Health reform essential for hospitals' survival
By Dumilah Ayuningtyas
DEPOK, West Java (JP): Indonesia marked World Health Day on May 6 and National Health Day on Nov. 12, but this year both were overshadowed by the dire impact the economic meltdown has had on health services here.
Minister of Health Farid Anfasa Moeloek marked World Health Day with a reminder that every year, 20,000 women die of aseptic labor, bleeding, eklamsia (poisoning during pregnancy) and as the result of poor nutritional intake which is 50 times worse than in other ASEAN countries.
The mortality rate, Moeloek said, is "equivalent to a Jumbo jet full of expecting mothers crashing every week."
On Nov. 12, President B.J. Habibie marked National Health Day by raising the alarm over an unfolding crisis: the food shortage that has affected Indonesia since last year will bring about an increase in malnutrition among children and will also lead to a "lost generation."
Malnutrition can lead to a loss of intelligence that results in lower quality human resources and in turn affects the country's ability to cope with future social, economic, technological and political challenges, Habibie pointed out.
Two-year-old Ainul Rizki fell victim to malnutrition. His head was disproportionately large for his small, frail frame. His face was pale and his skin wrinkled and darkened. His belly was distended, a tell-tale sign of marasmic kwashiorkor or edema resulting from hunger.
Sugeng Soegijanto from Dr. Sutomo Hospital in Surabaya, East Java, confirmed the case in September, which he said was last seen here in 1973. Hopefully, Ainul will by now have recovered, because even now we still cannot forget that around 700 adults and children died of malnutrition and drought-related disease in Irian Jaya in 1996 and 1997.
The sporadic reports of their suffering were only the tip of an iceberg. The real, but as yet silent problem, are the millions of children under two years old who come from poor families and are facing malnutrition.
Stephen J. Woodhouse from the United Nations' Children Fund (Unicef) recently emphasized the need to prevent the dire situation from arising rather than merely seeking to "cure" it. If malnutrition is allowed to take hold, treatment always comes too late because 90 percent of brain development takes place in the first year of life, Woodhouse explained.
Also part of the problem is a host of other health problems affecting parts of the population as a result of the economic crisis. Among these problems are iodine and vitamin A deficiencies, anemia, poor protein intake, and even the reemergence of infectious diseases such as tuberculosis.
In his speech in November, Habibie attempted to soften the blow of his warning by promising the government would begin an all-out campaign to mitigate the worst effects of the health crisis using funds from the Rp 1.4 trillion social safety net program which is now underway.
Throughout the past year, there have been numerous reports of Moeloek and other officials receiving foreign assistance to help Indonesian hospitals and clinics. Among the donations was US$4.6 million provided by Australia in the form of medicine and supplies including disposable syringes for 800 village health clinics (puskesmas) and 53 hospitals in remote areas of West Nusa Tenggara, South Sulawesi, Central Sulawesi and Maluku. The World Bank, Unicef and Japan are among other donors which have helped health services here.
Despite the assistance, hospitals and clinics are still facing financial difficulties because of their moral obligation not to cut services despite the high price of supplies and increasing poverty in society. That is why measures still need to be taken to guide hospitals and their patients through the crisis.
Moeloek has also promised a campaign against corruption and collusion in the health industry and to ensure the availability of medicines and efficient services. This brought relief to hospital administrators and managers throughout the country.
Among other steps taken was the establishment earlier this year of a health reform team consisting of experts from universities, the private sector, non-governmental organizations, health professionals and officials from the Ministry of Health. The team has given birth to what was later introduced by Moeloek as the New Paradigm in Indonesian Health Development.
Under the new paradigm, medical services will be geared toward helping people become healthier rather than just curing certain illnesses. A person who is not actually ill is not automatically healthy.
Sickness and health are not different sides of a coin, rather, they are part of a continuum. This approach fits better with the World Health Organization's definition of health as a state of physical, mental and social well-being which enables a person to be socially and economically productive.
The health status of a person is determined by a number of factors, including the environment and his or her genetic makeup. Only about 20 percent of a person's well-being is influenced by the availability of health services.
It therefore makes sense that hospitals should focus on maintaining and promoting health among the general public. It is also important that hospitals help the community take preventive measures by disseminating information on basic health care, individual hygiene and the prevention of communicable diseases.
Hospitals need to help organize the provision of basic health care that facilitates early diagnosis and prevents the spread of infectious diseases.
If successful, these "promotion and preventive" campaigns would mean a reduction in the cost usually incurred in treating patients.
Under the new paradigm, hospital should be translated into Indonesian as rumah sehat (house for the healthy) rather than rumah sakit (house for the ill).
The media and health experts have often discussed the "social function" of hospitals, which holds that they should not function as mere profit seeking institutions, but should serve the needs of all, including members of the community who do not bring in large amounts of revenue. There have been countless reports about how hospitals have suffered losses running into billions of rupiah because patients have been too poor to pay their bills and government subsidies nonexistent.
Hospital managers and entrepreneurs have understandably argued that the "social function" should by no means put hospitals in a loss making situation.
During the crisis, hospital managers have repeatedly been asked to be charitable and the key to their survival is therefore efficient management and service quality control.
Those involved in the health sector are now becoming familiar with KETAT -- K is for Konsolidasi and Koordinasi (consolidation and coordination), E for Efisiensi (efficiency), T for Transparansi (transparency), A for akuntabilitas (accountability), and T for Tingkatkan kinerja (improve performance).
Under the concept, hospitals should introduce a range of austerity measures, including saving on the use of water and electricity and optimizing their human resources. The following are some suggestions to bring about greater efficiency:
* Introduce tighter supervision in order to fight corruption. One way that hospitals can go about this is to establish a team to ensure cost efficiency.
* Restricting the use of medicines, facilities and equipment to only necessary and effective medical procedures. There are certain treatments which come at enormous cost and which hospitals only offer for the sake of profit.
* Establish cooperative links with other hospitals in order to take advantage of economies of scale and make efficiency savings. For example, clinics located close to one another could probably share the same incinerator.
* Merge clinics with bed occupancy rates below 30 percent.
* Outsource certain services such as laundry and catering so that hospitals can find more competitive packages while generating business for other enterprises.
* Establish a joint team of doctors and hospital managers to delineate new, more efficient strategies such as changing operational procedures to make them simpler and more cost effective. For example, hospitals could reuse certain equipment by sterilizing it rather than throwing it away.
Hopefully these measures will help hospitals to survive the economic crisis without sacrificing their core services.
The writer is a student at the University of Indonesia's post- graduate school of hospital management.
Window: Under the new paradigm, medical services will be geared toward helping people become healthier rather than just curing certain illnesses. A person who is not actually ill is not automatically healthy.