Hasbullah Thabrany

Health-financing reforms in southeast Asia: challenges in achieving universal coverage

In this sixth paper of the Series, we review health-financing reforms in seven countries in southeast Asia that have sought to reduce dependence on out-of-pocket payments, increase pooled health finance, and expand service use as steps towards universal coverage. Laos and Cambodia, both resource-poor countries, have mostly relied on donor-supported health equity funds to reach the poor, and reliable funding and appropriate identification of the eligible poor are two major challenges for nationwide expansion. For Thailand, the Philippines, Indonesia, and Vietnam, social health insurance financed by payroll tax is commonly used for formal sector employees (excluding Malaysia), with varying outcomes in terms of financial protection. Alternative payment methods have different implications for provider behaviour and financial protection. Two alternative approaches for financial protection of the non-poor outside the formal sector have emerged-contributory arrangements and tax-financed schemes-with different abilities to achieve high population coverage rapidly. Fiscal space and mobilisation of payroll contributions are both important in accelerating financial protection. Expanding coverage of good-quality services and ensuring adequate human resources are also important to achieve universal coverage. As health-financing reform is complex, institutional capacity to generate evidence and inform policy is essential and should be strengthened.

Catastrophic health expenditure and 12-month mortality associated with cancer in Southeast Asia: results from a longitudinal study in eight countries

One of the biggest obstacles to developing policies in cancer care in Southeast Asia is lack of reliable data on disease burden and economic consequences. In 2012, we instigated a study of new cancer patients in the Association of Southeast Asian Nations (ASEAN) region – the Asean CosTs In ONcology (ACTION) study – to assess the economic impact of cancer. The ACTION study is a prospective longitudinal study of 9,513 consecutively recruited adult patients with an initial diagnosis of cancer. Twelve months after diagnosis, we recorded death and household financial catastrophe (out-of-pocket medical costs exceeding 30 % of annual household income). We assessed the effect on these two outcomes of a range of socio-demographic, clinical, and economic predictors using a multinomial regression model. The mean age of participants was 52 years; 64 % were women. A year after diagnosis, 29 % had died, 48 % experienced financial catastrophe, and just 23 % were alive with no financial catastrophe. The risk of dying from cancer and facing catastrophic payments was associated with clinical variables, such as a more advanced disease stage at diagnosis, and socioeconomic status pre-diagnosis. Participants in the low income category within each country had significantly higher odds of financial catastrophe (odds ratio, 5.86; 95 % confidence interval, 4.76–7.23) and death (5.52; 4.34–7.02) than participants with high income. Those without insurance were also more likely to experience financial catastrophe (1.27; 1.05–1.52) and die (1.51; 1.21–1.88) than participants with insurance. A cancer diagnosis in Southeast Asia is potentially disastrous, with over 75 % of patients experiencing death or financial catastrophe within one year. This study adds compelling evidence to the argument for policies that improve access to care and provide adequate financial protection from the costs of illness.

Southeast Asia: an emerging focus for global health

The Venetians monopolised it, then the Portuguese took control of it, and most European colonisers battled fi ercely in the 17th and 18th centuries for nutmeg, mace, and cloves—once grown only in the Spice Islands of Indonesia, the world’s largest tropical archipelago. Throughout its history, southeast Asia has witnessed the rise and fall of cultures, empires, colonial powers, and ideological regimes. Its natural environment mirrors its tumultuous past. Life-giving monsoons, so important for farming and sailing, also inundate and wreak destruction in local cities each year. Volcanic eruptions enrich and renew the topsoil, but also fl atten scores of villages and bury vulnerable villagers. The wet and hot jungles between the Tropics of Cancer and Capricorn, friendly to infections and insurgents alike, also sustain animal and plant life unequalled in biodiversity. Life in all its compact, congested richness is what distinguishes the region of southeast Asia— straddling the vast Asian geography between India to the west and China to the north. In many ways, southeast Asia is a microcosm of global health, providing an impetus for this Lancet Series on the health of the region. Although these countries share many elements of history and culture, the region teems with sociopolitical contrasts and contradictions. Economic powerhouses and agrarian economies, socialist and democratic regimes, and Muslim, Buddhist, Hindu, and Christian faiths—all of these lie within the reach of a brief plane ride. This diversity also plays out in contemporary health achievements: life expectancy ranges from 56 years in Myanmar to 81 years in Singapore. Southeast Asia presents daunting health challenges. Hosting complex animal–human interactions, the region has borne the brunt of several emerging and re-emerging infections, testing the responsiveness of local health authorities and the ability of the regional and global communities to cooperate to control diseases that cross national boundaries. Several strains of multidrug-resistant microbes of global signifi cance have also emerged from the region. Recently, artemisinin-resistant Plasmodium falciparum has been identifi ed on the Thailand–Cambodia border. Several countries in the region have pioneered successful HIV/AIDS control programmes. From vast archipelagos to Himalayan foothills, southeast Asia’s volatile geography and climate also challenge the region’s peoples and nations to respond to natural disasters. The 2004 Asian tsunami that devastated the coastlines of Thailand and Indonesia and cyclone Nargis in Myanmar drew attention to the region’s vulnerabilities, but also stimulated new models of disaster-manage ment partnerships between governments, multilateral agencies, and nongovernmental organisations. Reminiscent of its heritage of maritime commerce, southeast Asia is witnessing accelerating movements in trade, especially of health services, marked by infl ux of foreign patients and foreign direct investment in hospitals. What is distinctive about the region, however, is international health-related population movements. Thailand attracts more than 1·5 million patients per year for health tourism, with Singapore and Malaysia a bit behind. The Philippines and Indonesia have an aggressive policy of exporting health workers, especially nurses, to generate foreign exchange. These trends are likely to intensify as the ASEAN (Association of Southeast Asian Nations) Framework Agreement on Services comes into real action. Beyond health services, southeast Asia has several major exporters of food and agricultural products, with implications for global food security and safety. The number of migrants on the move in southeast Asia has risen substantially in recent decades, refl ecting Published Online January 25, 2011 DOI:10.1016/S01406736(10)61426-2

Smoking and Socio-Demographic Determinant of Cardiovascular Diseases among Males 45+ Years in Indonesia

The main objective of this study is to present the prevalence of Cardio Vascular Diseases (CVDs) defined as been diagnosed or having symptoms of Coronary Heart Disease, Arrhytmia, or Heart Failure. The main risk factor analyzed is smoking behavior. The data used for this study was from Basic Health Survey of 2007, a National baseline data collected every three years which consist of more than one million samples representing 33 provinces in Indonesia. Information on socio-demographic characteristics, history of CVDs and smoking behavior were collected by highly-trained interviewers using a questionnaire which had been tested. A sub-sample of the survey consisting of 100,009 males aged 45 years and over was analyzed. Crude and adjusted odds ratio (OR) were analyzed using logistic regressions to estimate the prevalence of CVDs by smoking behavior and socio-demographic characteristics. Overall, 86.8% respondents reported that they had never been diagnosed as having CVDs or having any symptom of CVDs.; while 2.1% respondents reported that they had been diagnosed by a health professional (a doctor or a nurse) of having CVDs. The interviewers also identified three signs and symptoms of CVDs for all respondents if they reported of never been diagnosed CVDs. Among all respondents 2.3% had symptoms of coronary heart disease, 4.9% had symptoms of arrhytmia, and 3.9% had symptoms of heart failure. The prevalence of CVDs was significantly higher in former smokers (OR = 2.03), and duration of smoking for more than 20 years. The prevalence of CVDs was significantly higher among older groups. Old males who lived in Sulawesi island had higher probability of having CVDs (OR = 1.67). The lower prevalence of CVDs seemed to have associated with higher among Senior High School Graduate compared to those who Never Schooling (OR = 0.8). Since population of Indonesia is relatively young, the future of health care costs of Indonesia would be high due to high prevalence of smoking among males population. This finding suggests that Indonesia should ratify Framework Convention on Tobacco Control ans start impelementing measures to control tobacco uses in order to reduce public health and economic consequences of smoking in the future.

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.

An evaluation of health systems equity in Indonesia: study protocol

BackgroundMany low and middle income countries are implementing reforms to support Universal Health Coverage (UHC). Perhaps one of the most ambitious examples of this is Indonesia’s national health scheme known as the JKN which is designed to make health care available to its entire population of 255 million by end of 2019. If successful, the JKN will be the biggest single payer system in the world. While Indonesia has made steady progress, around a third of its population remains without cover and out of pocket payments for health are widespread even among JKN members. To help close these gaps, especially among the poor, the Indonesian government is currently implementing a set of UHC policy reforms that include the integration of remaining government insurance schemes into the JKN, expansion of provider networks, restructuring of provider payments systems, accreditation of all contracted health facilities and a range of demand side initiatives to increase insurance uptake, especially in the informal sector. This study evaluates the equity impact of this latest set of UHC reforms.MethodsUsing a before and after design, we will evaluate the combined effects of the national UHC reforms at baseline (early 2018) and target of JKN full implementation (end 2019) on: progressivity of the health care financing system; pro-poorness of the health care delivery system; levels of catastrophic and impoverishing health expenditure; and self-reported health outcomes. In-depth interviews with stakeholders to document the context and the process of implementing these reforms, will also be undertaken.DiscussionAs countries like Indonesia focus on increasing coverage, it is critically important to ensure that the poor and vulnerable - who are often the most difficult to reach – are not excluded. The results of this study will not only help track Indonesia’s progress to universalism but also reveal what the UHC-reforms mean to the poor.

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.

UICC-ARO Symposium at the UICC 2016 World Cancer Congress How Can We Mobilize Action to Realize UHC in Asia?

The 2016 World Cancer Congress, organised by UICC, was held in Paris in November 2016, under the theme “Mobilizing action – Inspiring Change.” As part of Track 4 presentations on the theme of “Strengthening cancer control: optimizing outcomes of health systems,” UICC-Asian Regional Office (UICC-ARO) held a symposium to discuss the issue of mobilizing action to realize UHC in Asia. Introducing the symposium, Hideyuki Akaza noted that universal health coverage (UHC) is included in the Sustainable Development Goals and one of the key issues for achieving UHC will be how to balance patient needs with the economic burden of cancer. Speakers from Japan and Indonesia addressed various issues, including the current status and challenges for medical economic evaluation in Asia, the importance of resource stratification, prospects for precision medicine, and the outlook for cancer control and UHC in developing and emerging countries in Asia. Key issues raised included how to respond to the rising costs of treating cancer as new and increasingly expensive drugs come to the market. Speakers and participants noted that health technology assessment programs are being developed around Asia in order to evaluate the cost-effectiveness of drugs in the face of budgetary constraints within increasingly pressurized national health systems. The importance of screening and early detection was also noted as effective means that have the potential to reduce reliance on expensive drugs for advanced cancers. The symposium was chaired jointly by Hideyuki Akaza and Shinjiro Nozaki (WHO Kobe Centre).