My final thesis about the Indonesian movement towards universal health coverage and its achievement in providing the right to health for Indonesian people.

1. Thesis
Moving toward universal
health coverage of Indonesia:
where is the position?
Ahmad Fuady
Health Economics, Policy and Law
Erasmus University Rotterdam
The Netherlands
2013

2. Introduction
• The WHO Director General, Margaret Chan: universal health
coverage is “the single most powerful concept that public health
has to offer”.
• The rights to health. The State must secure citizen’s rights to
access health care services and any underlying determinants of
health. Universal health coverage is one of attempts.
• Indonesia, accelerated health care reform since 1998.
• Does the health care reform comply with the rationale of providing
the right to the highest attainable standard of health?
• Has the health care reform toward universal health coverage in
Indonesia improved the fulfillment of the right to the highest
attainable standard of health?

3. Theoretical framework
• Health is a fundamental human right.
• Article 12.1 of the International Covenant on Economic, Social
and Cultural Rights: the rights to the enjoyment of the highest
attainable standard of health.
• International and local legal instruments.
Four interrelated and essential
elements:
1.Availability
2.Accessibility
a. Non discrimination
b. Physical accessibility
c. Economic accessibility
d. Information accessibility
3.Acceptability
4.Quality
from economic and policy perspectives

4. The role of policy actors
in fulfilling the right to health
• The national and international policy makers, together with courts,
non-governmental organisations, and other stakeholders :
adopting and applying features of the right into policy actions.
• Legal recognition, followed by policy actions.
• The interaction among actors : favorable or unfavorable factor?
• Different patterns of interaction:
– Thailand, health system reform was part of large design to
restructure the relationship between the State and civil society
and democratization process.
– Philippines, health system reform was considered as businessas-usual and was not a monumental process.
– Indonesia?

5. Method
• Literature review of studies with time framework of 1998 to 2013.
• Sources :
– Indonesian databases.
– Scientific databases (Google Scholar, PubMed, and
WebScience).
– International databases WHO, World Bank and the Joint
Learning Network (JLN) for Universal Health Coverage.
– local and/or international case law.
• Comparing to neighboring countries: Thailand and Philippines.
• Analysis using guideline assessment of four important elements,
adapted from Hunt (2006).

6. Indonesian health care reform:
a brief history
Indonesian health care system
• A mixed public-private health care provision
– Public providers, dominate the services in rural area and
primary to secondary-level health care services.
• Primary health centers (Puskesmas), operate in sub-district
and village level.
• Supported Puskesmas (Pustu) for remote area.
• Public district-level hospitals.
– Private providers, concentrated in the urban area and are
mostly for secondary and tertiary-level health care services.
• Poor referral system, in the implementation.

7. Indonesian health care reform:
a brief history

8. Indonesian health care reform:
a brief history
The policy actors and developed legal and policy instruments
• Central government, hierarchical control and authority to develop
regulation
• Pressure and cause groups

9. Decentralization:
a confounding issue
• Decentralization Act (2001): larger authority of local governments
to manage and regulate their health and financial system.
• Much depends on temporary local elite interests rather than
establishing sustainable system. For instance, case of Jembrana
and Tabanan.
• The change of the governor and regent/mayor elections mode 
health insurance becomes one of the most popular issues.
• Some manage their local resources effectively while others do not
(‘chaos’). The most recent case: ‘Jakarta Health Card’, promoted
in 2012.
• Some problems in availability and quality of health care
professionals and facilities.

10. WHERE IS THE POSITION?
Impacts of health care reform on right to the highest
attainable standard of health

11. Three dimensions of coverage
No cost sharing
(Jamkesmas)
Increasing coverage of
41.7% (2005) to 63.2% (2012)
Comprehensive
benefit package
(2012)

12. Three dimensions of coverage
• Less coverage, compared to neighboring countries
• A low coverage to formal workers group
3%

13. Availability
Availability of (functioning) health care facilities.
• Increasing number of facilities, but remains insufficient.
• Puskesmas with inpatient service has grown mainly in the urban
area while the remainings have shown a significant growth in the
rural area. Puskesmas ‘without doctors’.
Pustu  poor
quality of care, do
not operate
regularly, and lack
of drugs and
diagnostic kits.

14. Availability
Availability of trained health care professionals and their salaries.
• Problem of data validity and reliability
• Lack of health care professionals
• Problem of deployment policy and unclear decentralization policy
• Without domestically competitive salary

15. Availability
Improving drugs availability in public health facilities
• 2010, essential medicine in the majority of public health services
was below 80% while only 15% of health facilities had 80% of
essential medicines.
• 2011, about 90.4% essential medicine has already been available
more than 80% from required medicines throughout the public
health facilities.
• Classical problem: discrepancy between urban and rural area.

16. Accessibility
• Physical constraints along with financial constraints because of
transportation cost  poor utilization of those existing public
health facilities despite the free access.
• Access gap between rich and poor has remained high.
• Problems:
– Subsidy distribution is more pro-rich rather than pro-poor
– Leakage
– Considerable illegal fees, buying the card
– Illegal up-front payments

17. Acceptability
• …have to be respectful of medical ethics including the
requirement of informed consent and confidentiality of personal
health information, as well as culturally appropriate.
• Ethical violation increases. From 182 reported cases, MKDKI has
decided that 29 (15.9%) doctors have been proven guilty, and
their licenses have been revoked.
• Legal case of Mrs Darmoko vs Pondok Indah hospital  unclear
informed consent and incomplete information.
• Poor confidentiality in HIV/AIDS counseling work in Papua and
ignorance of the local culture in training modules development.

18. Quality
• Health providers in outer Java-Bali have worse quality than those
practicing in Java-Bali because of limited facilities.
• Private-solo practices worsen the quality of public health care
service in a rural area.
The quality in terms
of structural
indicators
has improved.

19. Conclusion
• Social movement has an important role.
• Decentralization policy has created both positive and negative
impact. Political circumstances, elite interests, and local
resources are the main determinants.
• The position:

20. Recommendation
General recommendation
• Examining local experiences and identifying lesson learned to
improve the national program.
• Identifying local governments with good, moderate, and poor
capacities. Those local governments with moderate and poor
capacities should be supervised to manage their resources
appropriately.
• Setting national target for local government.

21. Recommendation
Improving coverage
• No significant problem in the benefit package and proportion of
cost sharing.
• Attracting employer and informal sectors to involve in national
health insurance, particularly Jamsostek scheme. The low
monthly premium of Rp 40,000-50,000 (USD 4.3-5.4) may be
attractive
• Improving promotion and persuasion by both of the government
and PT Askes. Ensuring that all eligible people enroll to the
program.

22. Recommendation
Increasing availability
• Improving health care professional database. The MoH, KKI, and
IMA have to develop a better method in registering and reviewing
the health care professional.
• Mandatory placement for fresh graduated doctors in rural and
remote area. Incentives?
– Sending health care professionals in teams.
– Better payment and facilities.
– Better local infrastructure, need further coordination..
• Setting national design and dividing the clear authorities between
central and local government to build health care facilities.
• Advocating central government and the House of Representative
to increase the proportion of the health budget .

23. Recommendation
Widening accessibility
• Preventing the leakages through active validation. Resource
transfer from central to local government should be based on
verified enrolment.
• Eliminating illegal upfront payment and rejection.
– The MoH, PHO and DHO : developing a mechanism of
complaints, signing MoU with hospitals, and constructing
adequate penalties for hospitals violating the memorandum.
– Hospital association: maintaining hospital performance and
conducting equal supervision.
– Community: encouraging the well-implemented program and
monitoring any potential violation in the grounds.

24. Recommendation
Making it more acceptable
• Introducing specific disease, such as HIV/AIDS and tuberculosis,
into whole health program to reduce discrimination.
• Regarding to respect of medical ethics, the MKDKI and the IMA
should develop preventive measures instead of merely
accommodate people’s complaints of medical services. It would
be overlapping with concerns to improve the quality of services
explained further.

25. Recommendation
Improving quality
• Licensing and periodical review.
– The IMA: continuing national examination for physicians.
– The IBI and the PPNI: starting national exam for nurses and
midwifes.
– The government: limiting the recruitment for new civil workers
to those who have been certified and reviewed periodically.
• Moratorium of new development of health and medical schools
– The DGHE: accrediting all health and medical schools and
strengthen the regulation, such as limiting enrolment for those
poor-accredited schools or programs.
– The KKI, the IBI, and the PPNI: establishing competency and
education standards.

26. Recommendation
Improving quality
• Piloting the project of performance-based payments in an urban
setting.
• Considering the contracting system which focus on either primary
care services or specific diseases.
– The MoH: developing good, measurable indicators and
constructing the monitoring and evaluation systems.

27. Thank You