7-8 September 2016 | Sheraton Hotel & Towers | Ho Chi Minh City, Vietnam
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How to do public hospital reformation:The case of Indonesia public hospitals 1990 –
2015
Laksono TrisnantoroDepartment of Public HealthUniversitas Gadjah Mada
Indonesia
Content
• 1990s: The Policy of Financial Autonomy as a reform, a strong force for a better hospital.
• 2015: A setback of Pendulum of autonomy: New Policy in making become more bureaucratic in 2015
• Lesson learnt
• As Steward (regulator, enforcement agency)
• Financier• Provider of Services
One Impact of Reform in 1990s: The separation of hospital from District Health Office
District Health Office
District Hospitals (more than 500): not under DHOMore As Provider, under Local Government
Granted partial financial autonomy, more independent in managing human resources, and having authority to write strategic plan
Hospital Autonomy Reform :early 1990s
B ure aucr atic C o rpor ate ty pe O rg ani zatio n of O rga ni za tio n
D H O non s wa danaHos pit al
Sw ada naHospit al
RS B LU P T A ske s Indone sia
P NB P For Pr ofit State Corp orat io n Peru m (P ers ero) Sw ad ana
N on-P r ofit Org
Perjan
Presidential Decree 38/91
2015:?
District Health Office is transforming,until now
Implication to the District Health Office
+ As Steward (regulator, enforcement
agency) Managers of human and other resources
for health
Provider of Primary Services
How the impact for Public Hospital
• Some become a better hospital
• Some not.
• Positive impact of increasing private financing in public hospital
• Hospital becomes a financially strong organization at local government
Public hospital reformation: Managerialism impact
• The hospital reform changed the way in managing hospital
• The principle of hospital management can be applied in the reform implementation
• The result is real, although need 5 – 10 years of implementation
Before Financial Autonomy
(early 1990s) A very bureaucratic organization
Experience from Tabanan Hospital
20005 Years After Financial Reform
2005
Bureaucratic Organization
Patient-Oriented OrganizationUsing managerialismconcept
TREND PENDAPATAN TAHUN 1995 - 2002
10,407,928,264
6,657,766,094
1,019,038,0051,660,008,165292,053,650
377,838,975365,604,625
420,597,125-500,000,000
1,000,000,0001,500,000,0002,000,000,0002,500,000,0003,000,000,0003,500,000,0004,000,000,0004,500,000,0005,000,000,0005,500,000,0006,000,000,0006,500,000,0007,000,000,0007,500,000,0008,000,000,0008,500,000,0009,000,000,0009,500,000,000
10,000,000,00010,500,000,00011,000,000,000
Th. 1995 Th. 1996 Th. 1997 Th. 1998 Th. 1999 Th. 2000 Th. 2001 Th. 2002
Private Financing after financial autonomy reform
Indicator Tabanan District Hospital
X District Hospital(Not Reformed)
User Survey Result Routinely implemented Not yet implementedMedico-Legal Cases No cases No cases . There is no
cases reported in court.Clinical Output Indicators Available and used for
quality improvement.Not available
Strategic Business Plan availability Available2000-2005, 2006 - 2010
Not available
Indicators of Minimum Service Standard In process.This is one of requirement for becoming Public Service Unit. Since 2006.
Not available
The availability of Clinical Process Reports Available (limited)The clinical report such as: noscomial infection, delayed surgical operation, waiting time for emergency patient, etc.
Not availabe
The Availability of Financial Reports AvailableBalance sheet, cash flow report, inventory, etc.
Not available
[
What they did in reforming the hospital
Number and competences of Managers EnoughThe Director is trained in Graduate Program in Hospital Management. Most of the top managers are alsp trained in hospital management
Not enough, below standard.Only the Director has the master in Hospital Administration. The other managers are not.
Number and competences of Medical Doctors
Above standard. This hospital has some sub-specialists.
Below standard. Only 2 specialists (Internal Medicine and Peditrician) for 700.000 people
Number and competences of Nurses Above standard. This is the observation. Actually the nurses in Indonesia is still developing the competence. For example whether the nurses should have more specialist training like surgery nurse, pediatriac nurse etc.
Below standard
Number and competences of other health workers
Not yet measured No data available
Human resources satisfaction on compensation
Excellent.The director has insentive around Rp 20-25 milion/monthly.The managerial staffs have incentives from 2 to 6 million/monthly.The surgeon has incentive of more than 25 million a month
PoorThe incentive for the director is difficult to measure (may be aorund Rp 1 – 2 million. Some incentives come from projects and meetings that difficult to measure)The managerial staffs are lacking of incentivesThe surgeon has incentive about 10 million a month.
The availability of good staff renumeration system
Available Not available
The availability of Human Resources Management Information System
Available (limited )There is a system for tracking education, training, performance, etc. This is related to the remuneration system.
Not available
The availability of Billing System Available Not availableThe availability of Accounting System In process Not available
The capacity of producing good financial report
Has the capacity No capacity
The capacity of producing unit cost information
Developing capacity.Tabanan Hospital is still developing the hospital accounting system. This effort will be boosted by the decalaration of Tabanan Hospital as Public Service Unit. This legal status demand routine data of unit-cost. The data only can be produced by good accounting system.
No capacity
The availability of financial autonomy legal status
Has financial autonomy status . This is under national law. Financially, the management is much more flexible.
No financial autonomy. The finance is managed by local government using bureaucratic system
The availability of Pharmaceutical Management System
Available Limited
The availability of housekeeping management system
Available Not available
The Availability of Medical Record System
Available Limited
The availability of hospital surveillance system
Available Limited
The availability of other information system
Available Not available
The availability of Local Government Decree on Hospital Status.
Available Not available
The availability of system for maintaining facilities and equipment
Available Not available
The availability of quality assurance system
Available Not available
The availability of Hospital ByLaws Available Not availableThe availability of Medical ByLaws Available
The By Laws are developed by hospital, The ByLaws is concerned with the governance of the hospital. How the relationship between hospital owners, managers, and clinicians and other staff is written in the ByLaws.
Not available
is SwingingAUTONOMY POLICY
BUREAUCRATIC ORGANIZATION RETURN BACK
AUTONOMOUS
Government Law in 2014
A sudden policy turn in 2015
Hospital Autonomy; 2015
B ure aucr atic C o rpor ate ty pe O rg ani zatio n of O rga ni za tio n
D H O non s wa danaHos pit al
Sw ada naHospit al
RS B LU P T A ske s Indone sia
P NB P For Pr ofit State Corp orat io n Peru m (P ers ero) Sw ad ana
N on-P r ofit Org
Perjan
Presidential Decree 38/91
2015:?
A new Law: District Health Offices return back for managing
the public hospitals
District Health Office (DHO)
District Hospital, will be under DHO: Less Autonomy
More political influence from local government
Why the new policy is decided?
1. Technical Reasons: District Health Offices have difficulties in controlling hospitals: Hospitals become more separated from primary health care under District Health Office;
2. Knowledge of Policy makers on the role of Hospital as providers and the role of District Health Office as regulators;
3. Political and economic reasons.
Lesson‐learnt1. Since 1990s Indonesian public hospital managers
have the capacity for doing the hospital reform;2. However, some bureaucratic policy makers have
perception that too much autonomous is bad for health sector. Law in 2014;
3. In the 2015…began political and Law debate for shaping the presidential order concerning hospital autonomy. The legal debate between bureaucratic view vs managerialism began and may harm hospital management system.