Budi Hidayat

The financial burden of HIV care, including antiretroviral therapy, on patients in three sites in Indonesia

This paper assesses the extent of the financial burden due to out-of-pocket payments for health care incurred by people living with HIV (PLHIV) and the effect of this burden on their financial capacity. Data were collected in a cross-sectional survey of 353 PLHIV from three cities in Indonesia (Jakarta, Jogjakarta and Merauke). Respondents in Jakarta were sampled from one hospital and one non-governmental organization working with PLHIV. In Jogjakarta and Merauke, all HIV patients on antiretroviral therapy (ART) who came to selected hospitals during the interview period were asked to participate in the survey. The survey collected data on the frequency and extent of payments for HIV-related care, with answers cross-checked against medical records. Results show that PLHIV had different burdens of payments in the different geographical areas. On average, respondents in Jogjakarta spent 68%, and PLHIV on ART in Jakarta spent 96%, of monthly expenditure for HIV-related care, indicating a substantial financial burden for many ART patients. These patients depended on several sources of finance to cover the costs of their care, with donations from their immediate family being the most common method, selling assets and payments from personal income being the second most common method in Jakarta and Jogjakarta, respectively. Most PLHIV in these two areas did not have insurance. In Merauke, there were little observed out-of-pocket payments because the government covers medical costs via the local budget and health insurance for the poor. The results of this study confirm previous findings that providing subsidized ART drugs alone does not ensure financial accessibility to HIV care. Thus, the government of Indonesia at central and local levels should consider covering HIV care additional to providing antiretroviral drugs free of charge. Social health insurance should also be encouraged.

Modelling the effectiveness of financing policies to address underutilization of children's health services in Nepal

OBJECTIVE To estimate the price responsiveness of utilization of formal childrens health-care services in Nepal and to use this information to model the impact on utilization of subsidies or increases in user fees. METHODS A total of 8112 individual observations (of children aged < 15 years) from 2847 households in 274 communities were obtained from the 1996 Nepal Living Standards Survey. A logit model was applied to determine the net impact of price on a parent or caregivers decision to seek care for a given instance of illness. The models coefficients were used to calculate the price responsiveness of utilization decisions. FINDINGS Parents or caregivers reported that 9.7% of children (788/8112) had been ill or injured in the previous month. Parents reported that they had sought care in 566 (71.8%) of these cases; care was most frequently sought from public providers. The price elasticity of demand for childrens health-care services in the formal sector was estimated at -0.16. As prices rise, the demand curve exhibits continuous and declining price elasticity. Overall, a 100% subsidy of user fees would increase current utilization rates by 56%, while a 100% increase in fees would lead to a drop in utilization of only 12%. The differential in utilization across income groups was substantial after changes in fees were implemented. CONCLUSION While the effect of price on the utilization of childrens health-care services in Nepal is statistically significant, the size of the impact is modest. Policies to subsidize fees could increase utilization substantially, while fee increases would lead to modest declines in utilization and generate increased revenue.

The Selection of an Appropriate Count Data Model for Modelling Health Insurance and Health Care Demand: Case of Indonesia

We apply several estimators to Indonesian household data to estimate the relationship between health insurance and the number of outpatient visits to public and private providers. Once endogeneity of insurance is taken into account, there is a 63 percent increase in the average number of public visits by the beneficiaries of mandatory insurance for civil servants. Individuals’ decisions to make first contact with private providers is affected by private insurance membership. However, insurance status does not make any difference for the number of future outpatient visits.

Are smokers rational addicts? Empirical evidence from the Indonesian Family Life Survey

BackgroundIndonesia is one of the largest consumers of tobacco in the world, however there has been little work done on the economics addiction of tobacco. This study provides an empirical test of a rational addiction (henceforth RA) hypothesis of cigarette demand in Indonesia.MethodsFour estimators (OLS, 2SLS, GMM, and System-GMM) were explored to test the RA hypothesis. The author adopted several diagnostics tests to select the best estimator to overcome econometric problems faced in presence of the past and future cigarette consumption (suspected endogenous variables). A short-run and long-run price elasticities of cigarettes demand was then calculated. The model was applied to individuals pooled data derived from three-waves a panel of the Indonesian Family Life Survey spanning the period 1993-2000.ResultsThe past cigarette consumption coefficients turned out to be a positive with a p-value < 1%, implying that cigarettes indeed an addictive goods. The rational addiction hypothesis was rejected in favour of myopic ones. The short-run cigarette price elasticity for male and female was estimated to be-0.38 and -0.57, respectively, and the long-run one was -0.4 and -3.85, respectively.ConclusionsHealth policymakers should redesign current public health campaign against cigarette smoking in the country. Given the demand for cigarettes to be more prices sensitive for the long run (and female) than the short run (and male), an increase in the price of cigarettes could lead to a significant fall in cigarette consumption in the long run rather than as a constant source of government revenue.

Are there differences between unconditional and conditional demand estimates? implications for future research and policy

BackgroundEstimations of the demand for healthcare often rely on estimating the conditional probabilities of being ill. Such estimate poses several problems due to sample selectivity problems and an under-reporting of the incidence of illness. This study examines the effects of health insurance on healthcare demand in Indonesia, using samples that are both unconditional and conditional on being ill, and comparing the results.MethodsThe demand for outpatient care in three alternative providers was modeled using a multinomial logit regression for samples unconditional on being ill (N = 16485) and conditional on being ill (N = 5055). The ill sample was constructed from two measures of health status – activity of daily living impairments and severity of illness – derived from the second round of panel data from the Indonesian Family Life Survey. The recycling prediction method was used to predict the distribution of utilization rates based on having health insurance and income status, while holding all other variables constant.ResultsBoth unconditional and conditional estimates yield similar results in terms of the direction of the most covariates. The magnitude effects of insurance on healthcare demand are about 7.5% (public providers) and 20% (private providers) higher for unconditional estimates than for conditional ones. Further, exogenous variables in the former estimates explain a higher variation of the model than that in the latter ones. Findings confirm that health insurance has a positive impact on the demand for healthcare, with the highest effect found among the lowest income group.ConclusionConditional estimates do not suffer from statistical selection bias. Such estimates produce smaller demand effects for health insurance than unconditional ones do. Whether to rely on conditional or unconditional demand estimates depends on the purpose of study in question. Findings also demonstrate that health insurance programs significantly improve access to healthcare services, supporting the development of national health insurance programs to address under-utilization of formal healthcare in Indonesia.

Impact Evaluation of National Health Insurance toward Access Hospital Inpatient Care in Indonesia

Indonesian government launched officially the National Health Insurance (JKN Program) on January 14, 2014. JKN program constructed with participation is mandatory and there is no selection, the spirit of cross subsidy (rich-poor, healthy-ill, young-old), non-profit and fees calculated as a percentage of wages or income. One of the main objectives of JKN is to improve equity in access to health services. This study aims to evaluate the impact of National Health Insurance program that has been running more than one year over the access to inpatient care at the hospital. This study used Indonesian Family Life Survey IFLS-4 (2007) and IFLS-5 (2014/2015). The analysis used a combination of propensity score matching methods and difference in difference. This analysis enables the research resembles the experiment considering the access changes to the inpatient care on the same individuals were evaluated before and one year after the National Health Insurance starts. The results showed that the National Health Insurance program have impact 2.4% on access to health care of inpatient at the government hospital and or private hospital. The resulting effect of National Health Insurance is not final because the data is just collected in 2014 until mid-2015, about half a year of the commencement of National Health Insurance.

Guidance toward the implementation of multicriteria decision analysis framework in developing countries

ABSTRACT Introduction: Multiple Criteria Decision Analysis (MCDA) is increasingly used in health care mainly because it moves decision-making from ad hoc to an evidence-based and comprehensive process. Developing countries with more restricted financial and human research capacities, however, should consider their own methods of MCDA development and implementation. Areas covered: An MCDA framework to improve procurement decisions of off-patent pharmaceuticals was developed for developing countries and adapted to Indonesia, Kazakhstan and Vietnam during three policy workshops. Based on the experience of these workshops and one joint workshop with international experts and decision makers from multiple developing countries, general recommendations were formulated on how to implement MCDA specifically in developing countries. We provide 17 practical MCDA implementation recommendations in four major areas, including (1) MCDA objectives; (2) technical considerations of MCDA tool; (3) development and customization of MCDA tool and (4) policy implementation of MCDA in decision-making. Expert commentary: These practical MCDA recommendations for developing countries contribute to feasible, transparent, stepwise, iterative and standardized decision-making in health care.

PROVIDER CHOICE FOR OUTPATIENT HEALTH CARE SERVICES IN INDONESIA: THE ROLE OF HEALTH INSURANCE

Background: Based on house hold survei in 2001 it showed that the community behavior in maintaining dental health was still low. The dental condition of the people who complained of having dental problem was very bad, which was shown by the fact that from out of 6-7 teeth which were in bad condition, 4-5 teeth had already been pulled out. Methods: Data were based on the Riskesdas year 2007. The dependent variables were DMFT data in ordinal scales. The independent variables were the nutritional and consumption status, central obese, socioeconomic factors data in nominal scales. Multivariate analysis was done by ordinal regression. Results: Results indicated that the nutritional and consumption status, central obese; socioeconomic faktors: age, sex, household expenditure per capita, Jobs description were significantly associated toDMFT index p = 0.000 (p < 0.05, pada a< 0.05). Recommendation: Socialitation of dental health education was important enhance the awareness brushing teeth correctly and on right times. Socialization of using a pasta maintaining fluoride was for people to all various age group especially for female, because of female was much time for a message dental health education at family especially for a children. Dental health education was important enhance the awareness brushing teeth correctly and on right times for a pregnant women besides a comsumption calsium is enough to construct for bone and teeth was to sustain caries. It was also needed to encourage the important comsumption fruits and vegetable 5 a cup per ones day for a becomes system value of community. Key words: Index DMFT, Nutritional and Consumtive States, Socioeconomic factorsBackground: During pregnancy and birth period there are physical changes, some of muscle experiencing lengthening, especially uterus muscle and stomach muscle. After bearing, uterus was not back quickly like before, but through a process. Health recover process at post-partum was important thing for mother after birth period. Therefore, for turning back at early condition or recover period better so that body always health needed a exercise which popular as post-partum exercise. Methods: This research executed was prospective cohort design with quantitative approach. Interview was executed at 30 respondents post-partum mother. Subject got from population with simple random sampling. Depth interview was executed to get depth information about research which observed. Independent variables at this research were participation postparfum exercise and dependent variables are complication, narrow of uterus, swell oedema, treatment of stitching hurt loctation, early ambulation, urinate, defecate, drink and eat pattern. Results: Chi square result indicated difference health status between does exercise and neither was only early ambulation and defecates from other some variable. Variables early ambulation (p = 0.001) and deficate (p = 0.001) significant with exercise. But variables involution utery, oedema treatment of stitching hurt and drink and eat pattern not significant with exercise. Key words: post-parfum exercise, health statusThe main cause of mortality among Indonesian pilgrims was circulatory diseases. The death was common among old pilgrims, especially due to heart failure. It is known that hypertension is one of the causes of heart failure The study aimed to determine blood pressures among high risk pilgrims after umrah in Mecca, Saudi Arabia and blood pressure in Indonesia with influencing factors: sex, body mass index, accommodation room density, and number of condition/diseases.It was an observational study. Twenty eight high risk pilgrims of kelompok terbang (kloter) or flight group 30 JKS year 2003 were voluntarily participated in the study. The blood pressure of the respondents was measured at sitting position. Mean differences of systolic and diastolic blood pressure in Indonesia and after umrah was compared by paired t-test. Systolic blood pressure in Indonesia after umrah, by controlling confounding variables was analyzed by linear regression model. The systolic blood pressure of respondents after umrah tended to decrease to 0.43 mm Hg in comparison to 1 mmHg increase on examination in Indonesia, at number of conditions/diseases to be constant. It is likely that the psychological sincerity (ikhlas) has influenced the decrease of sympathetic intervations system in brainstem for blood pressure to lower of systolic blood pressure. Meanwhile, the systolic blood pressure after umrah tended to increase to 11.94 mmHg for a number of conditions/diseases to be constant. The pilgrimage activities is hard, especially in surrounding higher climate at the average of 39• C. So pilgrims with the condition as old people or having diseases influenced the systolic blood pressure. The peripheral vasoconstriction possibly caused increase systolic blood pressure. Pilgrimage is a hard physical activity, more over for high risk pilgrims. Hence, monitoring pilgrim health conditions, especially the high risk pilgnms, should be conducted by kloter health workers, like to control blood pressure as one of health indicators. Because hypertension is one of heart failure causes. Key words: systolic blood pressure, high risk pilgrims, old persons, diseasesBackground: People of East Java Province counted more than 38.3 million people, which 7.5 million among them was rated poor people. From several research shows that poor people usually exposed to health matter due to lack of nutrition and education. Mass media also mentioned that there were differences between poor people health care and common people. resulting health care unsatisfaction. This research commonly purposed to know People Satisfaction Index mainly poor people that came to RSU Dr. Soedono Madiun and RSU Haji Surabaya based on Minister of State Apparatus Efficiency letter of decree number KEP/25/M.PAN/2/2004. Methods: This research design was public policy research analysis The applied method is empiric approach that based on actual facts and evaluative approach. The research located in RSU Dr. Soedono Madiun and RSU Haji Surabaya. The population research done by purposively random sampling with the number of child and trauma overnight patient respondent reach 35 respondent. The data compiled by Minister of State Apparatus Efficiency instrumen and exhaustively interview. Results: result shows that Poor People Satisfaction Index toward health care overall reach 3.56 or converted number 89.0 with categorized very good and IKM for RSU Haji Surabaya 3.92 or converted number 98.0 with categorized very good. The recommendation gives to the People Satisfaction Index instrumen manual based on Minister of State Apparatus Efficiency letter of decree number KEP/25/M.PAN/2/2004 which consist of 14 substance need to be more described for operational and realistic. Key words: State Ministery for Administrative Reform, Satisfaction Index Society