Hospitals caught in social duty vs profit dilemma

By Santi WE Soekanto

JAKARTA (JP): Nurganti Bangun, a young mother in Medan, North Sumatra, left her newborn son at a maternity clinic because she could not pay the bills. As she promised the clinic manager, she would pick the baby up as soon as she had Rp 25,000 ($59).

In spite of her weak condition, Nurganti went to work in the field right away, planting cassava alone because her husband had previously left her. However, by the time she came to claim her son, the clinic owner said her debt had grown to Rp 865,000 ($411) due to the care necessary for baby.

Try as she might, the young mother just could not keep up with her debt, which continued to swell each day.

She gave up. Later, she told a reporter of the Kompas daily that she named her baby Sandera (hostage).

When Nurganti's story made the press in 1988, a strong public reaction ensued. Condemnations came hard and fast against the clinic and other hospitals for "commercializing" their service and neglecting their "social responsibility."

For some people, the term "social function" means hospitals should put compassion and charity before other considerations, including profits.

"Hospitals shouldn't forget their social responsibilities," consumer group activist Zumrotin K.S. said.

The hospitals, however, are not without their advocates.

It was reported in 1992 that almost every private hospital suffers an average loss of Rp 100 million annually, due to patients' inability to pay.

Management experts then urged hospital administrators to treat their services as an economic commodity which needs to be managed with economic principles.

"Like it or not, we have to accept the fact that health care is a commodity," said Dr. Broto Wasisto, an expert advisor to Minister of Health Dr. Sujudi.

It seems that even experts in the health care industry continue to have conflicting opinions over the ongoing question of where the line should be drawn between charity and economic considerations.

A seminar on the issue, held by the health ministry and the Forum of Health Professional Organizations and Associations (FKOPAK) this month, saw experts fiercely debating the same questions they had been raising in similar seminars over the last several years.

Many of the parties involved in the discussion referred to the 1992 Health Law in their arguments, yet most agreed that existing regulations fail to provide clear guidelines on the issue.

A 1993 ministerial health decree mandates that private hospitals have an "inherent social responsibility, which takes the form of moral and ethical obligations to provide health care services to poor patients."

It fails, however, to mention the so-called "social function" in relation to the hospitals' operating costs.

Zumrotin reminded the seminar that ignorance, or the fact that most people become health service consumers by necessity, may make them sitting ducks for the health industry's exploitation.

She listed various forms of exploitation, including turning down patients who are unable to provide payments in advance, compelling patients to take unnecessary tests using expensive facilities, extending patients' stay beyond what is medically necessary and hospitals' failure to reserve 25 percent of all their beds for poor patients.

"We have to admit that the old patterns of doctor-patient relationships have changed into industrial relationships, but profiting on people's suffering is just not right," she said.

Those who stand on the other side of the fence, including hospital administrators, have come to their own defense.

Dr. A. Mariono from the Indonesian Hospital Association (PERSI), pointed out that a free market enterprise and a 1992 law on health insurance have spurred competition among health industrialists to net clients with broad-based and expensive insurance schemes by offering sophisticated health services and facilities.

"Investors see health services and hospitals as a profitable industry because they have clearly defined market segments which insurance companies have already built," he said.

Change

The government started off the second 25-year development plan this month by permitting the private sector to build new hospitals, and by turning state-owned, subsidized hospitals into self-financing organizations.

The changes will undoubtedly urge the hospitals administrators to put economic and profit-making considerations a little bit higher on their priority scales, Dr. Mariono said.

The whole problem is aggravated by the fact that the average health expenditure here is only Rp 28,000 ($13), or around 2.5 percent of the national GNP per capita per year. Thailand, the Philippines, Malaysia and India spend an average of $73, $14, $67 and $21 respectively.

Of the total expenditure, only 30 percent or $4.2 per capita per year is contributed by the government, or 2.4 percent of the total annual government budget. The community and private sector contribute some 70 percent or $9.8 per capita.

Minister of Industry Tunky Aribowo, who gave the keynote address to the seminar, said the problem could be solved by establishing a cross-subsidy scheme in which patients who are better off pay more in order to finance service for poorer patients.

Many people have made the same suggestion over the years, although little follow-up has occurred.

Broto Wasisto seconded Tunky's opinion, saying the problem of hospitals' "social duties" may be solved by providing clearer regulations and establishing effective controls over the cross- subsidy scheme.

The health ministry issued the regulation on "beds for the poor" in 1988 in response to public criticism against the private hospitals for being too commercialized, charging high fees that only the wealthy can afford.

Many still complain, however. Among them is chairman of the Indonesian Medical Association (IDI) Kartono Mohammad who called the decree "mere lip service, even hypocrisy" because the regulation has yet to be effectively carried out.

"The regulation was created only to appease consumer groups' demands, to give the impression that the poor's needs for medical care are taken care of," he added.

The seminar participants finally concluded that perhaps the definition of the hospitals' "social obligation" should be redefined to mean more than just "charity."

It should be reviewed in order to enable hospitals to gain profits without neglecting service for poor patients.

Hospitals, drugs manufacturers, and the rest of the medical society should establish concrete roles in actively contributing to the country's health and health technology development, the seminar concluded.

Kartono had once made the same suggestion, saying that the private hospitals should provide a certain percentage of their profit to help finance medical treatment for the poor through the hospitals' social services department.