Hopes and fears as Indonesia rolls out universal healthcare 
|
JAKARTA, 14 January 2014 (IRIN) - The rollout of universal health coverage in Indonesia has been greeted with public enthusiasm, but health experts warn that inadequate funding could undermine the quality of care.
The government aims to have every Indonesian covered by health insurance by 2019 under a new scheme called Jaminan Kesehatan Nasional (JKN), with nearly 20 trillion rupiah (US$1.6 billion) allocated to cover premiums for the poor in 2014.
Around 65 percent of the country's 240 million people, including 86 million categorized as poor, are covered by some form of regional or national health programme and are automatically entitled to comprehensive coverage under the JKN, which has replaced the previous health schemes.
"This is a great programme. It should mean that people will no longer be denied treatment because they don't have money," said Wawan Mulyawan, a neurosurgeon and medical insurance consultant who works at a private hospital in Jakarta, the capital.
The World Bank estimates the insurance scheme will cost $13-$16 billion each year once fully implemented, while Jakarta has said it will double its spending on health to 16 trillion rupiah ($1.64 billion) in 2014 to cover the poor and "near poor".
Challenges and concerns
The rollout began on 1 January 2014, but implementation has not gone smoothly, with many workers at referral hospitals poorly informed about the programme's details.
"Hospitals are afraid they will lose money by not being reimbursed like in the past, while health workers are afraid they will make mistakes," Mulyawan conceded. "As a result, quality of treatment has been compromised because it doesn't follow clinical pathways set by the hospitals."
Under the previous national insurance for the poor, hospitals, both state and private, complained the government delayed payments for more than a year, and some hospitals refused patients unless they made partial payment in advance. However, the government says it has learned from its mistakes.
"We are strengthening the primary care system across the country by improving infrastructure and adding more health workers," Deputy Health Minister Ali Ghufran told IRIN.
Indonesia has 25 health workers per 10,000 people, which meets the World Health Organization's minimum of 23, but they tend to be concentrated in urban centres, leaving parts of the archipelago without an adequate number of health personnel.
More than 1,700 state and private hospitals are participating in JKN, with over 9,000 state-funded community clinics, known as Puskesmas, serving as the backbone of primary care, Ghufran said.
The government plans to build 150 new hospitals in 2014, and says all hospitals will be required to serve JKN patients by 2019.
People's welfare minister Agung Laksono said the challenges facing the health system in implementing universal coverage include a poorly functioning referral system, poor quality services at primary and referral levels, and high treatment costs.
Patient safety is also a concern, as not all hospitals are accredited, he said. Only around 65 percent of Indonesia's hospitals are accredited, with the majority of them being state-run.
The government plans to build 150 new hospitals in 2014 Problematic payments
"Indonesia is undergoing a transition in disease epidemiology, marked by the still high prevalence of communicable diseases, and yet at the same time degenerative and non-communicable diseases such as cardiovascular diseases and cancer are on the increase," he said.
The rate of mortality from non-communicable diseases rose from 41.7 percent in 1995 to 59.5 percent in 2007 - an increase of 42 percent - the latest figure available from the Health Ministry.
According to the Health Ministry's Basic Health Survey, the prevalence of diabetes was 2.1 percent in 2013, compared to 1.1 percent in 2007. Hypertension was prevalent among 31.7 percent of the population, up from 25.8 percent in 2007.
A report released in 2013 by Novo Nordisk, a global healthcare company, says 7.6 million people in Indonesia are living with diabetes, with millions more are at risk.
By 2030, the number of people with diabetes in Indonesia is projected to top 11.8 million, a 6 percent annual growth that by far exceeds the country's overall population growth.
Muhammad Imran, whose elderly father was receiving treatment for diabetes and high blood pressure as an outpatient under a previous insurance plan, said the Central Army Hospital had been inundated with patients referred by primary healthcare clinics.
"My father had to wait for hours to be seen by a doctor," he said. "After that we had to queue again for hours at the pharmacy. This is ridiculous."
While the government pays 19,225 Indonesian rupiah ($1.60) per month for treatment in a third-class hospital ward for each poor citizen, individuals can also purchase one of three insurance options: 25,500 rupiah ($2) per month for third-class treatment, 42,500 rupiah ($3.60) for second-class and 59,000 rupiah ($5) for first-class.
The 110,000-member Indonesian Medical Association says the amount the government is paying for the poor is too low, and has warned that this could compromise the quality of healthcare.
What about the doctors?
"There will inevitably be problems. Doctors will not be adequately paid and they won't be able to provide the maximum quality of care," said association chairman Zainal Abidin.
Indonesian President Susilo Bambang Yudhoyono said he was aware of the potential problem, and the government would issue an additional regulation providing financial incentives for doctors and other medical workers. The premium paid for the poor would also gradually be increased.
"An evaluation will be conducted after three months, and [again after] six months, to ensure that its implementation will be better in the future," the president said.
The JKN specifies that government doctors and dentists working at public clinics (Pukesmas) be paid according to "capitation", meaning that healthcare providers are paid a set amount for each enrolled person assigned to them during a period of time (usually a month), whether or not that person seeks treatment.
Under the programme, doctors and health facilities at the primary care level, both public and private, will have to treat all persons assigned to them, regardless of whether patients come to them for treatment or not.
But Abidin said the amount a primary care provider or family doctor receives for each enrolled person assigned to them - 8,000 rupiah, about 68 US cents - is too low.
For example, public and private clinics or family doctors will receive 40 million rupiah ($3,328) for 5,000 enrolled citizens in advance per month, regardless of how much they spend on treating those patients, and whether or not they seek care.
According to a 2013 paper by Australia's Nossal Institute for Global Health, there were potential inequalities in implementing universal health coverage in Indonesia.
Experience with the previous national health scheme, Jamkesmas, had shown that despite nominal comprehensive coverage for the poor, patients had difficulty accessing certain services, and sometimes had to pay for medicines not available at the facility, particularly in rural areas.
"Poor quality and unequal distribution of government health facilities have been issues with which the ministry of health has been struggling with for some decades, without much progress. Significant further government investment in health infrastructure and workforce will be needed," the paper said.
The Health Ministry says Indonesia needs more than 12,000 new doctors to meet its goal of 40 per 100,000 people. The country has 88,000 doctors, with a ratio of 33 doctors per 100,000 people, and its universities produce 7,000 doctors annually, the ministry noted.
"The majority of doctors are civil servants. If there's a surge in patients while... [the doctor] has to juggle working in two or three places to make a decent living, you can imagine the stress," said Mulyawan, the neurosurgeon and insurance expert.
The unequal distribution of health workers would not be a problem if they were adequately paid wherever they work, he said. "Most doctors choose to work in cities because that's where the money is."
ap/ds/he
Access report online |
| Push to decriminalize sex work, but stigma remains 
|
YANGON, 14 January 2014 (IRIN) - Despite a decreasing prevalence of HIV/AIDS among commercial sex workers, health workers say the stigma associated with prostitution and the harsh laws against it are undermining sex workers' access to HIV-related services.
"Myanmar has made remarkable progress, given the limited resources it's had [to combat HIV]. Resources are usually misspent by targeting the general community [rather than at-risk groups]. However, the country's national strategy has included some very strong targeting," said Eamonn Murphy, the country coordinator for the Joint UN Programme on AIDS (UNAIDS).
Myanmar currently allocates just 3.9 percent of its budget to health, but the figure will rise to 5 percent in 2014, which represents a fourfold increase since the end of military rule in 2011.
The Global Fund to Fight AIDS, Tuberculosis and Malaria resumed operations in Myanmar in 2011 and in September 2013 provided US$160 million for HIV services [until 2016] – an increase of $90 million.
According to the Myanmar Ministry of Health, there are 200,000 people living with HIV/AIDS, and approximately 15,000 people die of AIDS-related illnesses every year.
"Prevalence has been decreasing in all risk groups other than drug users," Anne Lancelot, director of the Targeted Outreach Programme at Population Services International (PSI) confirmed.
Surveys reveal that in 2008, prevalence among sex workers stood at 18.4 percent, whereas 7.1 percent of sex workers were HIV positive in 2012.
While government data estimates that there are currently 60,000 sex workers in Myanmar, PSI puts the real number at closer to 80,000. The national HIV infection rate is 0.5 percent, making HIV/AIDS a concentrated epidemic, said Murphy, adding, "However there have been quite a lot of deaths due to a lack of access to treatment."
Laws curb access to health services
The stiff penalties for commercial sex work contained in Myanmar's Suppression of Prostitution Act (1949) are a major barrier to accessing HIV treatment. The punishment is one to three years in prison for sex workers, but clients are not punished under the law.
"Very harsh laws are in place against sex workers, instead of the mobilizers, the traffickers and the gangs who push women into sex work," said Sid Naing, the country director for Marie Stopes, an international NGO working to improve sexual and reproductive health.
Even possessing a condom could be used as circumstantial evidence of prostitution until 2011, when the Ministry of Home Affairs issued a directive to the contrary, yet according to UNAIDS most of the public are unaware of the directive.
"People are still not comfortable about carrying large amounts of condoms because they could be targeted as sex workers," PSI's Lancelot noted.
Commercial sex workers watch TV at a PSI drop-in centre in Yangon Overcoming stigma
Another barrier to the prevention and treatment of HIV is the stigma surrounding commercial sex work - the word "prostitute" literally translates to "bad woman".
"Myanmar isn't like other countries where sex work is more organized, with red-light districts which are brothel-based. There's a great deal of indirect sex work, such as in massage parlours and karaoke bars," said Krittayawan Tina Boonto, the UNAIDS investment and efficiency advisor.
In 1998 an amendment broadened the 1949 legal definition of a brothel to include any place used habitually for sex. This was done in response to the growth of sex work conducted in karaoke bars and massage parlours, which frequently change locations due to harassment by police. The managers of these establishments often deny health workers access to employees for fear of prosecution.
Naing said as a result of this, trying to provide HIV services was "like trying to pin down a river. The next day you go back and the sex workers are no longer there."
Is parliament ready?
In July 2013, the founder of the Sex Workers in Myanmar network (SWIM), an advocacy group for commercial sex workers, Thuza Win, spoke in parliament about the legal barriers to accessing HIV services. "This government is so different from when I set up the network in 2009. I think the laws could even change before the 2015 [general] elections," she said.
Naing agrees – up to a point. "The legislature has a number of promising members who are trying to raise the issue. But there are also very vocal conservatives, and many who agree in conscience but fear they will be seen as attacking traditional values."
Sandar Min, an MP representing Myanmar's main opposition party, the National League for Democracy, led by Aung San Suu Kyi, told IRIN, "My mission is to work out how to draft a new law so that there is more protection for HIV patients. But although I'm not ashamed to speak out, many others are."
The policy officer for the Asia Pacific Network of Sex Workers (APNSW), Kay Thi Win, who is also the founder of the AIDS Myanmar Association (AMA), commented, "I'm not sure that Myanmar is ready to decriminalize sex work. However, before the 2010 elections, there wasn't even any public debate. I think that with more advocacy... we may be able to turn the tide of opinion."
jm/ds/he
Access report online |
|
|
|
No comments:
Post a Comment