Hospitals caught in social duty vs profit dilemma
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.