The Landscape of Private Hospital Providers
(Draft 1)
Laksono Trisnantoro
Center for Health Service Management
Faculty of Medicine
Universitas Gadjah Mada
Contents
A.
Country Profile
A.1 The History of Private provider (pre-indendependence)
A.2 The Development of new private hospitals in Orde Baru (1965 - )
2
2
4
A.
Country Health System
B.1 Decentralization
B.2 Health Financing
5
7
7
B.
Structure and Organizations of Private Providers
C.1 Promotive, Preventive and Primary Care
10
C.2 Secondary and Tertiary Care
11
C.
National Health Expenditure
9
26
D.
Key Issues
E1. Utilization
E.2 The role of government in the hospital sector
E.3 Tax and Levy policies
E.4 Contracting Out
1
28
28
31
39
41
A. Country Profile
Indonesia’s economy had largely recovered from the Asian financial crisis of the late 1990s.
Indonesia is a lower-middle income country with a nominal gross national income per capita
of US$ 1,650 (US$ 3,580 PPP) in 2007. The economy has grown approximately 6% per year
since 2005. However, the recent global financial turmoil has led to sharp declines in demand
and prices for key exports. Experts predict that the growth of Indonesia’s economy is
expected to slow, but continue to estimate that it will grow by 4-6% in 2009. Despite progress
in stabilizing the economy, Indonesia continues to struggle with a number of complex issues.
Nearly 18% of the population continues to live below the poverty line, while 49% of the
population lives on less than US$ 2 per day (World Bank, 2006(b)). Distribution of resources
across provinces remains highly unequal with provinces in the East of the country receiving
substantially less than those in the West.
Indonesian economy has a market based
characteristics. This situation influence the health sector.
Key health indicators, such as infant and child mortality, have improved steadily over the past
several decades. Despite these general trends, improvements in some indicators seem to have
slowed in recent years. Three indicators remain a cause for concern: 1) high child mortality;
2) maternal mortality rates which remain high at 420 deaths per 100,000 live births (Hill et al,
2007), despite increases in the number of deliveries attended by a health professional (from
66% in 2002-03 to 73% in 2007) and the number of deliveries taking place in a health facility
(40% to 46%) (IDHS, 2008); and 3) child malnutrition rates, which remain high at 25% for
children under five and have largely stagnated since 2000 (World Bank, 2008). Infant and
child mortality rates are more than four times higher among the poorest quintile (World
Bank, 2006(b)). Due to longer life expectancy and fewer childhood deaths from
communicable diseases, the demographic and epidemiological profile of Indonesia is
transitioning. In the decades to come, Indonesia will face a “double burden of disease” from
both communicable and non-communicable diseases. Already, the number of people with
diabetes, heart disease, and cancer is increasing as the population ages, diets change, and
lifestyles become more sedentary (World Bank, 2008). These changes have the potential to
greatly increase both demand for and the cost of health care.
A.1 The History of Private provider (pre-indendependence)
The current situation of private providers is influenced by the history of the healing and
health service organization. Boomgard1 expresses that the history of health service and
hospitals in Indonesia is inseparable from the development of Western medical science in
Asia that goes on since 1649. This period represents the origin of the changing on the
traditional health system in Asia which referred to the Chinese system and turned into the
Western system2.
1
Boomgard, P. 1993. The Development of Colonial Health Care in Java: An explanatory Introduction.
Journal of the Royal Institute of Linguistics and Anthropology.
See also Boomgard, P. 1996. Dutch Medicines in Asia, 1600 – 1900. In Warm Climates and Western Medicine:
The Emergence of Tropical Medicine.
2
Akira, O. 1996. Introduction to the History of Disease and Healing in Indonesia. Forum of International
Development Studies.
2
Institutional Providers Development in Dutch Colonial Period started with the establishment
of colonial hospitals. Healthcare practices more systematically carried out when the East
India Company founded a hospital in Batavia on July 1, 16263. The construction of the first
hospital in Indonesia, allows for offshore medical treatment to patients. But so far only
certain groups, especially the military, who can enjoy the services of this hospital. The take
over of the Dutch East India Company to the government in 1800 also passed the state's
financial condition is critical.
The Religious Private Hospital became new phenomenon of the development since the mid19th century and then flourished in the early 20th century. This periode was the beginning of
zending groups from Europe who founded several private hospitals as a medium of spreading
religion. The emergence of religious hospitals, especially zending, can not be removed from
the existing zending network in the Netherlands and Germany. Following then, the Plantation
Private Hospital emerged from plantations across Indonesia. The plantation company hoped
that the plantation workers can work hard and improve their productivity by establishing the
hospital as a means to maintain and care the health of the labor. This means that the
establishment of a plantation hospital expected return of investment with the increased
productivity of workers.
The world economic crisis in the late 19th century has led to a decreased level of prosperity
of the population, especially in Java. In early 20th century the colonial government tried to
find the cause of this by doing research, known as mindere welvaart onderzoek op Java. In
fact the low level of prosperity in Java has occurred since the mid-19th century. Burger
clearly states that the low levels of Javanese society's prosperity happened since the 1830s.
According to Burge, the causes include: the large number of the population of Java at the
time, cultuur stelsel application or cultivation system, liberal politics and the entrance of
industrial goods to rural areas of Java4.
On the basis of these reports on figures from the Ethical groups such as Van Deventer, De
Wolff and van Westerrode Abendanon called to pay the "debt" in the Dutch East Indies
population by improving the welfare of their lives with a famous trias "irrigation, education,
and emigration "as the basic idea of the Ethical Policy5. Ethical policy began to be applied in
the Dutch East Indies in 1901. According to Boeke this policy is purely a policy for economic
development among the mass of the Indonesian population. This Ethical Policy is realised in
health for the community by the presence of government subsidy to public and private
hospital.
As a note, during the colonial period doctors were permitted to open private practices6. With
the salary from the government and additional earning from private practice, doctors in Dutch
administration time were professions who relatively rich, and they had the upper class life
style. Many medical doctors became political leaders.
3
D. Schoute, 1937, Occidental Therapeutics in the Netherlands East Indies During three Centuries of
Netherlands Settlement (1600-1900) (The Hague: Netherlands Indian Public Health Service), p. 28.
4
D.H. Burger 1962, Sejarah Ekonomis Sosiologis Indonesia I (Jakarta: Pradnjaparamitha), p. 93.
5
Suhartono, 1994, Sejarah Pergerakan Nasional: dari Budi Utomo sampai Proklamasi 1908-1945
(Yogyakarta: Pustaka Pelajar), p. 16.
6
Observational data and some biography of colonial Indonesian medical doctors.
3
When the handover from the Dutch colonial government to the Japanese in Kalijati on March
8, 1942, all zending hospitals later taken over by the Japanese. Japan considers that all
doctors who become leaders and managers in all hospitals zending are spies for Allied
Forces. Therefore, they were then arrested and transported to concentration camps and not be
associated with the hospital staff they lead. A year later they were returned to the Netherlands
as a prisoner of war.
After independence in 1945, the decreased subsidy influenced the system of state and private
hospital management. Practically, hospitals in Indonesia should operate on limited source of
expense and searched for the earnings to support their operation. That resulted Indonesian
hospitals depend on the use of tariff (users-fee) to support the operational expenses. It should
be properly noted that in Orde Lama Period (before 1965) Indonesia government applied a
policy which was not relied on foreign aids.
The religious based hospital lost the subsidy and aids from the traditional financing sources
gradually. These hospitals relied on user-fees as the main source of income. This situation
became complicated when the medical technology development. The cost of medical service
increased which is difficult to be financed by middle and low economy class family. This
hospital in 1960s and 1970s then open new class of VIP and VVIP. This change indirectly
also alter their management from non-profit oriented become for profit oriented, although the
status is foundation. Some religious based hospitals were tranferred to local government.
A.2 The Development of new private hospitals in Orde Baru (1965 - )
The private providers started a new era. At the first stage, many senior medical school
lecturers established small hospitals around the teaching hospitals. These medical doctorsowned-hospitals started from their private medical practice. The prominent senior medical
school lecturers developed the “moonlighting” system of individual practice become a
hospital. Big houses were transformed into small hospitals (less than 50 beds). Although the
senior lecturers owned hospital, they did not resign as the clinical staff member of state
hospitals.
The final stage of private hospital development is the introduction of new policy which
allowing hospitals as a for-profit company (Perseroan Terbatas). One of the important
moments in the hospital management history is the change on Permenkes (Regulation of
Health Minister) 920 / 86 concerning private hospital owner. According to Permenkes 920/
86, private hospital owner may be individual, group, or foundation. Permenkes No. 84/
Menkes/ Per/ II/ 1990 enhances one keyword that is other legal institution. Thereby, various
legal institutions, including limited corporation which is profit-making can have a hospital.
This for-profit corporation (Perseroan Terbatas) may be domestic investor or foreign
investor. Permenkes No. 84/ Menkes/ per/ II/ 1990 becomes significant because it legalizes
commercialized vision of the hospital service and reflects the progressive foreign influence in
the hospital system in Indonesia.
This new policy creates new breed of private providers. Some investors built new hospitals.
The hospital approach is a pure commercial enterprise. Vision and philosophy based on
commercial business principles. These type of hospitals grow fast, have modern building and
4
facilities, and has sophisticated services. Managers who run these hospitals came from school
of business and school of public health. Hospital became an industry. Alongside the forprofit hospital, the traditional religious private hospitals still exist with many new non-profit
hospitals across Indonesia.
A. Country Health System
The Ministry of Health (MOH) had overall responsibility for national health policy. It
recruited and allocated public sector physicians and other key staff and operates the main
vertical programs. The MOH remained responsible for the allocation of key staff to the
subnational regions, despite decentralization. However, while the MOH is responsible for the
health system, various health insurance programs, the private sector, and local governments
are also important financiers, and in some cases providers, of services, resulting in significant
fragmentation of both roles and flows of funds.
Responsibility for implementation of health services was transferred to local governments at
the district level by decentralization policy, resulting in the growing importance of Ministry
of Home Affairs in the health sector. However, although districts are now responsible for
employment, deployment, and payment, regulations regarding authority to make decisions
and budgets, and the capacity to carry them out, do not exist, largely because overall civil
service reforms have stalled (World Bank 2005a). Ironically, public health facilities play an
important role as economic enterprises for local governments. Local governments officially
“own” public health facilities and hospitals but have never allocated sufficient resources to
manage them (Trisnantoro, 2008).
Since decentralization, province-level health offices have mainly been responsible for
training and coordination efforts as well as oversight of provincial hospitals, but they have
limited resource allocation responsibilities (Trisnantoro, 2008). In contrast, districts have
major responsibilities for delivering health services and allocating resources. At the sub
district level, Puskesmas (health centers) have been the linchpin of basic health services and
primary care since the 1970s, while curative services are provided by four types of hospitals
ranging from teaching hospitals in the country’s major cities to district-level hospitals where
all main services are provided and referrals are made for more complicated cases to the
higher level hospitals (WHO, 2008).
In the health sector governance area, there was a rapid development of government as the
financier agency. After the economic crisis, government launched a social safety net subsidy
for the poor family. Hospital cost is one of the safety net scheme. This is a new policy at
national scale for financing the poor for hospital treatment. Since then the government role as
financier agencies became stronger, not only at central government level, but also local
government. However this policy had more political motives than technical, let alone equity.
The broad benefit and the policy for allowing near poor family for using the scheme may
open new problems in government financing for health sector. In some places, this policy still
discriminates against the private providers as the fund was only limited for use in state
hospitals only.
5
On the other hand, there was a slow development of local government role as the steward and
controller of private hospital. In the last 10 years, there were some innovative development
for strengthening the role of local government for supervising private hospitals. However the
progress is still limited. Many local government do not pay enough attention on this issue.
The cultural aspect of medical doctors is moving toward the opposite direction of health
financing. Numerous research found that medical doctors (specialists) tend to work in high
economy regions, as they might earn high and “unlimited” income, shifting between the
public and private hospital without clear regulation, tend to not having trust for hospital
management and managed care. Some specialties were suspectedly monopolizing the supply
side. In some places, doctors might act as price taker in fee setting. This culture was a
challenge for private hospitals, except those who have strong bargaining power with the
doctor. Medical doctor’s culture has limited history of being managed or regulated under a
standardized system. There is hardly any policy on income cap for doctor earnings nor
standard for service. Doctor earns their living mainly from fee-for-service7. Governmental
doctors are commonly unsatisfied with the public sector compensation which resulted in their
work ethic: they are government employees in public hospitals, but they obtain their majority
of earnings from private hospitals and private practices.
Another feature is the fragmented health sector. At present, de-medicalization is happening in
government offices which manage health.
Ministry of Health and mostly
Provincial/District/City Health Offices lost their influence toward medical groups (medical
doctors, especially specialists). As the result, two different cultures in health sector exist: (1)
medical culture and (2) public-health culture. One factor of this cultural difference is the fact
that Provincial/District/City Health Offices operate in the coordination of Ditjen Binkesmas
(General Directorate of Public Health) for years whereas hospitals is under coordination of
Ditjen Pelayanan Medik (General Directorate of Medical Service). Artificially, there is a
bureaucratic separation between activities of Provincial/District/City Health Office and
those of hospitals. Another fact shows that National Health System (SKN) 2004 strongly
differentiate Public Health Attempts (UKM) with Individual Health Attempts (UKP)8. Within
the fragmentation atmosphere between UKM and UKP, some features in health sector
develop. Market influence due to neo-liberalism and globalization became stronger in health
sector. More market practices are conducted in health sector especially among medical
groups, without adequate control and regulation from government. The rapid development of
the private sector required a sound analysis of regulation aimed at the private hospital sector
which is related to a wider issues around regulating for market failures.
We also argue that the policymakers perception on private health providers is still
inconducive. Current regulation around taxation, for instance, does not differentiate between
profit and non profit hospital providers. This situation was a complete opposite to the colonial
period, when government provided subsidy for nonprofit hospitals.
7
Sanjana K. 1998. Hubungan antara Kompensasi, Iklim Kerja, Citra Kerja, Ciri Individu dan Kepuasan Kerja
Dokter Spesialis di Instalasi Bedah Sentral RSUP Sanglah Denpasar. Magister Manajemen Rumah Sakit.UGM.
Yogyakarta. Tesis.
8 Departemen Kesehatan. 2004. Sistem Kesehatan Nasional.
6
B.1 Decentralization
Rapid decentralization, a key part of democratization efforts which began in 1999, has further
complicated an already complex regulatory environment. There are two important issues on
decentralization for private hospital growth: (1) the influence of decentralization to economic
situation; and (2) the transfer of central government authority for controlling health service.
One impact of decentralization was the significant discrepancy in the fiscal capacity which
grew greater among provinces and districts/ municipalities. With the payment of Shared Fund
for some local governments by the central treasury, some provinces and districts/
municipalities suddenly became rich in a short time. The local government fiscal capacity
became one important factor for economic environment, alongside the community economy
strength. This economic development increases the number of state and private hospitals.
Another interesting aspect of decentralization is the transfer of authority in hospital regulation
between central and local government. Hospital regulation remained a heated debate almost
10 years after decentralization. Since the early implementation of decentralization, some
leaders in Ministry of Health had weak willingness to formulate the program for regulation
development. It was reflected in National Health System document which had no regulation
component. Consequently, the capacity of central and local government in regulating health
sector was weak.
B.2 Health Financing
According to the Indonesia Public Expenditure Review (World Bank, 2007), health insurance
coverage has started to increase significantly, largely due to rapid development of the
Askeskin health insurance scheme for the poor. However, Susenas (household consumption
and expenditure) data suggested that health insurance coverage has been very low at only
about 27% of the population (World Bank, 2007). Almost all health insurance schemes
allowed beneficiaries to seek services from contracted providers, regardless of whether they
are public or private facilities. However, there is no accurate information to quantify how
much insurance is utilized for services provided by private sector providers. For instance,
Jamsostek (Jaminan Sosial Tenaga Kerja), established in 1992 as the social health insurance
scheme for private employees, allowed beneficiaries to seek both public and private services.
It required contributions of 3% (if one is single) and 6% (if married) of gross wages, paid
entirely by the employer. However, participation in the scheme is not required, i.e.,
employers can “opt-out.” In 2005 Jamsostek covers 3.1 million people or less than 5% of the
intended target population (ILO, 2006).
Table 1. Overview of Social Health Insurance Landmarks in Indonesia
Year
1968
197490
1992
Initiative
Health insurance for civil servants – Askes
Promotion and experiments in community-based health insurance (CBHI)-Dana
Sehat
Social security for private sector employees-Jamsostek, JPKM (HMOs) and
7
CBHI
Financial crisis
1997
MoH attempt to mandate HMOs fails
1998
JPS (Social Safety Net): financial assistance for the poor, Asian Development
1999
Bank (ADB) loan
Comprehensive review of health insurance and amendment of constitution to
2000
prescribe the rights to health care
Decentralization law implemented
2001
Amendment of constitution on the right to social security; president establish a
2002
task force on social security
Parliament initiates a bill on National Social Health Insurance (June)
2003
Task force finishes drafting bill on National Social Security including health,
occupational health, provident fund and pension and death benefits (December)
Bill on National Social Security enacted (October 19)
2004
Preparation for extension of insurance coverage to 36,4 million poor people
2005
MoH cover 76.4 million poor and near poor through Askeskin/Jamkesmas
2008
programs; National Social Security Council established (October 2008)
Source: World Bank, 2009 adapted from presentation at Bandung Policy Seminar, 2007 by
Thabrany
Health financing in Indonesia is further complicated by decentralization because direct
payments of salaries and capital costs by all levels of government clearly impact the hospital
reimbursement schedules used by insurers. Meanwhile, fiscal capacity depended on both
local revenue-raising capacity and the flow of funds through the inter governmental fiscal
systems in which some funds are earmarked by central-level government while others are not,
and formulas used for redistributing funds from central to local governments often do not
reflect local need and fiscal capacity (Trisnantoro, 2008). The complexity of the flows of
funds, with some targeted to health while others are not, and with some payments made
through insurance organizations while others made directly to public providers, make for an
intricate, inequitable, inefficient, and fragmented set of financing flows (World Bank 2008c).
Table 2 below depicts the major health financing sources and their allocation mechanisms to
health care providers in Indonesia.
Table 2.Health Care Financing in Indonesia
Financing sources
Public financing
through general
taxation
Public financing
through general
taxation
Fund
management
agency
Government
Government
Beneficiary
Health
providers
Total
population
Public
providers
Targeted
population
Public
providers /
Private
providers
8
Payment
mechanism
Budgets: direct
investment/subsidy
to health care
providers
Budgets/contract for
specific health
programs
Public financing
through general
taxation
Askes
Public financing
through general
taxation
Private financing:
employer/employee
contribution
AskeskinJamkesmas
Private financing:
employer/employee
contribution
JPKM
(Community
Medical
Services
Insurance)
Dana Sehat
(social funding
scheme)
Private
insurance
(commercial)
Out-of-pocket
payment
Private financing:
community member
contributions
Private financing:
employer/employee
contribution
Private financing:
individuals income
Jamsostek
Civil servants,
military
personnel,
pensioners and
their
dependants
Health
insurance for
the poor
Private
employees
Public
providers
Capitation for
primary care
Reimbursement of
fees paid
Mostly
public
providers
Public
providers /
Private
providers
Public
providers /
Private
providers
Reimbursement of
fees paid
Rural
communities
Public
providers
Reimbursement of
fees paid
Private
employees
Private
providers
Reimbursement of
fees paid
Total
population
Mostly
private
providers
Fee-for-service
Private
employees
Reimbursement of
fees paid
Negotiated contracts
with registered
providers
Source: USAID, 2009
The latest report by World Bank (2009) indicated that private health expenditure has,
historically, played a more important role than public health spending in overall health
financing in Indonesia. Out-of-pocket expenditures come from not only the uninsured but
also the insured, due to high co-payments and very limited benefits (World Bank, 2005), for
example: Askes has very high co-payments and Jamsostek excludes coverage for catastrophic
events. The average monthly health expenditures by facility and wealth quintile among those
who utilized out-patient or in-patient services shows that even the poor population made most
of their health expenditures in private facilities; 68% and 51% of out-patient and in-patient
health expenditures were spent in private facilities (Saadah et al, 2006). Another study also
suggested that the private sectors provided 67% of all in-patient care (Ramesh and Wu,
2008). The report (World Bank, 2009) suggested that the trend also showed that public share
of spending had continually to increase due to the establishment of Askeskin in 2004.
B. Structure and Organizations of Private Providers
Institutional providers can be classified into primary care, secondary and tertiary care.
Based on profit motives, private providers can be classified as non-for-profit and for-profit.
There is a clear separation of state and private institutional providers. In 2000s, private
providers had been developed across Indonesia. In this analysis private providers can be
9
classified into two main groups based on level of service: (1) Promotive, Preventive, and
Primary Care; and (2) Secondary and Tertiary Care.
C.1 Promotive, Preventive and Primary Care
There are mainly two types of promotive, preventive and primary care: local and foreign
organizations.
Local Organization: Humanity Foundations: PKBI, Yayasan Kusuma Buana, Faith Base
Foundation, Chirstian (YAKKUM), Muhammadiyah (MKKM). Most domestic humanity
foundation such as PKBI and Yayasan Kusuma Buana operates in limited health services.
These organizations provide promotive, and preventive services and research in public health.
It is difficult to make separation of promotive and private with the curative care. Most big
NGOs which provide promotive and preventive care also providing curative care such as
Yakkum and MKKM.
Foreign Private providers
Many private providers work in Indonesia in the prevention and primary care. Most of private
providers are international non government organizations. By laws, these organizations
should register in the Ministry of Foreign Affairs.
On AIDS
 Clinton Foundation HIV/AIDS Initiative:Penanggulangan HIV/AIDS
 Family Health International (FHI): A Cooperative Program in HIV/AIDS
On Disabled Care
 Christoffel Blindenmission of Germany (CBM): Technical Cooperation in
Prevention of Blindness and Related Services to People with Disabilities
 Handicap International: Joint Initiatives to Support Health Services for People with
Disabilities
 Helen Keller International (HKI): The Cooperation in the Implementation of the
Visual Disorders and Blindness Prevention Program
On Communicable Diseases
 KNCV: Technical and Financial Assistance to the National Tuberculosis Program
 Netherlands Leprosy Relief Association (NLRA): Strengthening the Leprosy
Control in Indonesia
 Project HOPE (USA): Maternal and Child Health, Infectious Diseases and
Humanitarian Assistance
 Surf Aid International: Cooperation on Health Care Specifically Related to the
Prevention and Control of Communicable Diseases
 The Leprosy Mission International (TLMI): Leprosy Control and Rehabilitation
On Emergency and Disaster
 Medical Team Int’l: Community Health Nias
 Medical Relief, Lasting Health Care (MERLIN)
On Nutrition
10


Micronutrient Initiatives: Cooperation In Alleviating Micronutrient Deficiencies
Project Concern International (PCI): The Implementation of Community Health
and Nutrition Programs Through Strengthening Governmental, Non-Governmental
and Community Capacities.
On General Services:
 Action Contre la Faim (ACF): Cooperation in Health Care
 Americares: Bantuan tenaga medis
 Horizon Holand Foundation Cooperation in Health
 MAP International
 Malteser International: Cooperation in Health Services
 Medecins du Monde (MDM): Cooperation in Health Care
 Medecins Sans Frontieres (MSF) Belgium; Cooperation in Community Health
Development; Cooperation in Health Care
 Program for Appropriate Technology in Health (PATH): Cooperation to Improve
Health in Indonesia
 The Johanniter Unfall Hilfe e.V: Cooperation in Health Services
 Uplift International: The Cooperation in Community Health Services
Others
 Cambodia Trust: Sekolah Ortotik dan Prostetik di Poltekkes Jakarta I
 Interplast New Zealand – Australia: Expert on Plastic Surgery
C.2 Secondary and Tertiary Care
Hospital in Indonesia can be differentiated according to its ownership and its type of services.
Based on its ownership, Hospital can be categorized into:
1. State-Owned Hospital, managed by:
a. Ministry of Health
b. Provincial government
c. District/Municipal government
d. Army/Police
e. Other Ministries/BUMN (State Owned Corporation)
2. Private-Owned Hospital, managed by:
a. Corporates
b. Foundation/Association/Institution
Based on its type, hospital can be categorized into:
1. General hospital
2. Mental hospital
3. Special hospital, comprising:
a. RS Kusta (leprosy)
b. RS Tuberkulosa Paru (RSTP) (TB)
c. RS Mata (Eye)
d. RS Bersalin (RSB) (Maternal)
e. RS Ibu dan Anak (RSIA/RSAB) (Mother and Child)
f. RS Khusus Anak (Children)
11
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
RS Orthopedi (RSO) (Orthopedic)
RSPI Infections
RS Jantung (Coronary)
RS Kanker (Cancer)
RS Stroke
RS Gigi dan Mulut (RSGM) (Dentistry)
RS Khusus Penyakit Dalam (Internal Medicine)
RS Khusus Bedah (Surgery)
RS Khusus ENT Bedah (Ear, Nose, Throat Surgery)
RS Khusus ENT (Ear, Nose, Throat)
RS Khusus Ginjal (Kidney)
General hospital owned by Ministry of Health and local government can be categorized
according to its capacity, namely:
1. Class A General hospital
2. Class B General hospital
3. Class C General hospital
4. Class D General hospital
Meanwhile, army/police owned hospital can be categorized into:
1. Level 1 general hospital
2. Level 2 general hospital
3. Level 3 general hospital
4. Level 4 general hospital
Hospital can also be differentiated into:
1. Teaching hospital
2. Non teaching hospital
Based on the distribution, most hospitals are in Java Island. For state hospitals, 254 out of
667 are in Java. This is approximately 45% of state hospitals. For private hospitals, 61% (404
out of 653) is in Java. This shows the market attractiveness of Java for private hospitals.
Figure 1 shows the distribution of hospital across provinces in Indonesia.
Figure 1 Hospital Distribution
12
However if the ratio to population is used as the basis of comparison, the availability of
hospital beds to population shows different result. Java Island is the most dense populated
island. (Figure 2).
Figure 2. The Ratio of the number of hospitals per 100.000
In 1998, state hospitals number was bigger (589) than private ones (491), however, a
decade later, the number of private hospital increased to 653 and state hospital became 667.
The growth of private hospitals increased by 2,91 % (on average) per year, while the state
hospital is 1,25 % per year.
Graph 1 Growth of number of hospital
In general, the private hospitals have smaller number of beds. Graph 2 shows that
private hospitals beds is far below the state-ones. The state hospitals usually are big teaching
hospitals, and provincial hospitals, while the major private hospitals are faith based hospitals
which have long history since the pre-independence period.
13
Graph 2 Growth of number of hospital beds
C.2.1 The growth of state hospitals
As shown in the Graph 3, within the last decade, the three groups of hospitals based on the
number of beds have an average annual growth rate that is only slightly different: 3.1; 2.1;
2.6 respectively. Since 2003, the smaller hospital (0 – 50 beds) shows a steady growth rate,
the highest growth rate occurred in 2008 with the total amount of 11 hospitals. In the
medium size hospital (51 – 150 beds), evidence indicated that the highest growth rate
occurred in 2001 with the amount of 12 hospitals. However, the big hospital (beds > 150)
indicated a positive trend that occurred in the period 2004-2007 along with the highest
growth rate of 16 hospitals in 2007.
Graph 3. The Growth Rate of State Hospitals Based on the Number of Beds
14
In term of distributions, the highest average growth of hospitals (the period 19982008), for small hospital (0 – 50 beds) is in North Sumatra Province. It had an average
growth rate of 1 hospital per annum. The medium size hospital (51 – 150 beds) has higher
growth in Central Kalimantan Province (0.3), while the big hospital (beds > 150) is in West
Java province (0.8).
C.2.2. The Private Hospital Growth
The private hospitals consist of for profit and non-for-profit organization. The
definition of for-profit based on the legal status of hospital. Private hospital is regarded as
profit organization if the hospital use corporate status (Laws no 40/2007 on Limited
Company and Laws no 8/1995 on Public Corporation. Under this legislation, the owners of
hospital can receive payment or devident from hospital operation’s profit. For-profit private
health care organization can be classified into chain-hospital, ambulatory and out-patient
clinic care network, emergency providers, or single provider.
.
The non-profit is registered based on Foundation Law, or Statblad for Perkumpulan
(Association). There is no rules on ownership in the Foundation Law. The religious groups
are the common owners of these organizations such as: Moslem (MUKISI, with many
groups, the largest is Muhammadyah), Christian (YAKKUM, the modern successor of
zending movement), Catholic (PERDHAKI with many congregrations). Although the
foundations are non-profit, basically the management model is similar to the for profit ones.
The detail number of hospitals in the forms of Foundation (81,8%), Limited Company (PT,
13,8%) and Association (4,4%) as shown in Table 3:
Table: 3 Private Hospitals ownership
NO
Ownership
1 Companies
2 Foundation
3 Association
Total
N
90
534
29
653
2008
%
14%
82%
4%
100%
Using a more detailed table, the situation of private hospitals is shown in Table 4.
There are three provinces that have no private hospitals: Central Kalimantan, Gorontalo, and
North Maluku. On the other extreme, DKI Jakarta has 90 private hospitals, and Central Java
has 114 private hospitals. This situation is presumably relates to the socio-economic
condition of the provinces.
15
Table 4 Number of Private Hospitals and Their Beds classified according
to their ownership and region
PRIVATE
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
PROVINCE
NAD
Sumatera Utara
Sumatera Barat
Riau
Jambi
Sumatera Selatan
Bengkulu
Lampung
Bangka Belitung
Kepulauan Riau
DKI Jakarta
Jawa Barat
Jawa Tengah
DIY
Jawa Timur
Banten
Bali
NTB
NTT
Kalimantan Barat
Kalimantan Tengah
Kalimantan Selatan
Kalimantan Timur
Sulawesi Utara
Sulawesi Tengah
Sulawesi Selatan
Sulawesi Tenggara
Gorontalo
Sulawesi Barat
Maluku
Maluku Utara
Papua Barat
Papua
INDONESIA
CORPORATE
RS
1
6
4
1
1
1
2
34
18
4
4
5
1
1
4
1
1
1
90
TT
47
534
243
68
89
190
254
3,159
1,484
293
401
437
70
72
223
46
25
72
7,707
FOUNDATION
RS
6
62
18
4
3
8
1
10
2
4
50
58
109
25
66
10
19
2
6
8
8
6
11
8
18
2
1
5
1
3
534
16
TT
273
4,452
821
372
180
969
106
777
186
321
4,010
4,828
8,669
2,091
5,019
546
943
117
399
882
496
682
1,157
379
1,526
82
50
276
50
176
40,835
ASSOCIATION
RS
1
7
4
1
8
1
3
1
2
1
29
TT
149
1,848
1,103
25
1,074
92
160
15
250
30
4,746
TOTAL
RS
7
68
19
8
4
9
1
11
2
6
91
80
114
25
78
16
20
2
9
9
8
10
11
8
19
4
1
7
2
4
653
TT
320
4,986
970
615
248
1,058
106
967
186
575
9,017
7,415
8,987
2,091
6,494
1,075
1,013
117
559
954
496
905
1,157
379
1,572
122
50
526
122
206
53,288
The density of private hospital distribution across Indonesia could be seen in Figure 3.
Figure 3. Distribution of the Number of Private Hospitals
In the last 5 years, the most rapid growth is the Company-owned hospitals. In 2003
there were 49 for-profit private hospitals. In 2008, it almost doubled and became 85 hospitals.
Most new for-profit hospital were established in Jakarta and other big cities. In the same
period, the number of foundation hospitals increase from 530 to 539. The Association
hospital grew from 27 become 29. The 1998-2008 growth is shown in Table 5.
Table 5. The growth of Private Hospital (2006-2008)
Owners
Companies
Foundation
Association
Total
1998
20
448
23
491
1999
25
463
23
511
2000
25
470
23
518
2001
26
501
23
550
2002
29
526
25
580
2003
39
540
27
606
2004
42
548
27
617
2005
52
541
28
621
2006
60
538
28
626
2007 2008
71
90
539 534
28
29
638 653
It could be concluded that the foundation-owned hospital and association-owned hospital are
declining, while the company-owned hospital is growing.
17
The Number of Hospitals
600
500
448
463
470
501
526
540
548
541
538
539
534
39
42
52
60
71
90
29
400
300
200
100
20
25
25
26
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Companies
Foundation
Association
Graph 4: The Growth of Private Hospital according to its Ownership
The Private Hospital growth is more in the small hospitals (less than 50 beds) group and
medium size (between 50 to 150 beds) group. Since the year 2000 the small hospitals grew
rapidly. The big hospitals grew steadily, not drastically. It is interesting that this growth was
occurred during the initial stage of decentralization and also after monetary crisis in 1998.
Graph 5 The Growth Rate of Private Hospitals Based on the Number of Beds
As shown by the Graph 5 and table 6, the more detailed description of private hospitals has
some features. The small hospital (0 – 50 beds) had achieved an accelerated growth from
1998 to 2004. The highest growth rate occurred in 2003 that reached the amount of 16 Private
Hospitals. On average, the growth rate is 6.8 Private Hospitals per annum. This is less than
the growth medium size hospital (51 to 150 beds). This can be explained by the fact that
some of the smallest hospitals grew and becan the mid-soze hospitals.
18
Table 6. The Number of Private Hospitals
Bed
0 - 50
51 150
> 150
Total
225
Average
Growth
199 200 200 200 200 200 200 200 200 200
(Private
9
0
1
2
3
4
5
6
7
8
Hospital/year
)
234 239 254 268 284 293 285 280 295 293
6.8
210
56
491
217
60
511
199
8
216
63
518
233
63
550
246
66
580
253
69
606
255
69
617
266
70
621
273
73
626
271
72
638
283
77
653
7.3
2.1
The private hospital group of beds 51 – 150 had rising growth rate from 2001 to
2006. The highest growth rate occurred in 2001 with the establishment of 17 new private
hospitals. The average growth rate is 7.3 private Hospitals per annum. The private hospital
group of beds > 150 had a steady growth from 1998 to 2006. The highest growth rate
occurred in 2008 and the average growth rate is 2.1 per year. The highest average growth of
private small hospital period 1998-2008, is in East Java province. The medium size private
hospital highhest growth rate is in Central Java province (1.2 per annum). The big private
hospital growth is highest in West Java province and Central Java province (0.5 per annum).
Based on number of beds, the growth of private hospitals showed similar trends.
Graph 6. The Growth Rate of Private Hospitals Beds Based on the Group of Beds
The data shows that the private medium size hospital (51 – 150 beds) had the highest
and significant growth from 1998 to 2008. The highest growth occurred in 2001 with totaling
of 1372 beds. The average growth rate is 650.5 beds per annum, far exceeded smaller
hospitals. Although the small hospital had a rising growth from 1998 to 2004 with the
highest growth occurred in 2002 with the total number of 653 beds, the average growth rate is
only 225.7 beds per annum. The growth of big hospital (beds > 150) was rising in 2002 to
2006, yet it slowed down in 2007. The highest growth occurred in 2008 with the total number
of 943 beds, while the average growth rate of 313.7 beds per annum.
19
Table 7. The Number of Private Hospitals beds growth
Bed
199
8
199
9
200
0
200
1
200
2
200
3
200
4
200
5
200
6
200
7
200
8
0 50
51 150
>
150
Tota
l
8,37
3
18,0
00
15,0
16
41,3
89
8,86
2
18,0
13
15,6
82
42,5
57
9,06
1
18,1
29
16,1
22
43,3
12
9,56
7
19,5
01
15,7
69
44,8
37
10,2
20
20,6
68
16,3
57
47,2
45
10,6
48
21,3
96
16,9
02
48,9
46
10,9
10
21,6
54
16,9
48
49,5
12
10,4
63
22,2
53
17,0
59
49,7
75
10,3
77
23,4
60
17,5
38
51,3
75
10,7
94
23,4
71
17,2
10
51,4
75
10,6
30
24,5
05
18,1
53
53,2
88
Average
growth
(Private
Hospital/
year)
225.7
650.5
313.7
The highest average growth of beds (period 1998-2008), for the small hospital is in
East Java province (76.1 beds per annum), for the medium size hospitals is in Central Java
province (126.4 beds per annum), and for the big hospitals is in Central Java province (91
beds per annum).
C.2.2.i Private Hospitals owned by Companies
The Company owned private hospital grew rapidly during the last 10 years. Most hospitals in
this group was established in the strong economic provinces regions such as North Sumatera,
Riau, Jakarta, West Java, Central Java, and East Java, and East Kalimantan.
Figure 4. Company-owned Hospital Distribution
The growth of the private for-profit hospitals showed sharp increase in all groups. In the
small hospitals group a rising growth rate occurred from 2000 to 2005, it decreased slightly in
2006, but it increased again in 2007 and 2008. The highest growth rate occurred in 2008
indicated by the average growth of 3 hospitals per annum.
20
In the group medium size hospitals, a rising growth rate of hospitals had been consistent from
2002 to 2008. The highest growth rate occurred in 2008 that reached 7 hospitals alone in that
year, and also indicated by the average growth of 2.7 hospitals per annum.
Meanwhile, in the big hospitals group, the growth rate was steady from 2002 to 2008. The
highest growth rate occurred in 2003, 2006, and 2008 while the average growth is 1.3
hospitals per annum.
Graph 7 .The Growth Rate of Private Hospitals Owned by Companies Based on the
Number of Beds
In term of distribution, the highest average growth of hospitals is in DKI Jakarta province.
The average growth of 1 hospital per annum in the small hospital, 1.1 for medium size
hospitals, and 0.7 for big hospital.
Table 8. The Number of Private Hospitals Owned by Companies
Bed
0 - 50
51 - 150
> 150
Total
Average
growth
(hospital/year)
37
3
39
2.7
14
1.3
90
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
7
12
1
20
11
11
3
25
8
14
3
25
9
14
3
26
10
15
4
29
15
17
7
39
17
18
7
42
21
23
8
52
20
29
11
60
28
32
11
71
In the small hospital group, the growth began to increase from 2001 to 2005, and slightly
decreased in 2006, but then it increased again in 2007 and 2008. The highest growth rate
occurred in 2008 amounted at 359 beds, while the average growth rate of 110.8 beds per
annum. In the medium size hospital, the growth rate remained strong in 2000 to 2008. The
highest growth occurred in 2008 amounted at 687 beds, while the average growth rate of
240.2 beds per annum. Meanwhile, in the big hospital group, the growth rate was steady
21
during 2002 to 2006. The highest growth occurred in 2006 amounted at 768 new beds, while
the average growth is 259.4 beds per annum.
Graph 8 The Growth Rate of Beds at Private Hospitals Owned by Companies Based on
the Number of Beds
In terms of number of beds, DKI Jakarta showed growth of 33.4 beds per annum for small
hospitals, 90.6 beds per annum for medium size hospital, and 143.2 beds per annum for big
hospital.
Table 9. The Number of Beds at Private Hospitals Owned by Companies
Bed
1998
1999
2000
2001
2002
2003
2004
2005
284
454
308
354
410
589
668
811
0 - 50
847 1,229 1,286 1,375 1,435 1,569 1,855
51 - 150 1,096
223
641
636
636
859 1,517 1,517 1,611
> 150
1,603 1,942 2,173 2,276 2,644 3,541 3,754 4,277
Total
22
Average
growth
(bed/year)
786 1,033 1,392
110.8
2,517 2,811 3,498
240.2
2,379 2,347 2,817
259.4
5,682 6,191 7,707
2006
2007
2008
C.2.2.ii Private Hospital owned by Foundations
In term of distribution, the highest average growth of small hospitals can be found in East
Java province with an average growth of 1.7 hospitals per annum, while the medium and big
hospital are in Central Java province with an average growth of 1.4 hospitals per annum and
0.5 hospitals per annum, respectively.
Figure 5 Foundation-owned hospital distribution
In the small hospital group the growth rate, the highest growth rate occurred in 2001, while
the average growth is 3.6 hospitals per annum. In the medium size hospital group, the
highest growth occurred in 2001 while the average growth is 4.3 hospitals per annum. In the
big hospital group the highest growth rate occurred in 2008 while the average growth is 0.7
hospital per annum.
Graph 9. The Growth Rate of Private Hospitals Owned by Foundations
23
Table 10 shown the actual number of private hospital owned by Foundations, while Table 11
shown the growth rate.
Table 10. The Number of Private Hospitals Owned by Foundations
Bed
Average
growth
(hospital/year)
3.6
4.3
0.7
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
0 - 50
51 - 150
> 150
Total
212
191
45
448
219
197
47
463
227
194
49
470
241
211
49
501
252
223
51
526
263
226
51
540
270
227
51
548
257
233
51
541
253
236
49
538
260
230
49
539
248
234
52
534
In the small hospital group the highest growth occurred in 2002, with 508 beds, while the
average growth rate is 112.5 beds per annum. In the medium size hospital group, the highest
growth occurred in 2001 with 1295 beds, while the average growth is 374.5 beds per annum.
In the big hospital group, the highest growth occurred in 2008 that reached the amount of 635
beds, while the average growth is 73.9 beds per annum.
Table 11. The Number of Private Hospitals Beds Owned by Foundations
Bed
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0 - 50
51 150
7,839
16,13
7
11,25
0
35,22
6
8,253
16,14
8
11,59
5
35,99
6
8,598
16,04
2
11,79
6
36,43
6
9,058
17,33
7
11,63
3
38,02
8
9,566
18,40
8
11,96
6
39,94
0
9,820
18,86
3
11,89
1
40,57
4
10,00
3
18,98
7
11,93
3
40,92
3
9,383
19,26
4
11,94
5
40,59
2
9,322
20,10
4
11,42
2
40,84
8
9,512
19,68
2
11,35
4
40,54
8
8,964
19,88
2
11,98
9
40,83
5
> 150
Total
Average
growth
(bed/yea
r)
112.5
374.5
73.9
C.2.2.iii PRIVATE HOSPITALS OWNED BY ASSOCIATIONS
In terms of distribution, the highest average growth of small hospitals occurred in East Java
province followed with an average growth of 0.2 hospital per annum. The medium size, the
highest growth occurred in West Java province, East Java and Banten (0.1 hospital per
annum), while the highest growth for the big hospital was in West Java province (0.1 hospital
per annum).
24
Graph 9. The Growth Rate of the Private Hospitals Owned by Associations
In the small hospital group, the highest growth occurred in 2002 while the average growth
rate is 0.2 hospitals per annum. In the medium size hospital group, the highest growth
occurred in 1999 and 2003, while the average growth is 0.3 hospitals per annum. In the big
hospital group, the highest growth occurred in 2006 while the average growth is 0.1 hospital
per annum.
Table 12 The Number of Private Hospitals Owned by Associations
Bed
0 - 50
51 - 150
> 150
Total
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
6
7
10
23
4
9
10
23
4
8
11
23
4
8
11
23
6
8
11
25
6
10
11
27
6
10
11
27
7
10
11
28
7
8
13
28
7
9
12
28
8
10
11
29
Average
growth
(hospital/year)
0.2
0.3
0.1
In the small hospital group, the highest growth occurred in 2002 that reached the amount of
89 beds, while the average growth rate is 2.4 beds per annum. In the medium size group, the
highest growth occurred in 1999 that reached the number of 251 beds, while the average
growth of 35.8 beds per annum.
25
Table 13. The Number of Beds at Private Hospitals Owned by Associations
Bed
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
250
155
155
155
244
239
239
269
269
249
0 - 50
767 1,018
858
878
885 1,098 1,098 1,134
839
978
51 - 150
3,543 3,446 3,690 3,500 3,532 3,494 3,498 3,503 3,737 3,509
> 150
Total 4,560 4,619 4,703 4,533 4,661 4,831 4,835 4,906 4,845 4,736
Average
growth
(bed/year)
274
2.4
1,125
35.8
3,347
-19.6
4,746
2008
In the big hospital group, the highest growth of 244 beds occurred in 2000, but in average the
growth is -19,6 bed per annum.
In terms of distribution, the highest average growth of beds is in East Java province for small
hospital (7.4 beds per annum), in West Java province for medium size hospital (13.7 beds per
annum), and big hospital (37.8 beds per annum).
C. National Health Expenditure
In the last 10 years, a significant effort from government is to develop health
protection for medical care. This notion is reflected in the following Table 14
Table 14 Health Expenditure
Health
Expenditure
Expenditure ratios
Total expenditure on health
(THE) as % of GDP
Financing Agents
measurement
General government
expenditure on health
(GGHE) as % of THE
Private sector expenditure
on health (PvtHE) as % of
THE
General government
expenditure on health as %
of GGE
Social security funds as %
of GGHE
Private households' out-ofpocket payment as % of
PvtHE
Prepaid and risk-pooling
plans as % of PvtHE
Source : World Health
Organization, 2007
2001
2002
2003
2004
2005
2.7
2.8
2.9
2.8
2.7
33.1
33.7
31.6
34.2
34.7
66.9
66.3
68.4
65.8
65.3
4.2
5.3
4.6
5.0
5.0
8.9
10.2
11.7
10.8
21.3
75.1
75.3
76.0
74.7
74.3
4.1
5.1
5.6
5.9
6.0
26
This trend is the result of various milestones in the development of health protection.
In the early 1990s, the Jaminan Pemeliharaan Kesehatan Masyarakat (JPKM) or Health
Care Security for the Community Program, the principal Indonesian program of managed
health care, was introduced. JPKM was a means of providing prepaid comprehensive and
continuous quality health care. All prepaid health care programs run by the government as
well as by the private sector have to abide by its principles. Its payment mechanism is
through negotiated contracts with registered providers.
The Askeskin Program was introduced in 2005 to replace JPKM, with the national
health insurance company (PT Askes Indonesia) contracted to manage the program. This
national program targeted the poor and near-poor. It does reach many poor people, but has
had considerable problems with targeting and with the quality of service delivery. In addition,
the Askeskin premium is underfunded on a per capita basis. Other problems include
incomplete data collection on poor people, inappropriate charging by, and quality control of,
hospitals, nonoptimal claims verification, insufficient budgets for health services, and
inadequate support for local government in coordinating, monitoring and controlling the
program.
In 2008, Askeskin was changed into Jamkesmas with the aim of providing access to
health services for the poor and near-poor, by exempting them from user charges at the point
of delivery. In 2008, the program had enrolled 76 million poor people with targeted recipients
identified by local authorities. The health benefits are comprehensive and based on medical
indications. The program abandoned the insurance model. PT Askes’ Indonesia role was
reduced as the operator of the system and it is now limited to managing the poor and nearpoor members enrolled in the scheme. Jamkesmas is a social aid program, and is covered by
the national budget (APBN) as social security in the health sector. The budget in 2008 is
Rp.4.6 trillion. Alongside Jamkesmas,local governments in various provinces and districts
have Jamkesda.
The effect of the program was positive for hospital utilization in improving the access
and utilization. The data showed that JPSBK provided good effect, as it can be seen at the
result as follows:
0,3
Hos pital Inpatient
Care
0,2
Kakwani Index
0,1
Hos pital
Outpatient Care
0
KI 2001
KI 2004
Non-hos pital
Inpatient Care
-0,1
-0,2
Non-hos pital
Outpatient Care
-0,3
All Non Hos pital
Care
-0,4
Tahun
Graph 10. The effect of JSPBK toward the index of Kakwani
The Susenas data 2001 and 2004 indicated that the Kakwani index showed its
development. The utilization of rate of hospital and other health services showed that there
27
were more poor households who used health facilities. Starting in 2005 the government has
taken firmer stand to improve, finance and management of poor community health. The
effect was very clear. It strongly increased the Bed Occupancy Rate/BOR of the third class
words in the hospital up to 100%. The use of the health service by the poor drastically
increased up to 392% from 1.4 million in 2005 to 6.5 million in 2007. The hospital inpatient
care increased up to 432% from 562,167 in 2005 to 2,431,139 in 20079.
The problem related to the aspect of poor community included the criteria and process
of reporting the poor community. There were many other cards passed around like SKTM,
BLT (Cash Direct Support), Raskin (Rice for the Poor) and others. Most of them lived
relatively far from the service center which caused transportation problem for the poor. The
poor community depended much on their daily or weekly wage or field and agriculture so if
they got ill they had to leave their work. Some of them still experienced discrimination
service compared to those who paid. Other prominent problem was the lack of socialization
so that many poor communities were unaware of their right and duty on the health insurance
for the poor.
From the aspect of hospital care, there were many problems. The payment of hospital
claim was often delayed for months. The hampered of money supply caused chain of
problems. The hospital had to be responsible for the medicines that were not in the
formularies, the hospital had to manage many administration problems, even some hospitals
had to cross check by themselves if the patient was truly poor.
From the aspect of central government, the problem was generally related to the
planning, and slow implementation, especially the manual distribution. The implementation
of control and supervision needed to be improved, including developing manual for local
government to improve the insurance system for the poor family.
However, the main problem at the local government was that they did not really
function and involve in the program of health insurance for the poor. Role, function,
assignment and distribution of affairs in financing and health insurance as regulated in PP
No. 38/2004 and UU No. 32/2004 were not optimal yet. Some Local Governments thought
that financing of poor community health was the responsibility of the central government.
The local government had no sense of belonging toward the health insurance.
D. Key Issues
E1. Utilization
The result of Equitap research (based on DHS data) on health financing in Indonesia
between 2000 – 2005 indicated a positive trend. Health financing policy between 2000 to
2005 had somewhat improved the equity situation. Prior to the health financing reform,
hospitals (public and private) were merely used by the richer group in the community. Most
poor people did not use it because there were limited resources for doing so. The financial
protection program had reduced financial barriers to access for poor households in both
hospital and non-hospital services.
However another analysis (based on MoH data on hospital and human resources
distribution) showed a persistent inequity. The number of hospital and medical doctors is not
well distributed. The National Financial Health Protection Policy (Jamkesmas) allowed
9
Mukti AG. (2008) Alternatif pengelolaan Askeskin 2008. Workshop oleh Kemetrian Koordinator Kesejerahteraan Rakyat RI. Jakarta
28
private hospitals to treat poor and near-poor patients. The Benefit Package is comprehensive
enough which included high technology and costly medical treatment. This might increase
access of poor and near-poor in urban and Java for private hospital and high cost medical
care. It is projected that the health budget will be absorbed by these groups. However, there
is a concern on the affordability and geographical equity.
Table 15 Utilization Rate for Outpatient in Private Hospital
Non-standard
No
Code
Province
1
11
NAD
2
12
3
2005
2006
2007
n.a
0.67%
0.86%
Sumatera Utara
1.23%
1.09%
1.15%
13
Sumatera Barat
0.47%
0.41%
0.67%
4
14
Riau
0.79%
0.74%
1.74%
5
15
Jambi
0.32%
0.46%
0.19%
6
16
Sumatera Selatan
0.43%
0.67%
0.82%
7
17
Bengkulu
0.13%
0.17%
0.28%
8
18
Lampung
0.50%
0.40%
0.33%
9
19
Bangka Belitung
1.44%
1.15%
2.13%
10
21
Kepulauan Riau
1.00%
1.34%
2.27%
11
31
DKI Jakarta
1.08%
2.03%
2.16%
12
32
Jawa Barat
0.68%
0.74%
0.80%
13
33
Jawa Tengah
0.49%
0.43%
0.66%
14
34
DI Yogyakarta
1.41%
1.88%
2.62%
15
35
Jawa Timur
0.59%
0.62%
0.71%
16
36
Banten
0.69%
0.96%
1.13%
17
51
Bali
0.82%
0.86%
0.84%
18
52
NTB
0.22%
0.11%
0.06%
19
53
NTT
0.59%
0.94%
0.85%
20
61
Kalimantan Barat
0.37%
0.39%
0.50%
21
62
Kalimantan Tengah
0.09%
0.10%
0.12%
22
63
Kalimantan Selatan
0.17%
0.18%
0.20%
23
64
Kalimantan Timur
0.89%
1.02%
0.88%
24
71
Sulawesi Utara
0.96%
0.89%
0.77%
25
72
Sulawesi Tengah
0.18%
0.19%
0.20%
26
73
Sulawesi Selatan
0.33%
0.26%
0.39%
27
74
Sulawesi Tenggara
0.28%
0.29%
0.31%
28
75
Gorontalo
0.20%
0.44%
0.10%
29
76
Sulawesi Barat
n.a
0.10%
0.15%
30
81
Maluku
0.38%
0.43%
0.48%
31
82
Maluku Utara
0.45%
0.99%
0.17%
32
91
Papua Barat
n.a
2.01%
1.00%
33
94
Papua
1.13%
0.82%
0.62%
0.63%
0.70%
0.82%
Source : Susenas (2005-2007)
29
Utilization rate for both public and private sector services in Indonesia increased
across all income groups between 2001 and 2007. Notably, the rate of increase in utilization
rates was higher for the poorest quintile than for the richest quintile for all types of public
sector services. In particular, the poorest quintile’s utilization of state hospital inpatient
services quadrupled during this period, compared with a more moderate increase of
approximately 50 percent for the richest quintile. Despite these increases, the socioeconomic
gradient in the use of state hospital services continues to favor the rich, while the gradient for
the use of ambulatory care services favors the poor. The use of private hospital services did
not change much, but the use of private sector ambulatory care services increased
significantly, particularly by the poor.
E.1.1 Outpatient of Private Hospital
In 2001 mean of the utilization rate of Outpatient Care of Private Hospital was 0.51% (0.005
from 0-1 probability scale). The Richest community (20%) had a 6.77 times greater
utilization of Outpatient Care of Private Hospital than the Poorest community (20%). In
2005 the mean of the utilization rate of Outpatient Care of Private Hospital was 0.63%
(0.006). The Richest community (20%) had a 4.79 times greater utilization for Outpatient
Care of Private Hospital than the Poorest community (20%). In 2006 the mean of the
utilization rate of Outpatient Care of Private Hospital was 0.70% (0.007). Richest community
(20%) had a 6.44 times greater utilization of Outpatient Care of Private Hospital than the
Poorest community (20%). In 2007 the mean of the utilization rate of Outpatient Care of
Private Hospital was 0.82% (0.008). Richest community (20%) had a 5.21 times greater
utilization for Outpatient Care of Private Hospital than the Poorest community (20%).
E.1.2 Outpatient Care of Private Provider (Private Practitioners)
In 2001 households’ chance to utilize Outpatient Care of Private Provider was 8.25%
(0.083). The Richest community (20%) had a 1.48 times greater chance of utilizing
Outpatient Care of Private Provider than the Poorest community (20%). In 2005 the
utilization rate of Ambulatory Care / Outpatient Care of Private Provider was 8.05% (0.08).
Richest community (20%) had a 1.27 times greater chance of utilizing Outpatient Care of
Private Provider than the Poorest community (20%). In 2006 households’ chance to utilize
Outpatient Care of Private Provider was 8.0% (0.08). The Richest community (20%) had a
1.12 times greater chance of utilizing Outpatient Care of Private Provider than the Poorest
community (20%). In 2007 community’ chance to utilize Outpatient Care of Private Provider
was 12.88% (0.13). The Richest community (20%) had a 1.03 times greater chance of
utilizing Outpatient Care of Private Provider than the Poorest community (20%).
E.1.3 Outpatient Care of State Hospital
In 2005, the mean of the utilization rate of Outpatient Care of State Hospital was 1.23%
(0.012). Richest community (20%) had a 2.76 times greater chance of utilizing Outpatient
Care of State Hospital than the Poorest community (20%). In 2007 the mean of the utilization
rate of Outpatient Care of State Hospital was 1.38% (0.014). Richest community (20%) had a
2.06 times greater chance of utilizing Outpatient Care of State Hospital than the Poorest
community (20%).
30
E.1.4 Inpatient Care in Private Hospital
In 2005, the mean of the utilization of the Inpatient Care Unit of Private Hospital was 0.26
(scale: 0 to 1) or 2.62%. Estimation of the utilization rate of Private Hospital services was
2.62%. The Richest community (20%) utilization Inpatient Care Unit was 9.6 times higher
than the poorest community (20 %). In 2006, the mean of the utilization rate of inpatient care
unit of Private Hospital was 0.027 (2.70), or if it is Proxy for the utilization rate there were
2.70 % of the community that would utilize inpatient care unit of Private Hospital. The
Richest community (20%) utilization the service was 8.7 times greater than the Poorest
community (20%). In 2007, the mean of the utilization in inpatient care unit of Private
Hospital was 0.045 (4.46%) Estimation of the utilization rate in Inpatient Care Unit of
Private Hospital was 4.46 %. The richest community (20%) utilization of Inpatient Care Unit
was 6.14 times greater than the poorest community (20%).
E.1.5 Inpatient Care Unit in Private Provider (Non-Hospital)
The mean of the utilization of Inpatient Care Unit of Private Provider (2005) was 0.006 (or
0.61%). Estimation of the utilization rate in Inpatient Care Unit of Private Provider was
0.61% of. The richest community (20%) utilizing inpatient care unit was 1.96 times greater
than the Poorest community (20 %). In 2006, mean of the utilization in Inpatient Care Unit
of Private Provider was 0.005 (0.53%). Estimation of the utilization rate of inpatient care unit
of Private provider was 0.53 % . The Richest community (20%) utilization the service was
3.0 times greater than the Poorest community (20 %). In 2007, the chance of the Indonesian
community utilizing the service was 0.012 (1.18%). Estimation of the utilization rate of
inpatient care unit of Private provider was 1.18 % of the Indonesian community that would.
The Richest community (20%) utilization of the service was 2.13 times greater than the
Poorest community (20 %).
E.1.6 Inpatient Care, State Hospital
In 2005, the mean of utilization of inpatient care unit of State Hospital was 0.044 (4.39%).
Estimation of the utilization rate of inpatient care of State Hospital was 4.39 %. The Richest
community (20%) utilization of the care unit was 3.12 times greater than the Poorest
community (20 %). In 2006 the mean of the utilization rate of outpatient care unit of State
Hospital was 0.046 (4.58%). Estimation of the utilization rate of inpatient care unit in State
Hospital was 4.58 %. The Richest community (20%) utilizing inpatient care unit was 2.06
times greater than the Poorest community (20 %). In 2007, the mean of the utilization rate of
outpatient care unit of State Hospital was 0.073 (7.33%). Estimation of the utilization rate
of inpatient care unit in State Hospital was 7.33% The Richest community (20%) utilizing
the service was 2.19 times greater than the poorest (20%).
E.2 The role of government in the hospital sector
In describing the role of government in Indonesian hospital sector, this section uses the
World Bank’s report (1997) that emphasized on the state’s roles in improving the
distribution and market failure. The report mentioned that a state holds 3 levels of roles: ( 1)
minimum role; ( 2) middle role; and ( 3) role as activity executor. In the minimum role, a
government performs as a public service provider, for instances: defense, law and regulation,
31
copyrights, microeconomic management, and public health. Besides, the government should
improve programs to overcome poverty, protecting the poor, and handling disaster. In the
higher role, within the activity of overcoming the market failure, a government should
conduct a variety of activities, for instances: guaranteeing elementary education, protecting
environment, arranging monopolies, overcoming matters related to uneven information, and
to provide social insurance.
In hospital service the government major role can be differentiated into three functions
(Kovner 1995): financing, delivery, and regulation. In a decentralized country like Indoneisa,
there are multiple governments: national, provincial, and districts. These functions are
distributed using complex legal authority transfer. Moreover in a market-based system, the
role of government can be in the form of providing subsidy or taxation for preventing the
market failure.
Based on the historical observation it is clear that private hospitals in Indonesia
experienced a transformation from military and philanthropic organizations became for-profit
corporation between 1998-2008. The impact of this transformation is the increase of market
failure in hospital service. The progress of medical technology and epidemiology increase the
hospital service cost which can not be paid by poor family. The for-profit corporate hospitals
target the lucrative afluent community, while the non-profit organisations serve the poor
ones. The market failed to provide hospital services for everybody.
This section will discuss the role of government of Indonesia in overcoming the market
failure. An international analysis will be presented. The approach of the discussion used
circular flow which based on the following diagram:
Production Market
Household
expenditure
Revenue
Goods and
Services
demanded
Goods
and
Services
Provided
Firm
Household
Input factors
from household
Firms input
Production Cost
paid by Firm
Household
income
Production Factor
Market
Figure 6. The Circular Flow
Hospital can be regarded as a Firm, in the form of for profit or non-profit organization.
Hospitals produce services to household. The households demand hospitals services and use
payment to buy the service in the product market. On the production factor market,
households provide one of the inputs for production. The input will be paid by the hospitals.
32
Using this model, poor households who do not have enough financial resources for
accessing hospital service will be left out from the market. Moreover some hospitals can not
have medical doctors because the cost of paying the doctors is too high. Hospital will cease to
operate. Therefore there is a need for various government interventions in the hospital
market.
E.2.1 Financing function
The financing role in Indonesian hospital service takes a long route of transformation
from direct government subsidy to the hospital, community payment, and charity financing to
a new model of complex social security. Before the economic crisis in 1997, government
financing to hospital basically is a subsidy type for public hospitals. Private hospitals can not
get the subsidy, although in colonical period, government provided subsidy for missionarist
hospitals. The absence of direct subsidy to the hospitals make the hospitals serve more for the
rich. It is reported in series of Equitap research that Indonesia’ richer groups are using
hospital more than the poor10. This is a complete opposite compared to the utilization of the
health centers.
The lack of subsidy and the declining charity funds for private hospitals (which includes
the traditional Christian and Catholic hospitals), gradually marginalized the poor from
hospitals. Although missionarist hospital was established for charity purpose, the user of
these hospitals is dominated by the rich community. The non-profit hospital is branded as for
profit ones. This labelling became more problematic due to the economic behaviour of
medical specialists. The specialists became a very afluent and elitist group in Indonesian
society. Many traditional charity donation for faith-based (especially the Christian) hospital
gradually declined. Many faith-based leaders use the cross subsidy approach for financing the
poor patients. The meaning of cross subsidy is limited to the use of so-called “profit” from
VIP patients charges to cover the cost of services to the poor.
In early 1990s, the public hospitals policy were influenced by the corporatization and new
public management movement. A new policy of financial autonomy in public hospitals was
established through Presidential Decree (Swadana policy in 1993).This policy was actually
intended to improve the quality public hospital through the flexibility of financial
management and the direct use of hospital revenue. The hospital revenue can be used to
increase the doctor’ income through fee-for-service payment mechanism. The immediate
impact of this policy made many public hospitals built VIP ward, or formalizing the ilegal
doctor’s payment. Medical specialist enjoyed the increase of income through this policy.11
However some of high officers in Indonesia thought that financial autonomy (Swadana)
policy equal the decrease of subsidy for public hospitals. A nation-wide endorsement for the
so called “cross-subsidy” was organised during the implementation of Swadana policy.
Various cost-analysis studies done by Gadjah Mada University proved that there is no profit
from VIP wards. Using accounting principles, the VIP wards in public hospitals and also
some private hospitals, were making loss instead of profits. However the revenue from VIP
O’Donnell O, Van Doorslaer E, Rannan-Eliya R, Somanathan A, Co-Author; Adhikari S, Baktygul
Akkazieva B, Harbianto D, C. Garg C, Hanvoravongchai P, N. Herrin A, N. Huq M, Ibragimova S, Karan A,
Kwon S, M. Leung G, Rachel Lu J, Ohkusa Y, Pande B, Racelis R, Tin K, Tisayaticom K, Trisnantoro L, Wan
Q, Yang B, Zhao Y . 2008.; Who Pays for health care in Asia. Journal of Health Economics; vol.27, 460-475.
10
11
Trisnantoro L. 2004. The use of Economics in Hospital Management. Gadjah Mada University Press.
33
patients can be used directly for increasing doctor’s income and hospital facilities. The debate
of “cross-subsidy” became intense. The view from Gadjah Mada University pointed out that
hospital accross Indonesia should be managed by corporate-type management system but
should be subsidized for financing the cost of services to the poor patients. There is no place
for cross-subsidy in hospital management. The use of “profit” from VIP had no evidence and
was flawed. The rich, in fact, can be poor due to illness. The cost for the poor should be
financed by government budget not by community.
In 1997-1999, Indonesia suffered from catastrophic economic crisis. To overcome the
financial impact for the poor family Government of Indonesia launced a massive national
policy of Social Safety Net using ADB financing scheme. The Social Safety Net covered
health and hospital service called as Health Sector Social Safety Net. This policy actually
introduced for the first time: the subsidy for household (demand side). In 1999 national
hospital association meeting, the debate of cross subsidy was openly discussed. Trisnantoro
coined the new term of Indonesian hospital as a
This government intervention in the household growth politically and became social
security movement to support household for accessing hospital services. Social security in the
forms of: Social Safety Net (1999) was replaced by Askeskin program (2004) and Jamkesmas
(2005). This policy aims to lower the financial barier to the poor by providing social security.
The impact of this protection policy is clear. The incidence of catastrophic Out Of Pocket
health expenditures is relatively low and has declined over time12. Equity in utilization of
health services has improved over time, with significant improvements in access to public
hospital services. The incidence of public subsidies for health care has also become more propoor over time.
But, regional inequality in access to services has not improved over time.
Comparison of trends in inequalities with the distribution of health service infrastructure
across Indonesia suggested that physical barriers to access may underlie the regional
inequalities. Shortages in inputs such as medical specialist and trained nurses.
Financial health protection policy allows private hospitals to treat poor and near poor
patients. The Benefit Package is broad, including high technology and costly medical
treatment. The benefit packet increases the access of poor and near poor in urban and Java for
private hospital and high cost medical care. Based on Provincial Data (33) and Susenas
(Household Survey) data at Provincial Level showed that the higher the ratio of hospital bed
and population in a province, the more the utilization of hospital. The same pattern happened
accross quintile in public and private hospitals.
As summary, the national policy for financial protection have positive pro-poor
impact. But, this is insufficient. The regional inequity was not sufficiently tackled during
2001 – 2008. Without policy for improving medical service and medical doctors distribution,
it is projected that central government budget for financial protection will be used mostly by
urban and Java population.
E.2.2 Regulation function
According to other references, the regulation role of government covers of stewardship
function. Stewardship is defined as a “function of a government responsible for the welfare of
the population, and concerned about the trust and legitimacy with which its activities are
viewed by the citizenry”.13 Preker et al14 describe the stewardship function for guiding the
12
Trisnantoro L. Somanathan A, Harbianto D. 2009. Health care financing reforms in Indonesia: bridging
health economics and policy, Equity and Financial Protection in Health Care. IHEA Conference Beijing
13
World Health Report 2000.
34
health system along policies and coordinates the various stakeholders and players within an
established framework.
In Indonesian hospital system, Ministry of Health is one of the important actors in
regulation function. However, in reality Ministry of Health holds multi-function position as
Stewardship authority, financier agent, health and hospital governance policy makers, and
also executing operational management. This multi-function role is the responsibility of the
Director General of Medical Service. This DGs supervises more than 1400 hospitals across
Indonesia, while in the same time operates around 34 central government hospitals. The
supervising function is delegated to provincial and district level, through decentralization
policy.
In a decentralized Indonesia, it could be seen that the efforts to improve public health
status were not only government domain especially the Ministry of Health. Regulation No. 38
Year 2007 and No. 41 Year 2007 emphasized that Provincial and District Health Office
should coordinate various agents in health care sector. Decentralization of health care
principally delegated health affairs to the regional government. The local government offices
were the highest institution in charge of a sector delegated to the region. At provincial and
district level, the regulatory function is held by PHO and DHO respectively. Provincial and
district public hospitals were separated from PHO/DHO. The policy of shifting public
hospitals away from PHO and DHO is inline with an important concept was based on the
Good Governance as stated by the United Nations Development Program (UNDP): "The
exercise of economic, political and administrative authority to manage a country's affairs at
all levels. It comprises the mechanisms, processes and institutions through which citizens and
groups articulate their interests, exercise their legal rights, meet their obligations and mediate
their differences ...".
Using this definition, public hospitals are monitored and supervised by DHO/PHO and
should be re-licenced every 5 year. This licence policy is similar to private hospitals relicencing system. This policy reflects the political willingness of government to become the
regulator of health system which based on market system.
A state-owned hospital was similar to the private hospital concerning this matter. In
Government’s Regulation No. 38 Year 2007, the district administration was in charge of: (1)
giving recommendation concerning license on certain health facilities provided by the
government and the provinces, (2) Giving a license to health facilities including hospital from
class C, class D, the equivalent private hospitals, group practices, general/ specialist clinics,
maternity clinic, family doctor/ dentist, complementary medicine, traditional healing, and
equivalent supporting facilities.
One of the consequences of Government’s Regulation No. 38 Year 2007 was the
separation of government functions as a hospital regulator and operator. In the regional level,
it was clear that state-owned hospitals no longer acted as integrated service unit offices, but it
was an operator separated from the Office (Law No. 32 Year 2004, Law no. 1 Year 2005 on
public service agency, Government’s Regulation No. 41 Year 2007). In the region,
Government’s Regulation No. 41 Year 2007 as a derivative of Law No. 32 Year 2004 firmly
stated that Regional Hospital was not part of the Official services (Government’s Regulation
No. 41 Year 2007 Article 22). Local Hospital underwent a process called corporatization,
while the Health Office was expected to undergo the process as a regulator. Thus, in the
future, Government’s Regulation No. 41 Year 2007 gives clear directions to the relationship
between Health Office and state-owned Hospital based on the principle of good governance.
Provincial government was in charge of: (1) providing recommendation to the
government on license concerning particular health facility, and (2) giving a license to health
14
Preker A. Liu X. Velenyi E. Baris E. 2007. Public Ends Private Means. The World Bank
35
facilities including state-owned hospital class B non-teaching hospital, specific hospitals,
private hospitals and equivalent supporting health facilities.
At central level, this situation has not happened yet. DG of Medical Service still
manages the operational activities of big teaching hospitals and other central government
hospitals. This multi-function costs dearly. Various hospital policies and regulation are not
well managed by MoH. There is a battle of turf on licencing, accreditation system, and
equipment procurement. Corruption based on medical equipment facilities is increasing in the
last 10 years.
The separation of operator from the regulator was an important part of the governance
principle. By changing the central state-owned hospital into central public service agency, it
should have a change on Directorate General (DG) of Medical Services. The central stateowned hospitals authorities should change into hospital operators that received similar
treatment with the private hospital, the local state-owned hospital and military hospital. This
was stated firmly in Government’s Regulation No. 38 Year 2007. Meanwhile the Ministry of
Health should act as the regulator and policy maker. In the future it is expected central
hospitals become a non-bureaucratic institution (in terms of an institution that provides public
services) and transfered from DG of Medical Services. This DG should concentrates in the
regulatory function of hospital system in Indonesia.
E.2.3 Delivery function
The development of private hospital can not be separated from the policy of
organizational structure in the delivery function. After independence, gradually statehospitals becoming more bureaucratic. The management of public hospitals was confused
and had no conceptual framework. Medical doctors were not satisfied with professional
income and have multiple-practices in the private sector. Even, some prominent specialists
established their own hospitals. Public hospitals suffered from the effect of poor management
system, and they became the inferior-good compared to private ones.
To improve the delivery function, the limited financial autonomy (Swadana) policy was
continued with various changes. The latest was in 2007 by the Decree of Ministry of Home
Affairs (Kepmendagri) No. 61 on regional Public Service Agency (BLU). This Decree was a
final culminating point concerning the centralized policy on BLU that began in 2004 (Laws
No. 1 on State Treasury) and continued with the Government Regulation (PP) No. 23/2005.
The policy on Public Service Agency (BLU) is conceptually a governmental decree that
acknowledges facts that there are three types of services administered by government such as:
(1) Public goods; (2) Semi (quasi) public goods; and (3) private goods. The separation
between public and private goods is not a dichotomy, rather implies a spectrum, supported by
quasi-public goods.
Public Goods
Private Goods
Figure 7. A Continuum between Public and Private Services
36
In the hospital context, it is clear that the service is not a only public goods or private
goods. Whatever services done, original public goods are needed for all customers, for
example, in the ICU. Meanwhile, services using private goods, for example, are appropriate
for plastic surgical operation. The decision to choose public and private goods depends on the
willingness and ability of state to pay them.
In the ideal situation, all citizens have rights to get a good health service because they
deserve it. Indeed, this is an urgent need to access all public goods-oriented health services.
However, medical technology and hospital service are costly hence it is impossible for
Indonesian government to finance everything. Some customers are able to pay for every
service provided, but some others are not.
In the regulated market environment Government of Indonesia choose the policy of not
privatizing the delivery of public hospital services. This is also stated in the Hospital Laws
which was enacted on the end of 2009. The chosen strategy is Public Service Agency (Badan
Layanan Umum, BLU) that recognizes a concept called quasi-public goods. Therefore,
governmental revenues from Local Revenue & Expenditure Budget (APBD) and State
Revenue & Expenditure Budget (APBN) can be used, and this institution has authority to get
income from public health services paid by communities.
KONSEP BLUD
BLUD
PERSERO
BUMD
PUBLIC
GOODS
QUASI PUBLIC
GOODS
SEKTOR
SEKUNDER
PDRB
MENINGKAT
PRIVATISASI
JASA LAYANAN
JASA LAYANAN
APBD
SKPD
APBD JASA LAYANAN
SEKTOR
PRIMER
PENDAPATAN
MASYARAKAT
MENINGKAT
SEKTOR
TERSIER
PRIVATE GOODS
Figure 8. Public Service Agency (BLU) Concept Coined by Ministry of Home Affairs
Referring to the diagram above, it is clear that the status of a hospital as a Public
Service Agency (BLU) is a non-profit state corporation. This kind of hospital is managed by
central or local government, act as a service unit but continued to be subsidized for providing
the service for the poor. By using a Public Service Agency (BLU) system, state-run hospitals
avoid bureaucratic nature of services; however, it is not a for-profit State-Owned Corporation
or privatization. In this context, the Public Service Agency (BLU) is not a for-profit
Government-Owned Corporation. The position of a Public Service Agency (BLU) is in the
middle between PNBP (bureaucratic State Enterprise) and for-profit BUMD (Local-Owned
Corporation) or BUMN (State-Owned Corporation) as illustrated below:
37
Bureaucratic Institution Pole
DECREE No. 20/1997
PNBP
Swadana
Corporation Pole
DECREE No. 1/2004
BLUD
BLU
DECREE ON BUMD: DECREE No. 5/1962
DECREE No. 9/1969
( changed in 2003)
For-Profit State Owned Corp
Figure 9. A continuum between Bureaucratic Institution and BUMD
As a non-profit service institution, a Public Service Agency (BLU) cannot avoid an
economic measures in determining service tariffs. For certain poor communities, there is a
tariff that is discounted up to 0 rate to facilitate services. There is also a unit-cost tariff
applied for better off communities, for example, VIP ward services in hospitals. Hence, the
Public Service Agency (BLU) needs to have a unit-cost basis, for example, costs per nursing
patients, laboratory examination cost, and so on. In this matter, an understanding on subsidies
is important to know the costs related to market-cost disparities and the costs of certain
products set by government to fulfill poor communities’ needs. The characteristics of a nonprofit and social mission institution varies. It is neither purely based on humanity nor
commercial-oriented.
Table 16. Some Characteristics of Social and Commercial Institutions
Pure Social
Motivation, method
For goodness
and objectives
guided by a
mission of social
values
Benefited
parties
Do not pay at all
Pure Commercial
Mixed motivation guided
by a mission and market
values
Social and economic
values
Impressive for
self-purpose
guided by
market values
Economic
values
There are subsidies based Pay tariffs
on economic backgrounds based on
and those who cannot pay market value
at all
Capital
Humanity and
grant funds
A mixture between
humanity fund donation
and market value capitals
Market value
capitals
Workforce
Voluntary
It is paid under market
value or a mixture
between fully paid
voluntaries
Market value
compensation
Supply of
materials
It is hoped that the
supply of materials
is based on
humanity donation
Special discounts or a
combination between
donation of full-price
supplies
The supply of
materials is
paid based on
market value
Key
Stakeholders
Source: Dees, 1999.15
15
Dees J.G. (1999). Enterprising nonprofits. In Harvard Business on Nonprofits Harvard Business Press.
38
Combined with BLU policy, a new policy for having modern technology in hospital
service, some big teaching hospitals like RSCM in Jakarta was granted internationalisation
project for hospital service. This policy had impact on acquiring new medical technology.
Private hospitals, including the luxurious hospitals is left behind in terms of technology.
Using the new management system and flexible incentive system for medical doctors, some
specialists prefer to stay in the teaching hospitals. This will be the new generation of medical
specialist who do not want to continue on dual practices.
E.3 Tax and Levy policies
Using the circular flow concept, an important role of Government is identified in terms of
the tax and levy policies. The use of Taxation on product sales may reduce the household
consumption, such as in cigarette or alcohol tax. In the economy, tax incentives are usually
meant to either reduce the tax burden on a particular segment of society in the interests of
fairness and/or to promote some type of economic activity through reducing the tax burden
on those organizations or individuals who are involved in that activity. Values existed in
taxation policy. A nation's tax system is often a reflection of its communal values or the
values of those in power. To create a system of taxation, a nation must make choices
regarding the distribution of the tax burden—who will pay taxes and how much they will
pay—and how the taxes collected will be spent.
In Indonesia, before the new Hospital Law in 2009, the tax policy is not supportive for
hospital development, especially the non-profit. There is no tax incentives for hospitals which
provide charity care or social duty. There is no tax incentive for corporation which give
charity donation to support hospital. On top of these, there are many levies for hospital. This
was one of the reasons why many non-profit hospitals suffer from financial problems. In
domestic competition, the foundations based non-profit hospitals must serve the poor due to
faith-based dogma and humanity mission. Most foundation hospitals work in middle and
lower class of the society which is funded by Jamkesmas. This market segment is a making
loss market. On the other side the for-profit hospitals operated in higher economy group. This
market segment is lucrative. The irony is that the non-profit and for-profit hospitals have the
same tax treatment16.
The same taxation treatment for non-profit and for-profit hospitals is unfair. The charity
hospitals will be less efficient compared to the for-profit. It is worsen by the fact that some
religious leaders still applied the idea of internal cross-subsidy for financing poor patients. In
some big cities such as Jakarta and Surabaya, the market share of faith-based hospitals is
shrinking. Another problem is the relatively unclear Foundation Laws which is applied to
non-profit hospitals. Compared to the for-profit Corporate Laws, the Foundation Laws lacks
of governance arrangement and financial control system. As the result, some foundation nonprofit hospitals act like for-profit ones.
For international competition, the tax burden and also high levy and custom for medical
facilities increases the Indonesia hospital cost. For instance, compared to Malaysia, Vietnam
which has tax and custom incentives for hospital service, Indonesia hospitals have to pay
more taxes and levies. Up to 2009, Government of Indonesia opted the position not to
promote hospital sector as an economic activity based on industrial principle. However in
16
FGD, leaders of Christian, Catholic, Moslem, Local Government, and Indonesian hospital associations held in Granadi
September 2009.
39
2009, after an intense lobbying from faith-based hospitals and teaching hospitals associations,
the new Hospital Laws (initiated by Ministry of Health) provided a chance for having tax
incentive for public hospitals, non-profit private hospitals and teaching hospitals. However
this Law still has difficult implementation due to the fact that the Tax Laws (initiated by
Ministry of Finance) are not moving in the same direction. The Tax Laws stated that hospital
sector is unlike education or research, thus it is subject for taxation like any other industries.
Based on the function of government, the important question is that how the future policy
on private hospitals? From the discussion above it is clear that the policy on finance,
regulation, delivery, and taxation in not developed in an integrated manner. It can be stated
that at current situation, Government of Indonesia policy on state and private hospitals is still
an ongoing progress. One important statement is that being in the hospital business is not
charity in and of itself. This statement is important for addressing the roots of the problems of
hospital service: whether hospital is an industrial sector or a social one, or a combined
feature.
An interesting question is: from which country does Indonesia need to learn more
about hospitals policy? To answer this question it is important for some matching the macro
economy characteristic, the government functions and health system characteristics.
Table 17. The characteristics of some countries in health system
Country
Structure
Economy
Health
Financing
Regulation Delivery
Taxation
US
Federal
Regulated
Market
Multiple
sources
Highly
regulated
Big private
sector
UK
Centralized
Tax based
Indonesia
Decentralized
Highly
regulated
Low
regulated
Small private
sector
Big private
sector
Malaysia
Centralized
Cuba
Centralized
Regulated
Market
(un)
regulated
market
Regulated
market
Communism
Incentives
for
charity
care
No
nonprofit
Still in the
beginning
Highly
regulated
Government
Small private
sector
Government
providers
Multiple
Sources
Tax based
Government
Revenue
All private
are for profit
No private
The above table shows that Indonesia shared the most identical characteristic with the US. In
Indonesia, the Safety net system is typically the same principle with Medicaid and Medicare.
Medicaid, the health care program for low-income families, which is funded principally with
federal and state finance is similar with Jamkesmas (National social fund) and Jamkesda
(Local government social fund). The US public hospitals and clinics, which are funded with a
mix of federal, state and local tax dollars are in the same situation with Indonesian public
hospitals. Publicly-funded charity care, which is also subsidized with federal, state and local
tax dollars given to non-profit hospitals in the form of tax breaks is now became the subject
for tax incentives in Indonesia.
To further enable the private sector, in particular the non profit hospital to grow, the
government should have a clear regulation based on:
 Clear definition of “charity care”, “non profit”, “community benefits”, etc.
 Sound accounting practices for non profit hospital
 Requirement for charity care plan and policies
40
Some of the legislation choices that the government could make are:
 Tax exempt based on the amount of charity care or community benefit for
public hospitals;
 Levy relief based on the amount of charity care
 Tax incentives for corporate or individual donations
 Lowering import custom for medical technology equipment
 Social charges (discounted) for utilities charges (water, electricity, etc)
E.4 Contracting Out
After more than 8 years of applying decentralization policy in Indonesia, there is a
pertinent question to ask. Is decentralization able to improve health services efficiency and
even distribution? A myriad of facts shows that local government, particularly health
department at provincial and regional levels has something to do with difficulties to manage
health services in remote regions in hinterland or archipelago. In general, the governments
have limited or even no capacity to solve the problem concerning even distribution of health
services in such regions. Ideas and alternative solutions such as contracting out system should
be taken into consideration.
Regencies in Eastern Indonesia also tried contracting out system. Yahukimo Regency
in Papua pioneered contracting out system as well. It was directly managed by Yahukimo
Regent not through the bidding but through cooperation or a Memorandum of Understanding
(MoU) with a foundation based in Bandung. This foundation provides health and medical
workers to assist the implementation of health services in agreed remote areas. The model
applied in Yahukimo is legally possible due to the issuance of Government Regulation (PP)
No.50/2007 on Implementation Procedures of Local Cooperation though its operational
regulations are being in the process of completion.
Government Regulation (PP) No.50/2007 provides new cooperative opportunities with
local governments in regencies, Ministry of Health, Health Science College or University,
NGOs or foundation. The local governments have the initiative to take “opportunities” and
make an MoU with the college or university and then negotiate with the Ministry of Health to
get allocation of Non-permanent Employee (PTT) budget based on the needs, and finally
cooperate with NGOs or foundations to manage preparation, placement, empowerment,
monitoring, evaluation and contracted health and medical workers’ rotations. These
alternatives can be applied by regencies that have limited Local Revenue & Expenditure
Budget (APBD). On the other hand, for rich regencies, the contracting out alternative as
applied in Berau Regency is worth considering.
The prospect of contracting-out system in decentralized era is more promising.
However, for rich regions, the awareness and stakeholders’ commitments are required to
support those activities. By contrast, for poor regions, the creativity to cooperate with other
institutions is necessary, including asking for capable human resources and budgets from
either central, local governments or donors.
Source of funding may vary. For rich regencies, the support from Local Revenue &
Expenditure Budget (APBD) is not problematic like what has happened in Berau Regency.
For regencies in Papua and West Papua, they special autonomy funds and also the
opportunities to use a program called Save Papua initiated by central government, or they
take funds from donors like AusAid, or other donor agencies. For poor regencies, the
creativity to support cooperation with other institutions is important, but it is easy without
participations of central government and/or donors.
41
Sustainability or continuity of contracting-out activities can be seen from three aspects
namely permanent budget, the regional development and the agents involved. From the
budget perspective, the experience in Cambodia, which had strong dependency to donors,
budget availability and sustainability became huge problems. When donors stopped the
funding, Cambodia Government found difficulties to continue contracting-out activities. It
seems that richer country or regions had more potential to keep the sustainability of such
activities.
From the regional development aspect especially in remote regions, the contracting-out
activities are less relevant if the regions will be developed in years to come. In a long-term
plan, contracting-out opportunities are applied in remote regions.
From the health department and service provider aspect, the health and medical workers
might succeed in doing their work, but they tend not to renew the contract for the rest of their
lives. From the perspective of agents involved such as health and medical workers, the
anticipation of high turn over rate is common because it is hard to recruit permanent workers
who want to work in remote areas for the rest of their lives.
On of the big problems was little availability of contractor workers. Another serious
problem is legal/law aspect that was unclear. So far there was no legal procedure that might
regulate such a matter. The availability of contracting-out services is technically regulated
through the given procedures.
The Presidential Regulation (PP) No.50/2007 on
Implementation Procedures of Local Cooperation though its operational regulations are being
in the process of completion.
The problem of outsourcing law or contracting-out system particularly the contractingout availability of health workers and health services is greater than that of the contract in
company scope. In Government Regulation (PP) No. 41/2007 Article 14, the functions of
regional/municipal health department are:
1. The formulation of technical policy based on job descriptions
2. The administration of governmental affairs and public services suitable with the job
descriptions
3. Trainings and job implementations based on tasks/assignment scopes; and
4. Other jobs implementations offered by the regents/mayors akin to their functions.
According to the policy, the public service is one of the functions of health department.
In the scope of health department, one of the types of public services is health service. In its
implementation, this function is not done by the health department itself, but it is delegated to
the Integrated Service Unit (UPT) through the Community Health Center (Puskesmas). That
is why health department is proactive in formulating technical policies and trainings.
Referring back to the previous explanation, there are some legal problems that may
happen:
1. The duty and its function relating to the availability of health and medical workers
including the contracted ones is not part of health department’s function (it is usually
undertaken by Regional Officialdom Board/BKD).
2. Is the contracting-out initiative through health department categorized as one of
technical policy formulations function?
3. Is this matter against the Article 64 and 65 of the Decree (UU) No. 13/2003
concerning the labor system that becomes the basis of outsourcing implementation?
The existing regulations are insufficient to regulate contracting-out health services as
the main authority of health department. This is common because contracting-out system is
42
particularly used to manage health services in remote regions. There are some supporting
regulations that can be considered fully:
1. Presidential Decree of Republic of Indonesia (Keppres RI) No. 80/2003 that has
been amended seven times (finally through Presidential Decree No. 95/2007)
2. Decree on Labor No. 13/2003
3. The Decree of Labor and Transmigration Minister of Republic of Indonesia No.
101/2004 on Procedures of Licensing Service Provider Company for
Employees/Laborers
4. The Regulations of Minister of Home Affairs (Permendagri) No. 61/2007 on
Technical Guidelines for Financial Management of Regional Public Corporation as
particularly regulated in Article 2 Paragraph 1
5. Governmental Regulations No. 50/2007 on Implementation Procedures of Regional
Cooperation
6. The Regulations of Minister of Health No. 1199/2004 on Procedures on the
Availability of Health Workers using Work Agreement in State-owned Health
Infrastructures
Although these innovations are still difficult to implement, contracting-out system
could become one of the solutions in anticipating the lack of health and medical workers in
remote regions.
43
Appendix 1
Number of hospitals and beds in Indonesia according to their ownership
NO
PROVINCE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
NAD
Sumatera Utara
Sumatera Barat
Riau
Jambi
Sumatera Selatan
Bengkulu
Lampung
Bangka Belitung
Kepulauan Riau
DKI Jakarta
Jawa Barat
Jawa Tengah
DIY
Jawa Timur
Banten
Bali
NTB
NTT
Kalimantan Barat
Kalimantan Tengah
Kalimantan Selatan
Kalimantan Timur
Sulawesi Utara
Sulawesi Tengah
Sulawesi Selatan
Sulawesi Tenggara
Gorontalo
Sulawesi Barat
Maluku
Maluku Utara
Papua Barat
Papua
INDONESIA
STATE
H
26
61
22
17
13
23
8
10
5
9
30
56
60
10
88
10
13
11
16
19
11
18
18
9
11
38
11
4
3
11
6
7
13
667
B
2,266
7,382
2,988
1,484
1,037
3,009
705
1,296
429
710
7,712
8,705
11,444
1,716
13,609
1,459
2,187
1,098
1,586
1,815
721
1,694
2,287
1,603
1,070
5,093
788
460
159
983
379
514
1,208
89,596
PRIVATE
H
B
7
68
19
8
4
9
1
11
2
6
91
80
114
25
78
16
20
2
9
9
8
10
11
8
19
4
1
7
2
4
653
320
4,986
970
615
248
1,058
106
967
186
575
9,017
7,415
8,987
2,091
6,494
1,075
1,013
117
559
954
496
905
1,157
379
1,572
122
50
526
122
206
53,288
44
TOTAL
H
33
129
41
25
17
32
9
21
7
15
121
136
174
35
166
26
33
13
25
28
11
26
28
20
19
57
15
4
4
18
6
9
17
1,320
B
2,586
12,368
3,958
2,099
1,285
4,067
811
2,263
615
1,285
16,729
16,120
20,431
3,807
20,103
2,534
3,200
1,215
2,145
2,769
721
2,190
3,192
2,760
1,449
6,665
910
460
209
1,509
379
636
1,414
142,884
Appendix 2. The Number of State Hospitals
Bed
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
146
293
150
589
149
291
151
591
147
296
150
593
137
308
150
595
135
312
151
598
140
320
149
609
148
319
150
617
152
318
155
625
162
320
160
642
166
312
176
654
177
314
176
667
0 - 50
51 - 150
> 150
Total
Average
growth
(hospital/year)
3.1
2.1
2.6
Appendix 3. Number of Private Corporate Hospitals and Number of Beds across
Provinces
Type
N
O
GH
PROVINCE
1
2
MATERN
AL AND
CHILD
HOSP
EYE
HOSP
MATERNIT
Y HOSP
R T
S T
RS
TT
RS
TT
RS
TT
R
S
T
T
R
S
TT
9
10
11
12
13
14
15
16
17
18
R
S
TT
R
S
TT
3
4
5
6
7
8
SURGICA
L HOSP
ENT
HOSP
TOTA
L
MENTAL
HOSP
1
NAD
1
47
-
-
-
-
-
-
-
-
-
-
-
-
1
47
2
Sumatera Utara
6
534
-
-
-
-
-
-
-
-
-
-
-
-
6
534
3
Sumatera Barat
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4
Riau
3
218
-
-
-
-
-
-
1
25
-
-
-
-
4
243
5
1
68
-
-
-
-
-
-
-
-
-
-
-
-
1
68
6
Jambi
Sumatera
Selatan
1
89
-
-
-
-
-
-
-
-
-
-
-
-
1
89
7
Bengkulu
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
8
Lampung
1
190
-
-
-
-
-
-
-
-
-
-
-
-
1
190
9
Bangka Belitung
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
10
Kepulauan Riau
2
254
-
-
-
-
-
-
-
-
-
-
-
-
2
11
DKI Jakarta
22
2,705
1
25
1
19
1
34
8
356
-
-
1
20
34
12
Jawa Barat
11
1,209
-
-
-
-
-
-
5
225
2
50
-
-
18
254
3,15
9
1,48
4
13
Jawa Tengah
3
253
-
-
-
-
-
-
1
40
-
-
-
-
4
293
14
DIY
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
15
Jawa Timur
4
401
-
-
-
-
-
-
-
-
-
-
-
-
4
401
16
Banten
3
387
-
-
-
-
1
25
1
25
-
-
-
-
5
437
17
Bali
1
70
-
-
-
-
-
-
-
-
-
-
-
-
1
70
18
NTB
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
19
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
1
72
-
-
-
-
-
-
-
-
-
-
-
-
1
72
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
23
NTT
Kalimantan
Barat
Kalimantan
Tengah
Kalimantan
Selatan
Kalimantan
Timur
4
223
-
-
-
-
-
-
-
-
-
-
-
-
4
223
24
Sulawesi Utara
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
25
Sulawesi Tengah
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
26
1
46
-
-
-
-
-
-
-
-
-
-
-
-
1
46
27
Sulawesi Selatan
Sulawesi
Tenggara
-
-
-
-
-
-
-
-
1
25
-
-
-
-
1
25
28
Gorontalo
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
29
Sulawesi Barat
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
30
Maluku
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
31
Maluku Utara
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
32
Papua Barat
1
72
-
-
-
-
-
-
-
-
-
-
-
-
1
72
20
21
22
45
Type
N
O
GH
PROVINCE
R
S
33
Papua
INDONESIA
TT
MENTAL
HOSP
EYE
HOSP
MATERNIT
Y HOSP
R
S
R T
S T
RS
TT
TT
MATERN
AL AND
CHILD
HOSP
RS
TT
SURGICA
L HOSP
ENT
HOSP
RS
TT
R
S
T
T
R
S
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
66
6,838
1
25
1
19
2
59
17
696
2
50
1
20
90
Appendix 4 Newly established company-owned hospital (1998-2008)
Year
1999
TOTA
L
Province
Number
The name of Hospital
DKI Jakarta
3
Jawa Timur
Kalimantan Barat
1
1
RS Mitra Kemayoran
RS Medika Permata Hijau
RS Jiwa Mitra Menteng Abadi
RS Husada Utama
RS Agape
2000
Jawa Timur
1
RS Mitra Keluarga Surabaya
2001
Sumatera Utara
1
RS Gleneagles Medan
2002
Kep. Riau
DKI Jakarta
1
1
RS Casa Medical Centre
RS Keluarga Afia
2003
Sumatera Utara
DKI Jakarta
1
4
Jawa Barat
Bali
1
1
RS Horas Insani
RS Mitra Keluarga Kelapa Gading
RSIA Hermina Daan Mogot
RSIA Family
RSIA Puri Medika
RS Siloam Gleneagles
RSU Prima Cipta
2004
Riau
Kep Riau
Jawa Barat
1
1
1
RS Awal Bros Pekanbaru
RS Awal Bros Batam
RSIA Hermina Bogor
2005
DKI Jakarta
Jawa Barat
1
1
RSU Port Medical Centre
RSK Bedah Mitra Plumbon
2006
Riau
Lampung
DKI Jakarta
1
1
2
RSAB Eria Bunda
RSU Urip Sumoharjo
RS Gading Pluit
RSB Kartini
2007
DKI Jakarta
4
Jawa Barat
3
Jawa Tengah
1
RS Puri Mandiri Kedoya
RSIA Zahirah
RSIA Brawijaya
RSIA Berkat Ibu
RSU Meilia
RSU Santosa Bandung Internasional Hospital
RSK Bedah Plastik Aibee Aesthetic Center
RS Medika Mulya
46
TT
7,70
7
Year
Province
2008
Number
The name of Hospital
Banten
Kalimantan Timur
Sulawesi Tenggara
1
1
1
RSIA Ichsan Medical Center
RS Haji Dardad
RSIA Permata Bunda
Riau
Jambi
DKI Jakarta
1
1
2
Jawa Barat
7
Jawa Tengah
Banten
1
1
RS Nusalima
RS Asia Medika Jambi
RS Jakarta Medical Center
RS Royal Taruma
RS Hosana Medika
RS Graha Juanda
RS Ananda
RS Medika Galaxi
RSU AMC
RSIA Bella
RSIA Anna
RSU Deddy Jaya
RSB Putra Dalima
Appendix 5. Number of Foundation and Association Owned Hospitals and Their
Number of Beds according to their region and type of hospital
FOUNDATION AND ASSOCIATION
PROVINCE
2
NAD
Sumatera
Utara
Sumatera
Barat
MENTAL
HOSP
GH
LEPROCY
HOSP
TUBERCOLOSIS
/LUNG HOSP
MATERNITY
HOSP
EYE HOSP
TOTAL
OTHER
SPECIAL
HOSPITALS
MATERNAL AND
CHILD HOSP
RS
TT
RS
TT
RS
TT
RS
TT
RS
TT
RS
TT
RS
TT
RS
TT
RS
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
4
220
-
-
-
-
-
-
-
-
-
-
2
53
56
4,198
1
40
-
-
-
-
-
-
-
-
5
214
9
610
1
40
-
-
-
-
3
90
4
178
-
-
-
-
-
-
2
52
TT
20
6
273
62
4,452
19
970
-
4
372
3
180
8
969
Riau
4
372
-
-
-
-
-
-
-
-
-
-
-
-
-
Jambi
Sumatera
Selatan
2
136
-
-
-
-
-
-
-
-
-
-
-
-
1
44
6
857
-
-
-
-
-
-
-
-
2
112
-
-
-
-
Bengkulu
1
106
-
-
-
-
-
-
-
-
-
-
-
-
-
-
1
106
-
-
10
777
-
-
2
186
1
25
4
321
278
Lampung
Bangka
Belitung
Kepulauan
Riau
8
699
-
-
-
-
-
-
1
10
-
-
1
68
2
186
-
-
-
-
-
-
-
-
-
-
-
-
3
296
-
-
-
-
-
-
-
-
-
-
-
-
DKI Jakarta
33
4,696
4
202
-
-
1
48
1
18
6
424
2
192
10
57
5,858
Jawa Barat
40
4,993
1
46
-
-
-
-
-
-
8
273
8
466
5
153
62
5,931
Jawa Tengah
70
7,198
5
144
-
-
-
-
-
-
13
685
13
451
9
216
110
8,694
DIY
11
1,563
1
50
-
-
-
-
1
88
2
68
3
100
7
222
25
2,091
Jawa Timur
52
5,322
1
25
-
-
-
-
1
64
4
119
11
435
5
128
74
6,093
25
5
384
-
-
-
-
-
-
-
-
-
-
5
229
1
11
638
Bali
15
848
1
35
-
-
-
-
-
-
1
25
-
-
2
35
19
943
NTB
2
117
-
-
-
-
-
-
-
-
-
-
-
-
-
-
2
117
NTT
Kalimantan
Barat
Kalimantan
Tengah
Kalimantan
Selatan
Kalimantan
Timur
Sulawesi
Utara
8
489
-
-
1
70
-
-
-
-
-
-
-
-
-
-
9
559
-
-
8
882
-
-
1
28
-
-
-
-
Banten
6
674
-
-
-
-
-
-
-
-
1
108
1
100
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4
389
-
-
-
-
-
-
-
-
3
79
-
-
5
634
-
-
-
-
-
-
-
-
-
-
1
48
11
1,157
-
-
-
-
-
-
-
-
-
-
-
-
47
-
-
8
496
6
682
11
1,157
FOUNDATION AND ASSOCIATION
PROVINCE
2
Sulawesi
Tengah
Sulawesi
Selatan
Sulawesi
Tenggara
MENTAL
HOSP
GH
RS
TT
RS
3
4
5
4
251
-
LEPROCY
HOSP
TT
RS
6
7
-
TUBERCOLOSIS
/LUNG HOSP
TT
RS
8
-
TT
9
-
10
-
MATERNITY
HOSP
EYE HOSP
-
RS
TT
RS
11
12
13
1
25
1
TT
RS
14
15
20
1
TOTAL
OTHER
SPECIAL
HOSPITALS
MATERNAL AND
CHILD HOSP
TT
RS
16
17
32
11
1,217
-
-
-
-
-
-
-
-
6
237
1
72
3
97
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
TT
RS
18
19
1
51
-
-
-
-
-
-
-
-
TT
20
8
379
18
1,526
3
97
-
-
Gorontalo
Sulawesi
Barat
1
50
-
-
-
-
-
-
-
-
-
-
-
-
Maluku
6
476
-
-
-
-
-
-
-
-
-
-
-
-
1
50
Maluku Utara
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
1
50
1
50
7
526
Papua Barat
1
50
-
-
-
-
-
-
-
-
-
-
-
-
-
Papua
4
206
-
-
-
-
-
-
-
-
-
-
-
-
-
-
4
206
387
38,491
15
582
1
70
1
48
8
295
51
2,328
54
2,460
46
1,307
563
45,581
INDONESIA
Appendix 6 List of converted hospital (from Nonprofit to For-Profit)
Year
Province
Number
Hospital
2002
Sumatera Selatan
1
RSAB Bunda Prabumulih
2003
DKI Jakarta
Jawa Barat
Sulawesi Selatan
1
1
1
RS Mediros
RS Mitra Keluarga Bekasi
RS Grestelina
2005
Sumatera Utara
DKI Jakarta
Jawa Barat
Jawa Tengah
1
1
1
3
Jawa Timur
Banten
1
1
RSIA Rosiva
RSU Tria Dipa
RS Azra
RS Harapan
RS Puri Asih
RSB Bunda Semarang
RS Wijaya Kusuma
RSU Bhineka Bakti Husada
Sumatera Utara
DKI Jakarta
1
5
Jawa Barat
Jawa Timur
1
1
DKI Jakarta
5
Jawa Barat
Jawa Tengah
1
1
2006
2008
RS Permata Bunda
RS Pondok Indah
RS Mitra Internasional
RS Harapan Bunda
RSB Hermina Podomoro
RSK ENT Prof. Nizar
RSIA Sumber Kasih
RS Budi Mulia
RS MMC
RS Gandaria
RS Medistra
RS Sukmul
RSIA Hermina
RSIA Citra Insani
RSIA Bahagia
48
Appendix 7 List of converted hospital (from For-Profit to Nonprofit)
Year
2006
2008
Province
Sumatera Utara
Jawa Tengah
Number
1
2
Hospital
Jawa Timur
1
RSIA Rosiva
RS Puri Asih
RSB Bunda Semarang
RS Wijaya Kusuma
Sulawesi Selatan
1
RS Grestelina
49