7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam

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1 7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam

How to do public hospital reformation: The case of Indonesia public hospitals 1990

2 How to do public hospital reformation: The case of Indonesia public hospitals Laksono Trisnantoro Department of Public Health Universitas Gadjah Mada Indonesia

3 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

4 One Impact of Reform in 1990s: The separation of hospital from District Health Office District Health Office As Steward (regulator, enforcement agency) Financier Provider of Services District Hospitals (more than 500): not under DHO More As Provider, under Local Government Granted partial financial autonomy, more independent in managing human resources, and having authority to write strategic plan

5 Hospital Autonomy Reform : early 1990s Bure aucr atic Corpor ate type Organization of Organization Non-Profit PNBP Swadana Org For Profit State Corporation Perum (Persero) DHO non swadana Hos pit al Sw adana Hospit al RS B LU Perjan PT Askes Indonesia Presidential Decree 38/ :?

6 + Implication to the District Health Office District Health Office is transforming, until now Provider of Primary Services As Steward (regulator, enforcement agency) Managers of human and other resources for health

7 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

8 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

9 Experience from Tabanan Hospital Before Financial Autonomy (early 1990s) A very bureaucratic organization

13 5 Years After Financial Reform Bureaucratic Organization Patient- Oriented Organization Using managerialism concept

14 11,000,000,000 10,500,000,000 10,000,000,000 9,500,000,000 9,000,000,000 8,500,000,000 8,000,000,000 7,500,000,000 7,000,000,000 6,500,000,000 6,000,000,000 5,500,000,000 5,000,000,000 4,500,000,000 4,000,000,000 3,500,000,000 3,000,000,000 2,500,000,000 2,000,000,000 1,500,000,000 1,000,000, ,000,000 - TREND PENDAPATAN TAHUN Private Financing after financial autonomy reform 377,838, ,053, ,604,625 1,019,038, ,597,125 6,657,766,094 10,407,928,264 1,660,008,165 Th Th Th Th Th Th Th Th. 2002

18 [ What they did in reforming the hospital Indicator Tabanan District Hospital X District Hospital (Not Reformed) User Survey Result Routinely implemented Not yet implemented Medico-Legal Cases No cases No cases. There is no cases reported in court. Clinical Output Indicators Available and used for Not available quality improvement. Strategic Business Plan availability Available Not available , Indicators of Minimum Service Standard In process. This is one of requirement for becoming Public Service Unit. Since Not available The availability of Clinical Process Reports Available (limited) Not availabe The clinical report such as: noscomial infection, delayed surgical operation, waiting time for emergency patient, etc. The Availability of Financial Reports Available Balance sheet, cash flow report, inventory, etc. Not available

19 Number and competences of Managers Number and competences of Medical Doctors Number and competences of Nurses Enough The Director is trained in Graduate Program in Hospital Management. Most of the top managers are alsp trained in hospital management Above standard. This hospital has some subspecialists. 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. Not enough, below standard. Only the Director has the master in Hospital Administration. The other managers are not. Below standard. Only 2 specialists (Internal Medicine and Peditrician) for people Below standard Number and competences of other health workers Not yet measured No data available

20 Human resources satisfaction on compensation Excellent. The director has insentive around Rp milion/monthly. The managerial staffs have incentives from 2 to 6 million/monthly. The surgeon has incentive of more than 25 million a month Poor The 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 incentives The surgeon has incentive about 10 million a month. The availability of good staff renumeration system Available Not available

21 The availability of Human Resources Management Information System Available (limited ) Not available There is a system for tracking education, training, performance, etc. This is related to the remuneration system. The availability of Billing System Available Not available The availability of Accounting System In process Not available The capacity of producing good financial report The capacity of producing unit cost information Has the capacity No capacity Developing capacity. No 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.

22 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 The availability of housekeeping management system The Availability of Medical Record System The availability of hospital surveillance system The availability of other information system The availability of Local Government Decree on Hospital Status. The availability of system for maintaining facilities and equipment The availability of quality assurance system Available Available Available Available Available Available Available Available Limited Not available Limited Limited Not available Not available Not available Not available

23 The availability of Hospital ByLaws Available Not available The availability of Medical ByLaws Available Not 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.

24 Until 2014: Public hospitals enjoy more autonomous status But.

25 A sudden policy turn in 2015 AUTONOMY POLICY is Swinging AUTONOMOUS Government Law in 2014 BUREAUCRATIC ORGANIZATION RETURN BACK

26 Hospital Autonomy; 2015 Bure aucr atic Corpor ate type Organization of Organization Non-Profit PNBP Swadana Org For Pr ofit State Corp oratio n Perum (Persero) DHO non swadana Hos pit al Sw adana Hospit al RS B LU Perjan PT Askes Indonesia Presidential Decree 38/ :?

27 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

28 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.

29 Lesson learnt 1. 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.

30 Thank you

7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam

7-8 September 2016 Sheraton Hotel & Towers Ho Chi Minh City, Vietnam www.hospitalmanagementasia.com 2 Empower Hospital Quality Culture through Accreditation About Vinmec Mission To deliver world class