Pay up first policy puts life at risk

It is not only the abject poor who are vulnerable in dealing with the Indonesian health service. With only an estimated 40 million people capable of paying for their insurance from their own pockets or from insurance policies, most people have difficulties in settling hospitals payments.

And anyone can find themselves in an emergency room without their wallet.

This can be a potentially dangerous situation. With concerns over mounting budget deficits and bad debts, hospitals are increasingly wary of admitting patients who may not be able to pay. This cautious approach has been known to extend to the emergency room, a practice against Health Minister Decree 159b/1988 about hospital and Minister of Health regulation 920/1986 about private hospital.

Requiring deposits in emergency cases is a criminal offense but patients and families faced with demands for money are usually not in a position to argue.

In a notorious case which caused a major scandal over a decade ago, a senior Ministry of Health official died at a Central Jakarta hospital which had delayed giving him emergency treatment because he did not have a Rp 1 million deposit.

Almost everyone has heard similar tales of people being forced to wait unnecessarily in accident and emergency departments.

David Santoso, a 26-year-old employee at a five-star hotel in South Jakarta recently collapsed with a fever in the middle of the night and was taken to a nearby hospital by his friends.

"Before they would treat me, the hospital staff demanded a deposit of Rp 2 million but I did not have it and neither did my friends. Then they phoned the duty manager at the hotel where I work to check I was earning a salary. After about 30 minutes I was taken in for treatment," said David.

While emergency cases can be fatal and have resulted in hospitals being sued by legal aid associations there appears to be no sanctions enforced bar a mild reprimand. Apart from risking lives this illegal practice results in stress and hardship for families and friends who desperately try to meet the demands of hospitals to pay in advance.

"My neighbors' three-year-old son stepped into a pail of boiling water. I immediately rushed with him and his mother to the hospital across the road from where we live. At the accident and emergency department they said that we had to pay a deposit of Rp 300,000," said Noviar, a 24-year-old room boy at a serviced apartment complex in Central Jakarta.

"It was a big amount for us as middle class people. We couldn't afford it and we worried about the condition of the child while we discussed with the staff. I finally said, 'Of course we will pay after, just take him in and get him treatment or he will die!' As a temporary guarantee I told them we owned our own brick house across the road."

Noviar finally convinced the staff to treat the boy while he went to call on his neighbors to collect money for the deposit. He succeeded in raising Rp 275,000 from 20 neighbors during almost two hours running to and fro.

"At the time I did not know that there was a regulation against asking for money for an emergency. But even if I did they were still insisting on it. What could I do?"

Dr. Firman from the University of Indonesia's School of Medicine suggested that if more people use legal aid to take cases it could help to enforce the law. He called for condemnation from the medical profession and for action from the city medical authorities and the police.

"The doctors association cannot defend people doing this kind of thing," he said.

Farid Anfasa Moeloek, former health minister and now chairman of the Indonesian Doctors Association (IDI), suggested that people could phone the police but he recognized that enforcement of the laws was weak. He added that although it may not help at the time of an emergency, IDI could put moral pressure on the hospitals concerned through its ethics committee.

-- David Kennedy and Claudia Octora