not for profit private sector hospitals in...
TRANSCRIPT
Shita Dewi
Center for Health Service Management FK UGM
Not For Profit private sector hospitals
in Indonesia
The history
NFP hospital: Part of Church mission
Post-independence
Some NFPs are nationalized
Government’ subsidy
Owner’ subsidy
1970s
Moslem hospitals
1990s
Private investment
The number of hospital: State and Non State
(1998 – 2008)
589 591 593 595 598 609 617 625 642 655 667
491 511 518
550 580
606 617 621 626 638 653
0
100
200
300
400
500
600
700
800
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ju
mla
h R
um
ah S
akit
Pemerintah Swasta
The number of hospital beds: State and
Non State (1998 – 2008)
79930 80069 80286 80670 81095 81243 81581 82456 85391
88856 89596
41389 42557 43312 44837 47245 48946 49512 49775 51375 51475 53288
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
100,000
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Ju
mla
h T
em
pa
t T
idu
r
Pemerintah Swasta
Non State Hospital growth
(based on ownership)
34 39 39 40 42 49 52 55 60 71 85
434 449 456
487 513
530 538 538 538 539 539
23 23 23 23 25 27 27 28 28 28 29 0
100
200
300
400
500
600
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Ju
mla
h R
um
ah
Sa
kit
Perusahaan Yayasan Perkumpulan
Growth of Not-for-Profit Hospital (based
on hospital beds capacity)
Pertumbuhan Jumlah RS Swasta milik Yayasan menurut
kelompok TT
0
50
100
150
200
250
300
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
0 - 50 51 - 150 > 150
0
100
200
300
400
500
600
700
800
Government
Not For Profit
For Profit
688
484
319
97
208
143
Hospital in Indonesia (2011)
General Specialist
Who do they serve?
High tech Medium tech
Low tech
High end market
1 2 3
Middle class market
4 5 6
Low end market
7 8 9
Who pays?
Payment Hospital A (2000) Hospital B (2010)
OOP 71% 42%
Paid (or partly paid) by
employer
14% 40%
SHI 6% 7%
Other insurance 9% 10%
….suggesting that non financial barriers to use health services persist [email protected] 13
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
0
.005
.01
.015
.02
.025
.03
.035
.04
Util
izatio
n r
ate
2003 2004 2005 2006 2007 2008 2009 2010Year
All
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
0
.005
.01
.015
.02
.025
.03
.035
.04
Util
izatio
n r
ate
2003 2004 2005 2006 2007 2008 2009 2010Year
Bottom 3 deciles
Source: SUSENAS 2004-2009
Inpatient utilization rate, 2004-2009by insurance type
Two mothers who were left no option but
to sell their newborns to pay hospital bills
could have avoided their plight had they
been informed they qualified for insurance
and financing, health officials said on
Thursday.
Suparti, 41, a poor woman from Gunung
Kidul district near Yogyakarta, said she
was forced to sell one of the twin girls to
whom she had given birth to pay medical
expenses for the deliveries at a state-
owned hospital.
Her husband, Sarimin, 50, who makes a
living doing odd jobs, failed to get a loan to
pay the Rp 6 million ($660) bill. She said a
hospital staff member offered to pay the
bill if she allowed one of the twins to be
adopted by another hospital employee.
“I had to sell one of my twin girls, whom I
gave birth to only 10 days ago, because I
couldn’t pay the bill at Wonosari General
Hospital,” Suparti told state news agency
Antara on Wednesday. “On Tuesday, I
was allowed to go home. One of my
babies was taken by Mbak Rina [the staff
member]. I was not allowed to see [my
child].”
Munawaroh, a poor woman who gave birth
in Bali to a daughter with lung problems,
was also faced with a Rp 6 million bill. Her
husband, a laborer at a furniture store, had
disappeared and her hospital bill grew by
Rp 1.5 million per day.
“I am willing to give up my baby if
someone wants to buy it, as long as I can
get out of the hospital,” she told the
Jakarta Globe.
Usman Sumantri, the head of the Health
Ministry’s financing and insurance unit, told
the Globe that parents who were not
covered by Jamkesmas, the national health
insurance scheme for the poor, should have
been covered by Jamkesda, the local
insurance plan.
“There should have been another health
care scheme to help the parents,” Usman
said. “Selling the babies is not the way to
solve the problem.”
Bondan Agus Suryanto, head of the
Yogyakarta Health Office, said patients had
options available to help pay hospital bills.
“We are also going to warn the hospital that
when there are patients who do not have
insurance, it should give them information
on other options.”
A hospital employee declined comment,
saying the press officer had left for the day.
Syahrul Aminullah, chairman of the
Indonesian Public Health Association
(Iakmi), said hospitals could be sued if they
did not provide care to the poor.
Local governments are also responsible for
providing health insurance to poor residents,
Syahrul said.
Additional reporting from Made Arya
Kencana and Antara
It is distressing that after nearly 65 years of
independence, we are still finding cases
where women who live in abject poverty
have no other option but to sell their
newborn babies to pay their hospital bills.
First there was the case of Suparti, a
woman from a poor district in Yogyakarta,
who had to give away one of her twin baby
girls to a member of staff at the state-run
hospital where she had just given birth in
order to pay the Rp 6 million ($660) bill for
her Caesarean section.
Then there was Munawaroh, a
washerwomen in Bali, who said she would
have to sell her prematurely born daughter
to cover her maternity costs.
These cases highlight the fact that our
hard-won independence has failed to
improve the lives of many Indonesians.
In Suparti’s case, the story is even more
distressing because she gave birth in a
state-owned hospital in Wonosari, a
medical facility operated by the very
government that is supposed to protect its
citizens — especially children, the elderly
and the poor.
And these two poor women are only the
latest to come to the public’s attention.
Long is the list of reports of infants being
sold to cover medical costs, and there
have been just as many cases of poor
patients being virtually held hostage by
their hospitals for failure to pay their bills.
True, the government does have a
dedicated health insurance scheme for
the poor — Jamkesmas at the national
level and Jamkesda in the regions — but
these schemes have been hindered by red
tape and bureaucracy.
The government, as some officials point
out, has also failed miserably at effectively
disseminating information about health
insurance options and how citizens can go
about accessing them.
These cases point to an urgent need for
the authorities, including the central
government and local administrations, to
improve their health services and health
insurance coverage for the needy.
The government should be more proactive
in both promoting its health insurance
schemes for the poor and in assuring that
these schemes reach those who truly need
them.
The authorities should also be stricter in
admonishing health care institutions,
especially those owned and operated by
the state, that refuse to treat poor people
or try to exact payments that they clearly
cannot afford.
Our Constitution clearly states that the
state should protect its citizens and work
for their well-being. How can we claim to
be a modern, civilized society as long as
incidents such as these continue to occur?
In the cases of Suparti and Munawaroh,
we hope that it is clear to the authorities
what their first course of action must be.
The children must be returned to their
mothers. Immediately.
Health Care Is Failing Our Most Vulnerable In the Dark About Insurance, Mothers Give Up Newborns to Pay Hospital Bills Nurfika Osman | July 09, 2010
Govt to make 45,000 hospital beds free for poor people
The government plans to offer free
medical services for patients using
third-class facilities at public hospitals
this year, a move aimed at helping the
large percentage of low-income and
poor people who are uninsured.
Health Minister Endang Rahayu
Sedyaningsih said many patients from
low-income families were facing
financial difficulties in gaining access
to adequate health services, and that
those who were covered by health
insurance were hampered by complex
bureaucracy.
The government will expand third-
class health facilities at 93 public
hospitals, she said.
“We have agreed to universal
coverage. We have been troubled by
various administrative procedures. So,
it will be no problem for us to give free
medical treatment for patients using
third-class facilities,” Endang said. “It
would be easier for us because we
don’t have to ask them to provide any
documents anymore.”
The public health insurance program
(Jamkesmas), funded by the state
budget, and Jamkesda, arranged by
regional administrations, both of which
were established in 2008, have not
brought medical coverage to all low-
income families.
“In many cases, patients from low-
income families are not members of
the Jamkesmas or Jamkesda
programs,” Endang said.
Titik Purwasih, a 29-year-old housewife
and a member of the low-income bracket,
did not have access to public health
subsidy when she was pregnant.
Titik suffered a severe premature rupture
of the foetal membrane, which made
childbirth risky for her, necessitating a
Caesarean section.
Titik’s mother-in-law, Mariani, said her
family did not have the means to pay for
Titik’s operation, but the situation left
them with no choice.
“We had neither the money nor health
insurance,” she told The Jakarta Post on
Thursday. “They asked me to think about
her baby and her own life first instead of
the medical expenses,” Mariani said.
“About 60 to 70 percent of the total
64,441 third-class facility beds both in
public and private hospitals have been
allocated for Jamkesmas and Jamkesda
holders,” Endang said, adding that this
showed that the country still lacked
third-class beds.
Private hospitals should expand the
number of their third-class facilities due
to the high number of poor people, she
added.
“They can arrange a kind of hospital
social responsibility scheme, so those
who come from poor families can afford
medical treatment even at private
hospitals,” Endang said.
Citing the latest data from the Central
Statistics Agency (BPS), she said that
76.4 million out of 237.6 million
Indonesian people belonged to the poor
and low-income brackets.
The government has allocated Rp 5.13
trillion (US$564.3 million) for
Jamkesmas this year from a total health
budget of Rp 27.66 trillion, which is an
increase from Rp 24.86 trillion in 2010
and Rp 20.17 trillion in 2009.
Rieke Dyah Pitaloka, a member of
House of Representatives Commission
IX, said the government should provide
a clear definition of “poor people” who
would be eligible for the subsidy.
Citing BPS data, she said that 28
percent of Indonesian people got sick
every year, and that 3 percent suffered
from serious illnesses.
“A clearer definition of poor people
would guarantee that any insurance
program can be better distributed to the
targeted people,” she said. (ebf)
In the end Mariani and her family were
able to raise the money for Titik’s
operation, and Titik delivered the baby
safely. Titik is now recovering in the third-
class wing of a hospital.
To ease the financial burden, Mariani and
her family registered for government
subsidy for the operation.
But the process was long and arduous,
involving a stack of documents and
several trips to several government
offices.
According to the Health Ministry,
Indonesia has 1,523 hospitals — private
and public — with a total of 151,000 beds.
About 45,000 of the 64,441 third-class
facility beds belong to public hospitals.
The Jakarta Post, Jakarta | Fri, 01/21/2011
Hospital beds need (by Province)
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
Beds need
Total beds available
Key points
NFP sustainability at risk
Serving low-end market
Jamkesmas reimbursement at below-cost
No tax exemption or any other concession (treated the same as for-profit hospitals)
Decreasing support from owner and no systematic fundraising effort
MoH has started to pay attention to the NFP hospitals
Hospital Act (2009) : rights to tax incentive (MoF ???)
Ministerial Decree (2010) : rights to receive government support (facility & equipment)
NFP hospitals have to put more effort into good governance,
accountability and transparency measures.