
A
S
P nch
N
SS
Carrier
B
R
I
A
S
A
SS
Carrier
I
N
F
O
R
M
A
L
Nat
Soc
Security
Carriers
5 years
Branch Branch Branch h
Branch Branch Branch Branch Branch
Each single existing carrier follows its own regulation
- For profit entities
Source: MOH : Ida Bagus Indra Gotama, Donald Pardede
Nat Soc Security Council directs main policy
- Nat Soc Security Carriers implement the program, not for profit
- Synchronization of multiple schemes 24

• 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

• 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

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

TYPES:
JAMSOSTEK
Social Security.
Social
HMO
Current Health Insurance Systems in Indonesia
Private Insurers ASKES, HMOs
Military Health
Services
Commercial Health
Insurance
P.T. ASKES
(14)
ASKESKIN
(76)
HMOs &
Comm.
Financing
(2)
Free Health Services
COVERAGE, Millions of People
3 5 92
Source: Health PER, World Bank 2008
106 Million (approximately 48% of population) targeted
2
28

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.

The national health security program increased government budget
4/11/2020 30

Since 2001,
- the health program for the poor had improved the utilization of public hospital by the poor
- Kakwani Index is improving
0.2
0.1
0
-0.1
-0.2
-0.3
-0.4
KI 2001 KI 2004
Hospital Inpatient
Care
Hospital
Outpatient Care
Non-hospital
Inpatient Care
Non-hospital
Outpatient Care
All Public Health
Care
Tahun

• There is still a geographical inequity
Due to the access to
• Medical specialists
• Hospitals
Across Indonesia

(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

Average Number of Public Hospital at a district
High Fiscal capacity in local government
Low economy in the community
High economy in the community
2.5
2
Low fiscal capacity in local government
0.5
0.31
35

Average number of Private Hospital at a district
High Fiscal capacity in local government
Low economy in the community
High economy in the community
1.05
2.11
Low fiscal capacity in local government
0.5
1.91
36

• 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

This hipothesis may explain why
Indonesian Insurance Coverage Status in
2007 (based on social economy survey) looks not good.
2,4 2,9
1
6
14,4
Unisured
JAMKESMAS
ASKES
JAMSOSTEK
Other
JPKM
73,3
Source: SUSENAS 2007
38

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
• This discussion focuses on specialist

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

How many are really needed?  Perception of 32 districts*
Doctor
Specialist Doctor
Dentist
Midwife
Nurse
Pharmacist
Dietician
Public Health
Sanitarian
Public Health
Epidemiologist
Total
Need Availability GAP (%)
987
64
497
4565
4492
89
652
415
737
182
21
13.793
593
30
294
2951
3295
47
404
312
530
82
0
9.216
33,2
39,9
53,1
40,8
35,4
26,6
47,2
38,0
24,8
28,1
54,9
100,0
42
*) Bappenas Study in 2005

Doctor Distribution in 2003-2004
43

As an illustration:
Data: IDAI (Pediatrician Association,
2006)

136
141
153
154
163
168
240
287
DKI
Jat im
Jat eng
Jabar
Sumut
Bali
Sulsel
Sumsel
Sumbar
DIY
Riau
Bant en
Lampung
Kalt im
Kalsel
Kepri
Kalbar
Sult ra
NTT
Papua
Bengkulu
Babel
Sulbar
Goront alo
Papua Barat
M alut
Jambi
NAD
Sult eng
Kalt eng
Sulut
NTB
M aluku
1
3
2
4
1
4
7
11
8
9
6
8
5
8
10
12
5
6
7
10
15
16
13
20
17
21
22
27
29
25
27
23
34
39
46
0 50
56
71
100
101
150 200 250 300
2006 2008
Typical graphic description of medical specialist distribution
350

46

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
47

RPJM (Medium Term Plan)
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.
48

RPJM (Medium Term Plan)
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.
49

RKP 2008 (Annual Plan)
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
4/11/2020 50

51

(KKI, 2008)
Province
DKI Jakarta
Jawa Timur
Jawa Barat
Jawa Tengah
Sumatera Utara
D.I.Jogjakarta
Sulawesi Selatan
Banten
Bali
Sumatera Selatan
Kalimantan Timur
Sulawesi Utara
Sumatera Barat
Propinsi Lainnya
%
3,59%
2,91%
2,90%
1,79%
1,68%
1,43%
1,38%
9,14%
23,92%
16,39%
15,57%
10,19%
5,11%
4,01%
100,00%
Number
434
352
350
216
203
173
167
1.104
2.890
1.980
1.881
1.231
617
485
12083
Cumulative
78,77%
81,69%
84,58%
86,37%
88,05%
89,48%
90,86%
100,00%
23,92%
40,30%
55,87%
66,06%
71,17%
75,18%
People served
8.814.000,00
35.843.200,00
40.445.400,00
32.119.400,00
12.760.700,00
3.343.000,00
8.698.800,00
9.836.100,00
3.466.800,00
6.976.100,00
2.960.800,00
2.196.700,00
4.453.700,00
52.990.200,00
224.904.900,00
Ratio
1 : 20043
1 : 27943
1 : 9905
1 : 32296
1 : 14585
1 : 12697
1 : 26668
1 : 47998
1 : 3049
1 : 18102
1 : 21502
1 : 26092
1 : 20681
1 : 6892
1 : 18613

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
03 04 05 06 07
Owner
49 52 55 60 71
For Profit
Corporation
08
85
530 538 538 538 539 539
Non-Profit
(Foundation)
27 27 28 28 28 29
Non-Profit
(NGOs)
606 617 621 626 638 653
Total

• 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 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

Specialists prefer to provide services in the middle and upper class using feefor-service
Try to set own fees
No standard income

• 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

Does not meet the criteria of
Health System Reform
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
58

• 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.

• Riau
• Riau Island
• Bengkulu
• Bali
• North Sulawesi
• South East Sulawesi
• Central Sulawesi

• 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

Reform Topics
Health Finance
Riau Riau
Island
1
Beng kulu
1
Bali Nort h
Slws
2
S
East
Slws
1
Cent ral
Slws
5
Health service provision 9
Stewardship/regulation
2 3 7 4 2 6
1
33
1
Human Resources
Community
Empowerment
Health System development
Total
2
1
12 3
1
2 1
7 10 8
2
2 1
1
5
2
9
5
54
3
7

• 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

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

• 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.
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
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).

Notes: in the
Decentralization Policy:
centralization
Act
22/99
Act
32/04
De-centralization

2000-2007: The era of confusion and “strange” situation
• Change without significant change
Indonesian health sector is a decentralized sector but experiencing:
• Change in the Laws and
Regulation but not significant change in the process and the improvement of health status indicators.
• a more “centralized” financing system (06-07).
• Not coordinated change.
Will be discussed in Nossal Institute, University of
Melbourne, Thursday 20th of May 2009

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 centralization
Act
22/99
Act
32/04
De-centralization

Is there any future of Indonesian Health Reform
• at National Level?
• at Provincial?
• at District?

• Pesimistic? No health reform
• Optimistic? There will be health reform at national, provincial and district level
• Current activities in Indonesian
Health Reform

• 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

(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

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

Evaluation
EThics
Politics Problem identification
Health Sector
Reform Cycle
Implementation Diagnostic
Political Decision
Program
Schedule
Policy Development
Preparation-
FGD at each
Prov/
District
- Acquiring data set
Incampus training
(I) Off campus I: work assignme nt
In-campus training
(II)
Off campus
II: work assignme nt
Post-Course
Consultation and
Workshop
78

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.