Gunungkidul’s Road to Universal Health Coverage

[caption id="" align="aligncenter" width="570" caption="Annette Martin, Results for Development Senior Project Manager"][/caption] Last April, Annette Martin, Results For Development Senior Program Officer, visited Yogyakarta in assessment for Jonit Learning Network – universal health coverage dashboard—project. District Gunungkidul became the first assessment destination for its advantage as the pilot project for electronic health information system project which supported by TELKOM Inc., Indonesia. This pilot project will be launched on July, 2013, furthermore it will be a breakthrough for the Health Care services issues in rural areas with poor road networks such as Gunung Kidul. Gunungkidul is the largest district in Special Region Yogyakarta Province. Most Gunungkidul citizens live from farming, plumber industry, trading or office jobs such as civil servants. Dry climate, rocky landscapes, poor road network are great disadvantage for Gunungkidul. Those natural conditions result sluggish economic growth and less job markets provided for its people. Hence, Gunung Kidul is acknowledged to be the district with the largest poor population. The Gunungkidul Regency area is bounded by Klaten Regency, Sukoharjo Regency, Central Java Province at north side. Wonogiri Regency, Central Java Province at east side. Indonesia Ocean at south side and Bantul Regency, Sleman Regency, DI Yogyakarta Province at west side. The area of Gunungkidul Regency is 1,485.36 sq. km which consist of 18 districts and 144 villages/wards. Semanu District is the largest district, with area of about 108.39 sq.Km or about 7.30 percent area of Gunungkidul Regency. Number of total population in Gunungkidul is 677.998 (National Statistic Survey,2010) and increases each year. This large number becomes an issue when it comes to universal health coverage. Gunungkidul total income is rated lower than other three districts, it is considered unfeasiable to cover all citizens without financial aid. To help this financial hardship, Provincial government along with district goverments agree to create mutual social insurance programs, namely Jamkesta.

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There are four major social insurance program in Gunungkidul: Jaminan Kesehatan Sosial (Jamkesos); Jaminan Kesehatan Semesta (Jamkesta); Jaminan Kesehatan Masyarakat (Jamkesmas); and Jaminan Kesehatan. Recently the district and provincial health departments signed partnership with TELKOM, Inc., to create a pilot project for their Health Information System Projects, namely Coordination of Benefits (COB). People in COB are collected from the Jamkesta Mandiri and Jamkesos Mandiri members. Basically they have the same benefits, the differences lay on the information and membership database access. COB membership is solution for the non-existing integrated shared health information service platform in Gunungkidul.

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Jamkesmas is the national health care program, targeted for the poor people under TN2PK (National Task For for Poverty Elimination Acceleration) database. Somehow, due to the transitition membership, many of the target populations are not registered or membership duplication. Due to the Jamkesmas membership issues, the district government decided to create new healthcare program to cover the unregistered population target, namely Jamkesta. Jamkesta membership belongs to the people of Gungkidul district who do not have any health insurances. The district government provides certain budget to support this group. Jampersal itself is a part of Jamkesmas program. Jampersal is a new Ministry of Health programme (started early 2011) that provides women universal free delivery care, including pre-natal and post-natal consultations. Consultation and delivery care are provided in health centres or third class wards in hospitals. This program is directed towards pregnant women, postpartum mothers (up to 42 days postpartum), as well as new born babies (0 - 28 days) who have not been covered by any maternal health program. Participants of Jampersal program can utilize services in all health care centre and facilities; both first level and advanced level in III class, that already have Cooperation Agreement with the Jamkesmas Management Team as well as BOK district level. Jampersal services is not limited to birth delivery service only, but also cover pregnancy check-up, ante natal care (ANC), and post natal care (PNC). With this program, pregnant women could obtain free birth delivery, attended by skilled health personnel, by only showing their National ID Card. This program aims to reduce MMR and Infant Mortality Rate to achieve MDGs in 2015. Jamkesos is a Yogyakarta provincial program, which is expanded for the Gunungkidul district populations who are still uncovered under Jamkesmas program. Due to the limitations of district Gunung Kidul fund to cover their populations, provincial health department support them by expanding Jamkesos program. By numbers, all citizens of Gunungkidul are covered, which means that this district has sucessfully implemented universal health coverage for its citizens, meanwhile even the Capital District of Jakarta is struggling to cover theier population. Lucky for district Gunungkidul, the provincial government concerns about their problems, that they provide various health care programs to cover the population. Before Telkom, Inc., piloted its project many of Jamkesmas or Jamkesta family members have go back and forth Gunungkidul and Yogyakarta district to go through administration procedures. This can take more than four hours trip to go, only for administration procedure. Moreover, people still have to queue for their turn. So much time and energy wasted, which frankly can be cut off by providing integrated shared information platform to improve the health care services. Challenges for Health Information System Indonesia’s health care ecosystem is complex. This has been a long term issue, which somehow are still unresolved due to the geographical, technology information facilities and human resources challenges. The natural landscape of rocky and poor road networks are grand challenges for the people to do their social insurance administration procedures. Despite Telkom, Inc., have piloted their health information system platform in Gunungkidul, there are urgent issues to resolve for better health information service . • Duplicate Membership Issues Until 2013, there are still many membership duplication cases found by BPK (State Audit Board). This is a strong issues, because there are numbers of target population who cannot get their health care. Hence, the syncronized membership database among health facilities, district population department, health care providers will give valid information about memberships of each programs and dupilcate membership cases will decrease significantly. • Regulations There are many regulations are applied to health care in Gunungkidul. These regulations are confusing. The district governers are still working to arrange the regulations that eventually they will help people to understand the health care policies. Besides, other districts are not willing to cooperate to unify their report forms due to the strict district regulations. These diverse report forms can be such hustle. Previously, the verificators worked manually and it could take long time to verify and distribute claims to health facilities. Lots of time can be saved if each district governors and health department can cooperate to unify the health care form reports. Commitment To Change Implementating universal health coverage is not only shaping new ways of health care regulations. This “revolution” of health care involves the changing environment of health system technology and service delivery. These two main aspects require continues commitment from all stakeholders. Including the people themselves. “We need the technology. However , we do not want the new technology complicates our work,” said one of the participants in Annette’s presentation session at Jamkesos Provincial office, Yogyakarta. Mostly public health care are managed by the civil servants. Mostly they are over 30 years old and not categorized as “tech savvy”. The gap between the manual procedures of health care verification proccess and the new ones –implied by the new concepts that UHC offers. This information technology savvy gaps are wide, that it is proven to be difficult to imply new health information system in an area. “Some people might refuse because they are already adjust to one system that they do not want any changes. Changes are percieved as new adjustments, new adjustments means problems”, says another participants. This health information transformation issues can be so difficult to resolve without the commitments from the service providers, governments and health facilities managers. Without the commitment to transform into a interconnected system –and expected to be nationally—the dream of good quality health care will be just another balderdash. Author is Rifka Sibarani, current creative media writer at KPMAK. A graduate from Bachelor of Political Science in journalism, Universitas Gadjah Mada, she proclaims herself a fail journalist-to-be and prefers the title "storyteller".  She frequently writes about health financing and insurance management issues for KPMAK website. Her subject of interest are Iran's politics, social development issues and comedy. Reach Rifka online @RifkaSibarani