Time for healthy change in ailing health service

David Kennedy, Contributor, Jakarta, d_kenn@yahoo.com

When a man is discharged from hospital in excruciating pain and with part of his intestines hanging out because he is unable to pay his bills, it rightly attracts a lot of attention. That it provokes enough public outrage to have the man swiftly given medical treatment is commendable, but there is a downside.

The recent case of Sumaryono, the 24-year-old man living in a rented hut by a flood canal in Central Jakarta who suffered for months with an untreated tumor, is just the latest installment in a saga of horror stories about the health service and the terrible fate that will befall anyone in its clutches.

In this particular case, claims the patient was refused treatment by Cipto Mangunkusumo General Hospital (RSCM) in Central Jakarta have since been refuted by the director of the hospital.

Dr. Merdias Almatsier told The Jakarta Post that Sumaryono was treated on three occasions at the hospital and stopped coming as an outpatient of his own accord after he was asked to renew his medical card.

However, the damage was already done. Such stories of hospitals' seemingly callous attitude to their patients are so popular that they run the risk of destroying the trust people still have in the health service.

Certainly, there is no denying the many problems affecting the country's hospitals. But reducing those problems to colorful anecdotes and urban myths means wasting an opportunity to talk seriously about the challenges facing the health sector.

A lack of investment coupled with the endemic corruption, collusion and nepotism that plagues other sectors of the economy are at the root of the problems, according to government officials and NGOs such as the Indonesian Health Consumer Empowerment Association.

"The big problem is lack of money," said Choliq Amin, a finance expert at the Ministry of Health.

The national health budget is between 1.5 percent and 2 percent of GDP per annum, although the World Health Organization recommends a minimum of 5 percent. Per capita spending on health is about US$12 per annum.

"At the last hearing at the House of Representatives, the legislators said the whole hospital system was not so good. They mentioned bad conditions of the rooms, apparatus, buildings and low levels of service," said Ministry of Health medical services director Dr. Achmad Hardiman.

"But to have good equipment and systems we'd need to increase the budget to three percent."

The ministry received Rp 3.5 trillion for developing the health service in 2003 while improvements needed in hospitals are estimated to cost in the region of Rp 40 trillion.

Ministry of Health officials acknowledge the need for a new approach and they are looking at successful models abroad for inspiration.

"In Singapore they have the philosophy that our health is our own responsibility. Of course, the government is responsible but individuals are too," Achmad said.

He added that reforms were underway to introduce a national health insurance scheme which would cover every Indonesian citizen.

While the ministry is reluctant to release figures on the likely cost of national health insurance, critics such as Hans Vriens, director of U.S.-based consultancy APCO Indonesia, claim it will be unworkable and will involve a $3.1 billion bill for the government and an extra 6 percent tax on salaries.

Despite its critics, the ministry is determined to press ahead with an ambitious timetable once the legal framework is agreed upon by the House. The government is expected to foot the bill for the 40 million poor people unable to contribute. It is still unclear what the new insurance scheme will mean for existing insurance policies like Jamsostek and PT Askes.

"In not less than five years we hope to cover 50 percent of the population. Total universal coverage is expected in not less than 10 years," said Choliq Amin, adding a telltale caveat that progress will depend on government policies, growth of the economy and other issues.

"Some people say universal coverage is impossible but we must try because it's important to protect people's health," added Choliq, referring to the UN Human Development Index which includes health care as a major factor contributing to the economic growth and prosperity of a country.

In addition to long-term reforms, a new social safety net scheme that provides free healthcare for the poorest families was introduced earlier this year, with about Rp 74 billion earmarked for Jakarta.

Dr. Marius Widjajarta, head of the Indonesian Health Consumer Empowerment Association, was recently appointed as an independent observer of the scheme. He is critical of earlier programs which he said had only limited success and tended to use the poor as an excuse to draw down funds.

The Sumaryono case illustrated the lack of knowledge among the poor population of the assistance that is available. Bureaucracy also scares people off from applying for health cards as they need to obtain three signatures from local associations and officials.

"I would like to change the system of the health card," said Marius, advocating a more proactive approach which eliminates administrative obstacles and opportunities for misuse of the system.

"It should be the local neighborhood leader who gives the card to those who are really poor. They must be active in finding out who needs them and issue them directly."

Another scheme which is little known among the poor is the regulation that all hospitals are required to reserve a proportion of their beds for poor patients.

Head of Pondok Indah Hospital in South Jakarta Dr. Hermansyur said that although his hospital agrees that private hospitals participate in the scheme and reserves 10 to 15 percent of beds for the poor, the regulations need to be made clearer. In practice, most beds for the poor in the third class wards are occupied by paying patients and there are no inspections to enforce the regulation.

"Private hospitals have no subsidies so we have to be very careful with costs," he said.

He added that the hospital sometimes admits poor patients who cannot pay for emergency care and have no health card but that arrangements need to be put in place for the city health authorities to subsidize poor patients.

Echoing his sentiments about the social role of hospitals which often bear the costs of patients who are destitute or lack the necessary papers, Merdias expressed his frustration at the lack of sufficient subsidies.

"There is a tendency to forget that it's not our job to bear the costs of the poor. It's the responsibility of the government. As a corporate hospital we have to be accountable, efficient and motivate our staff by providing decent salaries and incentives. But if we have budget deficits of Rp 4 billion we cannot develop the hospital or motivate our staff."

Public hospitals are now being given more autonomy from government. As a new "corporative" hospital director, Merdias now has complete control over his budget and can hire staff but not fire them. The hospital has a private ward which raises revenue.

However, revenues are insufficient to raise salaries for personnel who are obliged like most civil servants to work in other private sector jobs to make a living.

"The salaries of medical personnel in public hospitals are very low. Doctors do not earn more than US$150 per month. It's demoralizing for staff," said Dr. Firman at the University Of Indonesia's School of Medicine.

"This means they may spend only a couple of hours in a government hospital each day and then go to the private hospital. So they have to compete with themselves. If you have to compete between the public and the private wards, and only one of them earns you money, you will probably put more effort into that one. So the quality of the public hospitals remains very low."

Given the lack of public funding for the health service there appears to be few alternatives to this competition. Private wards provide cross subsidies and help fund life saving drugs and equipment. They are also part of a global trend towards public private partnership and the privatization of health services.

"In the world today governments are trying to give more autonomy to hospitals. We cannot improve performance if we are still a unit of a government department," said Merdias.

"If we get corporate status then we have performance indicators, medical clinical indicators and patients' satisfaction is taken into account."

To date less than half of the country's 1,178 hospitals have received the Hospital Accreditation Award and hospitals failing to reach even minimum medical standards are not sanctioned.

Low medical standards do not encourage patients who have the choice of seeking healthcare abroad; a senior health official recently estimated that $300 million is currently being spent on healthcare overseas.

Eric, a 28-year-old consultant from Norway living in Jakarta, has been to a hospital in Singapore but expressed doubts about ever visiting one in Indonesia.

"The fact that international doctors are not allowed to practice here must mean the standards are lower. In Singapore I have found that the hospitals were better than in Norway and I was very happy with the treatment I had. If I have to go to hospital again I will definitely go there."

Many patients who cannot afford hospital treatment abroad fear local hospitals and opt for traditional cures first.

"Even patients diagnosed with cancer sometimes say they want to try another treatment outside the hospital. Then they come back later and their condition is worse," said Hermansyur of Pondok Indah Hospital.

"The worrying thing is that we are losing trust between each other -- between doctors and patients and between the government and the people. We have to fight to return to trustworthiness."