THE GEOGRAPHIC DISTRIBUTION OF SPECIALIST DOCTORS IN A MIXED PUBLIC-PRIVATE SYSTEM: REGULATORY CHALLENGES FOR INDONESIA
Andreasta Meliala Krishna Hort Laksono Trisnantoro
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?
HOW TO DISTRIBUTE SPECIALIST DOCTOR?
NATIONAL REGULATION
Health Act
Hospital Act
Medical Act
System: Public Safety
Organization: Licensing & Accreditation
Individual: Max 3 Locations
Specialist Doctor
TYPE OF REGULATION OF SPECIALIST DOCTOR IN INDONESIA National Health Regulation Local Health Regulation Hospital Regulation Medical Regulation Professional Regulation
PUBLIC & PRIVATE HOSPITAL IN INDONESIA Element Organization & Entity
Public Hospital Owned by Government (Central, Provincial, or District), Public Enterprise
Private Hospital Corporation, Foundation, NGO’s
Health Act, Hospital Act, Medical Act, Government Regulation, Ministry of Health regulation, Local Regulation Law & Regulation
Ministry of Internal Affairs, Ministry of Civil Corporation Law, Foundation Law Servant Comply to national licensing & National Accreditation system
Licensing & Accreditation
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 Clients
Retrospective & Prospective 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, Financial
DOES IT GOOD?
BEFORE UHC TRIAL ON MARCH-MAY 2014 IN JAKARTA
UHC TRIAL ON MARCH-MAY 2014 (JAKARTA) Has been Asking for more doctors Asking for more doctors
Utilization Increased: In patient: 56% Out-patient: 64% Operation: 30-44%
Has been Asking for more doctors Has been Asking for more doctors
Has been Asking for more doctors
Utilization steady: In patient: 2/day Out-patient: 5-10/day Operation: 0
PEDIATRICIAN IN HOSPITAL (2013) DKI JAKARTA JAWA BARAT JAWA TIMUR JAWA TENGAH SUMATERA UTARA BANTEN BALI SULAWESI SELATAN DI YOGYAKARTA SUMATERA SELATAN RIAU NANGGROE ACEH DARUSSALAM SUMATERA BARAT SULAWESI UTARA LAMPUNG NUSA TENGGARA TIMUR KALIMANTAN TIMUR NUSA TENGGARA BARAT JAMBI KALIMANTAN BARAT KALIMANTAN SELATAN KEPULAUAN RIAU SULAWESI TENGAH PAPUA BARAT KEPULAUAN BANGKA BELITUNG SULAWESI TENGGARA PAPUA BENGKULU MALUKU GORONTALO KALIMANTAN TENGAH MALUKU UTARA SULAWESI BARAT
5 0
50 45 40 39 38 34 29 29 25 16 16 15 14 14 13 13 13 12
67 66
482
236 229
135 130 127 117 109 98
530
580
640
Dynamic distribution
Static distribution 100
200
300
400
500
600
700
OB-GYN IN HOSPITAL (2013) 740 739
DKI JAKARTA JAWA TIMUR JAWA BARAT JAWA TENGAH SUMATERA UTARA BANTEN SUMATERA SELATAN BALI SULAWESI SELATAN RIAU DI YOGYAKARTA SUMATERA BARAT NANGGROE ACEH DARUSSALAM SULAWESI UTARA JAMBI LAMPUNG NUSA TENGGARA BARAT KALIMANTAN TIMUR KALIMANTAN BARAT NUSA TENGGARA TIMUR KALIMANTAN SELATAN SULAWESI TENGAH KEPULAUAN RIAU SULAWESI TENGGARA GORONTALO KEPULAUAN BANGKA BELITUNG BENGKULU KALIMANTAN TENGAH PAPUA BARAT PAPUA MALUKU MALUKU UTARA SULAWESI BARAT
640 542 312 239 173 168 168 133 124 113 96 79 64 61 61 55 50 46 38 37 34 22 21 20 18 17 16 16 13 10 6 0
Dynamic distribution
Static distribution 100
200
300
400
500
600
700
800
INTERNAL MEDICINE IN HOSPITAL (2013) 549
JAWA TENGAH
534
JAWA TIMUR
505
DKI JAKARTA
447
JAWA BARAT
282
SUMATERA UTARA
155 155 146
BALI SULAWESI SELATAN DI YOGYAKARTA
130 121 108 100 93
SUMATERA SELATAN BANTEN NANGGROE ACEH DARUSSALAM SUMATERA BARAT RIAU
63
SULAWESI UTARA
49 48 48 44 42 39 36 30 22 20 18 17 16 16 15 14 14 10
LAMPUNG NUSA TENGGARA TIMUR NUSA TENGGARA BARAT KALIMANTAN TIMUR KALIMANTAN BARAT JAMBI SULAWESI TENGAH KALIMANTAN SELATAN KEPULAUAN RIAU GORONTALO BENGKULU KALIMANTAN TENGAH PAPUA BARAT SULAWESI TENGGARA MALUKU KEPULAUAN BANGKA BELITUNG MALUKU UTARA PAPUA
Dynamic distribution
Static distribution
3
SULAWESI BARAT
0
100
200
300
400
500
600
SURGEON IN HOSPITAL (2013) 503
JAWA TIMUR
480
JAWA TENGAH
436 427
DKI JAKARTA JAWA BARAT
224
SUMATERA UTARA
162 154
BALI SULAWESI SELATAN
136
DI YOGYAKARTA
105
BANTEN
95 92 91 89
RIAU NANGGROE ACEH DARUSSALAM SUMATERA BARAT SUMATERA SELATAN
53 53 51 49 45 37 32 32 31 24 21 18 18 18 15 12 12 12 9 5
NUSA TENGGARA BARAT LAMPUNG JAMBI SULAWESI UTARA KALIMANTAN TIMUR KALIMANTAN BARAT KALIMANTAN SELATAN NUSA TENGGARA TIMUR SULAWESI TENGAH KEPULAUAN RIAU SULAWESI TENGGARA MALUKU GORONTALO BENGKULU KALIMANTAN TENGAH PAPUA PAPUA BARAT KEPULAUAN BANGKA BELITUNG MALUKU UTARA SULAWESI BARAT
0
Dynamic distribution
Static distribution 100
200
300
400
500
600
FACTORS BEHIND
• Number of population • Fiscal capacity • Number of public hospital • Private sector • Regulation (?)
POPULATION VS SPECIALIST DOCTOR 2500
2000 J u m 1500 l a h D o k t 1000 e r
Number of Doctor
IN 33 PROVINCES
500
0 0
5,000
10,000
15,000
20,000
25,000
Jumlah Penduduk
Number of Population
30,000
35,000
40,000
45,000
FISCAL CAPACITY VS SPECIALIST DOCTOR DISTRIBUTION (2009)
IN 33 PROVINCES Number of Doctor
PUBLIC HOSPITALS VS SPECIALIST DOCTOR (2010) Asosiasi&Rumah&Sakit&VS&Dokter&Spesialis&di&Pemerintah& (2008) 1,200 1,000 S p J D e u o Numbers k i of m Doctor l t a a e l h r i & & s
800 600
y"="$9.1223x"+"371.53
IN 33R2PROVINCES "="0.0773
400 200 0 0
5
10
15
20
25
30
35
Jumlah&Rumah&Sakit&Pemerintah
Number of Public Hospital
!
PRIVATE HOSPITALS VS SPECIALIST DOCTOR
IN 33 PROVINCES Number of Doctor
Number of Private Hospital
!
SUPPLY & ENFORCED REGULATION
+ + ENFORCED REGULATION
-
SUPPLY
-
Effective Regulation (evenly distribution)
Ineffective (under supply)
Multiple practice (over supply)
No man’s land (no existence); barrier to entry
PRIVATE FACTORS
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
Others
6,8
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
Others
16,6
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
SOURCE OF INCOME & PROPORTION: PEDIATRICIAN Fixed salary as a Civil Servant
11,4
Incentive (Public Hospital)
2,1 18,2
Private Salary (Private Hospital) Private Incentive (Private Hospital)
44,3
Private Practice
15,3 1,0 2,2 0,8 0,1 4,6
Incentive from Pharmaceutical Ind., Lab, etc Lecturing Fee
Insurance 1 Insurance 2 Others
REGULATION FACTOR
Specialist Doctor
TYPE OF REGULATION OF SPECIALIST DOCTOR IN INDONESIA National Health Regulation Local Health Regulation Hospital Regulation Medical Regulation Professional Regulation
They don’t work in undersupplied area & low regulating capacity
MEDICAL ACT VS PRACTICE FACT Specialist Specialist 01 Specialist 02 Specialist 03 Specialist 04 Specialist 05 Specialist 06 Specialist 07 Specialist 08 Specialist 09 Specialist 10 Specialist 11 Specialist 12 Specialist 13 Specialist 14 Specialist 15
Hospital Private Practice State Non-‐State 1 2 2 1 1 1 1 2 1 1 1 1 1 3 1 1 5 1 1 3 1 1 2 -‐ 1 2 2 1 3 1 1 4 1 1 1 2 1 4 -‐ 1 3 -‐ 1 1 1
Total 5 3 4 3 5 7 5 3 5 5 6 4 5 4 3
DUAL PRACTICE, IN PRACTICE Business Hours: 07:30 – 15:00
Working Hour: 12:00 – 12:00
Softly Regulated
DISCUSSIONS
MODEL OF DOCTORS DISTRIBUTION: Regulation & Contract
Professional facilities
Social facilities
HRH’s price
Production Issue
Engagement factors
Distribution
Barrier to Entry Modified from: Prekker, 2008; Fieldstein, 1979
FACT OF DOCTORS DISTRIBUTION: Regulation & Contract HRH’s price: Population Private Sector
Production Issue
X
Professional facilities Dual Practice
X Distribution
Engagement factors
Social facilities
X X
Barrier to Entry
X: negative factor
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 supply > regulatory efforts
WHAT TO DO?
POLICY & REGULATION OF OTHER COMPONENTS
Distribution
Contract • Social facilities • Education • CPD
Comprehensive Regulation
Payment mechanism
Institution standard & capacity
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
THANK YOU
