THE GEOGRAPHIC DISTRIBUTION OF SPECIALIST DOCTORS IN A MIXED PUBLIC-PRIVATE SYSTEM: REGULATORY CHALLENGES FOR INDONESIA

(1)

Andreasta Meliala

Krishna Hort

Laksono Trisnantoro

THE GEOGRAPHIC DISTRIBUTION OF SPECIALIST

DOCTORS IN A MIXED PUBLIC-PRIVATE SYSTEM:

REGULATORY CHALLENGES FOR INDONESIA

(2)

CONTEXT &

QUESTIONS

• Universal Health Coverage 2014

• Unequal distribution of Specialist Doctor and inequity issue

particularly in eastern part of Indonesia

• How does specialist doctors distributed in Indonesia?

• Would regulation be the main instrument to tackle

maldistribution?

(3)

(4)

NATIONAL REGULATION

System:

Public Safety

Organization:

Licensing &

Accreditation

Individual:

Max 3 Locations

Health

Act

Hospital

Act

Medical

Act

(5)

TYPE OF REGULATION OF SPECIALIST DOCTOR

IN INDONESIA

Sp

ec

ia

lis

t D

oc

to

r

National Health

Regulation

Local Health

Regulation

Hospital Regulation

Medical Regulation

Professional

Regulation

(6)

PUBLIC & PRIVATE HOSPITAL IN INDONESIA

Element

Public Hospital

Private Hospital

Organization & Entity

Owned by Government (Central,

Provincial, or District), Public Enterprise

Corporation, Foundation, NGO’s

Law & Regulation

Health Act, Hospital Act, Medical Act, Government Regulation, Ministry of Health

regulation, Local Regulation

Ministry of Internal Affairs, Ministry of Civil

Servant

Corporation Law, Foundation Law

Licensing & Accreditation

Comply to national licensing & National Accreditation system

Additional legal aspect enacted by other

Ministries & Local regulation

Human Resource

Civil Servant (first appointment)

Full Timer & Part Timer (civil servant)

Financing

Public (subsidized)

Private (minimum subsidy)

Payment mechanism

Retrospective & Prospective

Clients

High to Low (OoP & Insurance-based)

Role in Social Insurance

To provide health service for low income

group

25% of beds for low income group

Performance Indicator

Service, Customer satisfaction

Service, Customer Satisfaction,

(7)

(8)

BEFORE UHC TRIAL ON MARCH-MAY 2014 IN

JAKARTA

(9)

UHC TRIAL ON MARCH-MAY 2014 (JAKARTA)

Utilization steady:

In patient: 2/day

Out-patient: 5-10/day

Operation: 0

Utilization Increased:

In patient: 56%

Out-patient: 64%

Operation: 30-44%

Asking for

more

doctors

Has been

Asking for

more doctors

_{Has been}

Asking for

more doctors

_{Asking for}

Has been

more doctors

Has been

Asking for

more

doctors

(10)

5

12

13

14

15

16

25

29

34

38

39

40

45

50

66

67

98

109

117

127

130

135

229

236

482

530

580

640

0

100

200

300

400

500

600

700

SULAWESI BARAT MALUKU UTARA KALIMANTAN TENGAH GORONTALO MALUKU BENGKULU PAPUA SULAWESI TENGGARA KEPULAUAN BANGKA BELITUNG PAPUA BARAT SULAWESI TENGAH KEPULAUAN RIAU KALIMANTAN SELATAN KALIMANTAN BARAT JAMBI NUSA TENGGARA BARAT KALIMANTAN TIMUR NUSA TENGGARA TIMUR LAMPUNG SULAWESI UTARA SUMATERA BARAT NANGGROE ACEH DARUSSALAM RIAU SUMATERA SELATAN DI YOGYAKARTA SULAWESI SELATAN BALI BANTEN SUMATERA UTARA JAWA TENGAH JAWA TIMUR JAWA BARAT DKI JAKARTA

PEDIATRICIAN IN HOSPITAL (2013)

Dynamic distribution

Static distribution

(11)

6

10

13

16

17

18

20

21

22

34

37

38

46

50

55

61

64

79

96

113

124

133

168

173

239

312

542

640

739

740

0

100

200

300

400

500

600

700

800

SULAWESI BARAT MALUKU UTARA MALUKU PAPUA PAPUA BARAT KALIMANTAN TENGAH BENGKULU KEPULAUAN BANGKA BELITUNG GORONTALO SULAWESI TENGGARA KEPULAUAN RIAU SULAWESI TENGAH KALIMANTAN SELATAN NUSA TENGGARA TIMUR KALIMANTAN BARAT KALIMANTAN TIMUR NUSA TENGGARA BARAT LAMPUNG JAMBI SULAWESI UTARA NANGGROE ACEH DARUSSALAM SUMATERA BARAT DI YOGYAKARTA RIAU SULAWESI SELATAN BALI SUMATERA SELATAN BANTEN SUMATERA UTARA JAWA TENGAH JAWA BARAT JAWA TIMUR DKI JAKARTA

OB-GYN IN HOSPITAL (2013)

Dynamic distribution

Static distribution

(12)

3

10

14

15

16

17

18

20

22

30

36

39

42

44

48

49

63

93

100

108

121

130

146

155

282

447

505

534

549

0

100

200

300

400

500

600

SULAWESI BARAT PAPUA MALUKU UTARA KEPULAUAN BANGKA BELITUNG MALUKU SULAWESI TENGGARA PAPUA BARAT KALIMANTAN TENGAH BENGKULU GORONTALO KEPULAUAN RIAU KALIMANTAN SELATAN SULAWESI TENGAH JAMBI KALIMANTAN BARAT KALIMANTAN TIMUR NUSA TENGGARA BARAT NUSA TENGGARA TIMUR LAMPUNG SULAWESI UTARA RIAU SUMATERA BARAT NANGGROE ACEH DARUSSALAM BANTEN SUMATERA SELATAN DI YOGYAKARTA SULAWESI SELATAN BALI SUMATERA UTARA JAWA BARAT DKI JAKARTA JAWA TIMUR JAWA TENGAH

Dynamic distribution

Static distribution

(13)

5

9

12

15

18

21

24

31

32

37

45

49

51

53

89

91

92

95

105

136

154

162

224

427

436

480

503

0

100

200

300

400

500

600

SULAWESI BARAT MALUKU UTARA KEPULAUAN BANGKA BELITUNG PAPUA BARAT PAPUA KALIMANTAN TENGAH BENGKULU GORONTALO MALUKU SULAWESI TENGGARA KEPULAUAN RIAU SULAWESI TENGAH NUSA TENGGARA TIMUR KALIMANTAN SELATAN KALIMANTAN BARAT KALIMANTAN TIMUR SULAWESI UTARA JAMBI LAMPUNG NUSA TENGGARA BARAT SUMATERA SELATAN SUMATERA BARAT NANGGROE ACEH DARUSSALAM RIAU BANTEN DI YOGYAKARTA SULAWESI SELATAN BALI SUMATERA UTARA JAWA BARAT DKI JAKARTA JAWA TENGAH JAWA TIMUR

SURGEON IN HOSPITAL (2013)

Dynamic distribution

Static distribution

(14)

FACTORS BEHIND

• Number of population

• Fiscal capacity

• Number of public hospital

• Private sector

(15)

POPULATION VS SPECIALIST DOCTOR

0

500 1000

1500

2000

2500

0 5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

J

u

m

la

h

D

o

k

te

r

Jumlah Penduduk

IN 33 PROVINCES

Number

of Doctor

Number of Population

(16)

FISCAL CAPACITY VS SPECIALIST DOCTOR

DISTRIBUTION (2009)

Number

of Doctor

(17)

PUBLIC HOSPITALS VS SPECIALIST DOCTOR (2010)

Asosiasi&Rumah&Sakit&VS&Dokter&Spesialis&di&Pemerintah&

(2008)

y"="$9.1223x"+"371.53

R

2

"="0.0773

0

200

400

600

800 1,000

1,200

0

5

10

15

20

25

30

35 Jumlah&Rumah&Sakit&Pemerintah

J

u

m

l

a

h

&

D

o

k

t

e

r

&

S

p

e

s

i

a

l

i

s

!

Number

of Doctor

Number of Public Hospital

(18)

PRIVATE HOSPITALS VS SPECIALIST DOCTOR

!

Number

of Doctor

Number of Private Hospital

(19)

SUPPLY &

ENFORCED REGULATION

Effective Regulation (evenly

distribution)

Ineffective (under supply)

Multiple practice (over supply)

No man’s land (no existence);

barrier to entry

SUPPLY

ENFORCED

REGULATION

+

-

(20)

(21)

SOURCE OF INCOME & PROPORTION: INTERNIST

Fixed salary as a Civil Servant

10,2

Incentive (Public Hospital)

5,2

Private Salary (Private Hospital)

16,2

Private Incentive (Private Hospital)

44,8

Private Practice

14,7

Incentive from Pharmaceutical Ind., Lab, etc 1,7

Lecturing Fee

0,5

Insurance 1

0,0

Insurance 2

0,0

(22)

SOURCE OF INCOME & PROPORTION: SURGEON

Fixed salary as a Civil Servant

_8,9

Incentive (Public Hospital)

_3,6

Private Salary (Private Hospital)

_30,9

Private Incentive (Private Hospital)

_28,0

Private Practice

_6,7

Incentive from Pharmaceutical Ind., Lab

_2,7

Lecturing Fee

_1,5

Insurance 1

_1,1

Insurance 2

_0,0

(23)

SOURCE OF INCOME & PROPORTION: OB-GYN

Fixed salary as a Civil Servant

6,6

Incentive (Public Hospital)

2,7

Private Salary (Private Hospital)

34,5

Private Incentive (Private Hospital)

33,5

Private Practice

13,2

Incentive from Pharmaceutical Ind., Lab,

etc

2,0

Lecturing Fee

1,5

Insurance 1

0,2

Insurance 2

0,2

Others

5,6

(24)

SOURCE OF INCOME & PROPORTION: PEDIATRICIAN

Fixed salary as a Civil Servant

_11,4

Incentive (Public Hospital)

_2,1

Private Salary (Private Hospital)

_18,2

Private Incentive (Private Hospital)

_44,3

Private Practice

_15,3

Incentive from Pharmaceutical Ind., Lab, etc

_1,0

Lecturing Fee

_2,2

Insurance 1

0,8

Insurance 2

_0,1

(25)

(26)

TYPE OF REGULATION OF SPECIALIST DOCTOR

IN INDONESIA

Sp

ec

ia

lis

t D

oc

to

r

National Health

Regulation

Local Health

Regulation

Hospital Regulation

Medical Regulation

Professional

Regulation

They don’t work

in

under-supplied area &

low regulating

capacity

(27)

MEDICAL ACT VS PRACTICE FACT

Specialist

Hospital

Private Practice

Total

State Non-‐State

Specialist 01

1

2

5 Specialist 02

1

3 Specialist 03

1

2

1

4 Specialist 04

1

3 Specialist 05

1

3

1

5 Specialist 06

1

5

1

7 Specialist 07

1

3

1

5 Specialist 08

1

2 -‐

3 Specialist 09

1

2

5 Specialist 10

1

3

1

5 Specialist 11

1

4

1

6 Specialist 12

1

2

4 Specialist 13

1

4 -‐

5 Specialist 14

1

3 -‐

4 Specialist 15

1

3

(28)

DUAL PRACTICE, IN PRACTICE

Business Hours: 07:30 – 15:00

Working Hour: 12:00 – 12:00

(29)

(30)

MODEL OF DOCTORS DISTRIBUTION:

Distribution

Production

Issue

HRH’s price

Regulation &

Contract

Professional

facilities

Social

facilities

Barrier to

Entry

Engagement

factors

Modified from: Prekker, 2008;

Fieldstein, 1979

(31)

FACT OF DOCTORS DISTRIBUTION:

Distribution

Production

Issue

HRH’s price:

Population

Private Sector

Regulation & Contract

Professional

facilities

Dual Practice

Social facilities

Barrier to Entry

Engagement

factors

X

X: negative factor

(32)

REGULATORY FAILURE

• Provincial / district health oﬃce lacks capacity to

monitor / enforce

• Local government unwilling to sancQon specialist

doctors in case they seek alternaQve locaQon

• ‘Regulatory capture’ – regulators are also doctors

with private pracQce

• Market forces in situaQon of high demand, low

(33)

(34)

POLICY & REGULATION OF OTHER COMPONENTS

Comprehensive

Regulation

Distribution

Institution

standard &

capacity

Payment

mechanism

Contract

• Social facilities

• Education

• CPD

(35)

THE MESSAGES

• Special policy for needy region should be developed to

back up specific regulation & strategy to distribute

specialist doctor in deprived area

• Regulation of other components is very important to

change current behavior of the doctors and it should be

enforced to distribute doctors across Indonesia

• Professional association and other stakeholders must

be taken into account in the policy development in

order to enhance its effectiveness

(36)