Rp 26 000 is not a big amount money for you, but it is for me

During osce remedial of year 3, I had to repeat eye/ENT station.

"I will refer you to eye specialist," I said to a simulated patient with glaucoma.

"But how much is the fee?" asked the patient. I was stunned when she asked that question.

"You have Jamkesmas, don't you?" I asked.

"No, I don't have" said the patient.

"oh...If you go to Hospital Dr. Sardjito, you can just have to pay about Rp 26 000 for the registration and specialist consultant fees. Don't worry, it is not too expensive," I said with a confident smile.

"Rp 26 000 is not a big amount money for you, but it is for me. I can't afford the payment," said the patient.

Read till here, what is your comment?

Although this is a conversation between a simulated patient and me, this actually reflects the current situation in Indonesia. A poor patient without Jamkesmas. What do you think? Is she categorized as moderate income group,but not yet near-to-poor group? or because the information about the existence of Jamkesmas and ways to register it, is not disseminated well, so she does not know how to register for Jamkesmas? If she is in the middle-income group, does it imply that citizens in this group will not apply Askes, not until they suffer from a chronic disease or sustain a heavy injury, in which they need to pay a huge amount of money for the treatment?

Why would this happen?

Data of the targets(Low income group) is not complete yet. Besides, Ministry of Health is not able to reach all the target due to the limited budget on dissemination of information regarding to Jamkesmas.

According to Prof. Dr. Ali Ghufron Mukti, the community need to pay for Askes by themselves regularly. Dr. drg. Yulita Hendartini and PT askes cabang DIY told us that the community have to pay around Rp. 28 000 per month. Lets apply the scenario above to this reality. Do you have a clear picture why not all poor families with Askes? Just imagine the bread winner of a family earns Rp 1 500 000 per month. Lets give an example. Say, there are only 3 persons in a family: father, mother and a kid. They spent Rp 5000 per meal (eg tempe/sayur+telur+nasi). Everyday, they take 2 meals. So, they will spend Rp 900 000 per month on meals only. What about the transport fees? assume Rp 2 000 per trip. The breadwinner go to work per day. round trip per day costs Rp 4000. In a month, total is Rp120 000.  How about the electricity n water bills?more than Rp 400 000? How about school fees for the kid? Hmmm...yeah, Rp. 28 000 is not a small amount of money for them. Note, it s per person. So, if one wants to pay for the whole family, then it will be more than Rp. 50 000. Can such a family afford the payment?

Other than that, in Indonesia, decentralization has affected health finance system. The government has limitations in pooling the fund from the community and private sector. One of the solution for this issue is pooling the fund from community through health insurance mechanism. BUT, this is not as easy as we think. In the reality, the community has lost faith to the government because all this while, the health standard is not satisfied and consequently their demands are not fulfilled yet. So, the community has lost the credibility to this health insurance mechanism.

Due to these factors, 70% of health care expenditure is still currently paid "out-of-pocket". This deters the poor to seek medical care when they are sick.....

So, what is the solution for the scenario I mentioned above?

Tell the patient that she can apply Jamkesmas through RT (rumah tetangga). =)  p/s: the examiner suggested this option to me. To my friends who read this post, don worry, the examiner in the Eye/ENT station told me that I did very well and I pass! yeay!! :D

Hopefully more communities are covered by health insurance, so that more people can access the health service, and hence increase of health status.

Reference:
1. Prof. Dr. Ali Ghufron Mukti. Lecture: Health Finance
2. http://www.searo.who.int/LinkFiles/Conference_Panel-C2.pdf
3. Dr. drg. Yulita Hendrartini and PT Askes Cabang DIY. Panel discussion: Physician economics behavior, health insurance, managed care and quality.
4. Laksono Trisnantoro. Desentralisasi Kesehatan Di Indonesia Dan Perubahan Fungsi Pemerintah: 2001-2003. UGM Press. Juni 2005.
5. Menteri Kesehatan Republik Indonesia. Jamkesmas tahun 2008.Disampaikan dalam Rapat Dengar Pendapat Dengan DPRRI. 27 Maret 2008.