ISQUA16-3178HOSPITAL HEALTH SERVICE QUALITY AND UNIVERSAL HEALTH CARE IN INDONESIA

Abstract

Objectives: Full implementation by 2019 of Indonesia' Jaminan Kesehatan Nasional (JNK), will provide the country's 250 million people with financial coverage for comprehensive medical care. The objective of this study is to determine how the first 2.5 years since introduction has affected the quality of hospital health care and project how it will continue to do so as it is fully implemented in the coming years. The hospital accreditation process impact evaluation (HAPIE) is a 4 years study that examined the quality of services in nine classA hospitals in Indonesia beginning in 2011. It examined the changes from before implementation of JKN to after 2.5 years later. Methods: Quantitative data on indicators of quality of care were collected from chart reviews for patients admitted to the hospitals for childbirth or with diagnoses of pediatric pneumonia, myocar-dial infarction or hip fracture. We also collected data from observations and reviews of hospital documents, regulations, and policies along with interviews with key informants from all hospitals. A questionnaire captured patients' experiences with their care during their inpatient stay. Data were analyzed to determine the difference between the pre- and post-JKN implementation period. Although the study was designed to evaluate the effect of hospital accreditation on quality of care, implementation of JKN after baseline data were collected provided an opportunity to compare the quality of care delivered before and after the universal payment system was implemented. Results: Improvements were seen in about half the indicators collected but there was substantive variability between the hospitals that appeared to be associated with other factors. There was a slight decrease in indicators of positive patient experience in general. In qualitative interviews with administrators, some hospitals had difficulties receiving timely payment for health services provided with implementation of JKN and the case mix was reported to have changes, especially for uncomplicated childbirth. This was due to a change in the referral system. Key informants in hospitals reported that implementation of JNK did have implications of the quality of care delivered - some positive and some negative. Conclusion: It appears that the first year of implementation of JKN had some positive and negative impact on the quality of care delivered or patient experience in these nine hospitals in Indonesia. The universal health care system has the potential to positively influence the quality of care delivered through its developing monopsony power. There are currently no substantive measures in place to incentivize improvements in hospital health care delivery and it remains to be seen whether one will be developed in the coming years to address poor quality care.