AGUS PURWADIANTO

Head of Legal & Organization, Dept of Health R.I. Phitsanulok meeting, 22 June, 2007

MENTERI KESEHATANREPUBLIK INDONESIA

Scope of discussionScope of health care Minimum services standardEmpirical data from MEHB/MKEK & Police reportProfessionalismEthicolegal perspectivesHealth care legal reform

Self Care

Primary Care

Secondary

Tertiary

Education System

H Financing System

Integrated Health Care system-suprastructures

Just, Accessible, Affordable, Qualified

Competency Based

Managed Care

Medical Acts No 29/2004jo MOH Decree No.512/2007

Nat.Social Security ActsNo. 40/2004 Education System Acts

No 20/2003

Teacher & Lecturer Act No 14/2005

Gov RegNo.65/2007Of MSS

Local AUTONOMY

LOCAL BUREAUCRATIC

REFORM

GOODLOCAL

GOVERNANCE

Organz. restructuring H Personal restructuring Management restr Increae accountability

Changing fromCentralization to desentralization

Local empowering Democratization Services approach

Good bureaucration+ community & private

Sector particip+

GOVT AFFAIRS

Concurrent(Central & Local Govt))

AbsolutE (central govt)

- Hankam

- Moneter

- Yustisi

- Politik Luar Negeri

- Agama

Obligatory(Basic Services)

Eg : Health ,

Education, Environment, Publ

Works & Transportation

Optional(Competitive sector)

Eg: Agriculture, Industri, Tourism, Marine, etc.

MSS

DIVISION OF GOVT AFFAIRS

Govt Reg65/2007

Maternal & Child Health Poor people health servicesEmpowering health personelCommunicable dis, malnutrition, health crises due to disastersHealth services for the very remote, being left and territorial area & islands .

MENTERI KESEHATANREPUBLIK INDONESIA

PRO POOR, GROWTH& AUTONOMY

HEALTH STATUS ACHIEVMENTS

NO INDIKATORAchievement Target

2004 2005 2006 2007 2008 2009

1

2

3

4

IMR (PER 1.000 LH)

MMR (PER 100.000 LH)

Under 5 malnutririon (%)

Life expec (years)

35

307

25,8

66,2

32

262

24,7

67,8

30,8

253

23,6

69,4

29,2

244

22,5

69,8

27,6

235

21,4

70,2

26

226

20

70,6

MENTERI KESEHATANREPUBLIK INDONESIA

SCOPE OF POOR PEOPLE H. SERVICES YEAR 2005 2006

DIAGNOSAyEAR 2005 yEAR 2006

case cost case costMothers delivery 374.468 56.170.200.000 501.622 60.461.632.185

HEMODIALISA 4.862 6.370.461.200 5.418 15.622.815.000

Heart surgery 380 3.330.000.200 2.950 27.237.263.800

SECTIO CAESARIA 1.254 2.068.616.300 7.141 11.782.078.500

LAPARATOMy 162 358.425.800 983 2.333.991.500

Cancer OPERATION KANKER

780 1.190.747.600 617 956.780.000

OPEN REDUCTION FRACTURE

96 216.521.600 2.744 6.242.705.000

MENTERI KESEHATANREPUBLIK INDONESIA

Lampiran-3

Basic health facilities

achievement Target

2004 2005 2006 2007 2008 2009

com h centre nursing care

2.010 2.077 2.227 2.377 2.645 2.845

com h centre non nursing care

5.540 5.592 5.614 5.944 6.514 7.171

Satelite com h centre

21.854 22.002 22.171 23.298 25.645 28.044

Mobile CHC 4 wheel 5.064 5.552 6.341 7.572 8.334 9.114

Boat CHC 489 591 622 749 825 902

Motor CHC - 9.259 15.795 16.642 18.318 20.032

yEARActivities

Note : Total subdistrict yEAR 2009 : 10.016 (Dept of Home Affairs )

Lampiran-4MENTERI KESEHATANREPUBLIK INDONESIA

MENTERI KESEHATANREPUBLIK INDONESIA

HEALTH PERSONEL Lampiran-6

DESENTRALISASI Law No 22 /1999 regarding LOCAL GOVERNMENT, REVISED WITH LAW NOUU 32/2004LAW NO 25 /1999 regarding MONETARY BALLANCING BETWEEN CENTRAL & LOCAL GOVT, REVISED WITH LAW NO UU 33/2004

GOVT REG regarding GOVT AFFAIRS DIVISION GOVT REG NO 65/2005 reg HOME AFFAIRS MIN REG NO 6/ 2007 regr TECHNICAL GUIDELINES FOR COMPOSING & ESTABLISHING MIN SERVICE STANDARD

REVISION OF MOH DECREE NO 1457/2003 regr MINIMUM SERVICES STANDARD OF HEALTH AT DISCTRICT/CITY LEVEL

MINIMUM SERVICES STANDARD

MSS INDIKATOR COVERAGE BY >90 % DISTRICT/CITY LEVEL IN INDONESIA

1. coverage ante natal care visit k4 (1a)2. Under 5 y care (7b)3. coverage NEONATAL VISIT(1d)4. coverage pregnant women got 90 TABL FE (8b)5. Under 5 y increasing their body weight (7a) 6. Referral of High risk Pregn women (1c) 7. UCI of every village (4a)8. TB curement (BTA +) (13 a)9. coverage Under 5 y got VIT A 2X/yEAR (8a ) 10. coverage delivery by health personel (1b)11. coverage infant visit (1e)

4 HEALTH SERVICES

1. BASIC H SERVICES2. REFERRAL SERVICES 3. EPIDEMIOLOGY & CONTROLLING

THE EXTRA ORDINARY EVENTS 4. HEALTH PROMOTION &

EMPOWERING THE COMMUNITY

Local cost allocation

MSS TARGET should be achieved at year 2010Local govt should established MSS achievement target every year local planning by local regulationMSS health financing & costing facilitated by D.o HLocal govt should allocate reasonable fiscal capacity to support the MSS implementationProv govt & central govt could help the lack of financial capacity if they fail to achieve

Dr& Dentist situation

Ethicolegal Problems after Med Practice Act No. 29/2004

DR/dentist

MEHB-IMA Health Disc B.Trantitional

MKDKI

Trial by press

Health ConsumersMini Trial

Hosp EC/MSO Comm

Penal Court

Civil court

DRs Risk Possibility of Being Examined Due To Supra-structural Instability after Med.Practice Acts come into effect

EB of Hosp Assoc

Art 66 (3)Being damaged

Adverse event = malpractice

ethicaldismissalfr MKDKI

Art 55

Art 68

2 Years Complaint to Med.Ethics Hon.Board(MEHB)-IMA (2004 2005)Mos

Yrs

Jan Feb Mar Apr May

Jun Jul Aug Sep Oct Nov Dec

2004 3 6 1 1 3 2 11 5 6 2 4

2005 3 10 11 10 5 2 4 12 10 1 1 9

Total Cases : 122 Cases2004 : 44 Cases 2005 : 77 Cases

The Sources of ComplaintsSender Total

Private 32IMA Chapter 17Law Firm 16IMA CEO 14Med spec.org. 10NGO/institution 11Hospital 9University 4M.O.H 4Police Inst. 3

No123456789

10

The Problem SpecialistNo Area of Training Total1 Ob-gy 72 GP 73 Surgery 74 Pediatrician 45 Internal Med 46 Anesthesiology 27 Hospitals CEO 28 Nutrition specialist 19 Psychatrist 1

10 Ophtalmology 1

Type of Problems

No Type of Problem/complaints Total1 Suspected Malpractice/Med Error 222 DR-DR, DR-Hosp/Clinic Disputes 103 Info Clarifications letter 104 Hospital services 85 Need the speakers/consultation 86 Provincials Med Ethic H.B. report 107 Asking Medical Record 68 DR/Clinics advertising 69 Workshop invitation 6

Type of Problems (2)No Type of Problem/complaints Total1 Inter-professional & membership

disputes6

2 Violence against DR 33 Insurances disputes 34 Fake DR 25 Medical Acts amendments 26 Medical Acts responsiveness 27 Asking Expert witness 28 Euthanasia 29 Household conflicts 5

MALPRACTICE SUIT POLICE REPORTED CASES

No. Casesl Victimn Hospital

1. Kematian krn operasi usus Wulan Yulianti RSCM

2. Penggelapan Medical Record Lucy Maywati RS. Bersalin YPK

3. Pendarahan dibatang otak Jeremi Sitorus RS Budi Lestarisetelah operasi ceasar

4. Kemaluan miring kekiri stil operasi hernia Mindo Sihombing RS Persahabatan

6. Tewas stlh operasi ceasar Klucy Maywati RS Bersalin YPK

5. Tewas krn pembiaran saat menderita malaria Jajang RUDSSukabumi

7. Operasi salah membuat cacat permanen Robinson Lumban RS Rumkit Kodam I

8. Perbuatan tdk menyenangkan Kudrat Adriansah Yayasan amal peduli seribumemulangkan pasien

9. Tangan bengkak stlh operasi payudara Ngatmina RS Persahabatan

10. Tangan membengkak stlh Rochyati RSUD Tarakanoperasi payudara (tewas)

11. Keracunan akibat salah obat Revi Anastasi RS Cikini

12. Perbuatan tdk menyenangkan Revi Anastasi Apotik RS Cikini

13. Usus keluar stlh operasi ususbuntu Fellina Azzahra RS Karya Medika Cibutung

14. Kelalaian media membuat cacatpermanen Agan Isna Nauli RS Islam Bogor

15. Membiarkan pasien perlu dirawat (tewas) Anggi & Anjeli RSCM

16. Usus keluar stlh operasi usus Maena Nurrochman RS Setia Mitra Jaksel

17. Kesalahan penanganan saat kelahiran Andras Paskah RS Pasar Rebo Jaktim

18. Operasi usus buntui Fellina Azzahra RSCM

19. Penyanderaan oleh RS Lenny Fransiska RS Siloam Tangerang

20. Terlambat lakukan operasi Farrel Davin Evasari RS Ibu & AnakCesar sehingga tewas Rawamangun

21. Penyanderaan oleh RS Leonardus WPH RS Siloam Tangerang

22. Infeksi akibat operasi Lexiano Hamsalim RS Medistraklep jantung (tewas)

Police reported data after issuance of Med Practice Act

No. Cases Victim Hospital

H U. Republika, 5 Oktober 2004

2 years after- Issuance of Med Practice Act

Problems Magnitude Anticipation/solutionCross-membership of IMAs at district

++ SOP about membership/> details IMA bylaws

Issuance-jam of Registration Certificate

+++ Provincial Med. Council (branches)

Slow performance of Med.Council

++ Web-based info / transparencies

Competence-Proficiency check at district level

++ Unifying & coordinating of professional org. at district level

Med.Hon.Disciplina-ry B. action

+++ Empowering ex member of MEHB + good medical lawyer

2 years after- Issuance of Med Practice Act

Problems Magnitude Anticipation/solution Drs criminalization

+ Judicial Review of MP ActMOU IMA-Police (Prov Level)DRs Advocating Body (IMA)

Private Hosp become Satellite Hosp

++ MOU Med.School Private Hosp based on & Criterion

DR/s migration from District/s small hosp

+ DRs Mapping & the issuance of temporary license

Lack guidelines of temporary license

++ Specific criterion for specialist distribution

Re-filing malpractices suit to Med. Hon.Disc.Board

+++ Criteria of admissibility & time expiration

PUBLIC MISTRUST

public perception that medicine failed to self-regulate in a way that can guarantee competence, and that it put its own interest above that of patients and the public medicine has protected incompetent or unethical colleagues in the name of collegiality

Cruess SR et al: MJA 2002 177 (4): 208-211

Med.Ethics H.B. strategies Nat.workshop 2005 :

Proactive & responsiveness from ethical issues : problems, dilemma, misconduct etc integrated peer assessments : MEHB IMA other IMAs unit member (active & former but senior) > independent power (not depend on executive board)Deployment of Indonesian Med Ethics Code Renewal Issuance of MEHB Guidelines & Bylaws

Med.Ethics H.B. strategies IMA Nat Congress 2003 :

> transparancies & accountabilityAnticipating the supra-structural regulation on litigious society/anomic situation : ballancing 3 : patients safety - medical goals professional dignity by preventing & solving DRs/health personnels conflicts via ethicolegal systemImproving ethics as 1 major topic/session at every Nat. congress improving guiding principles on every subject + Code of Ethics + lege artis culture networking with other local and foreign professionals Ethics Board

MEHB-IMAs role in Ethical Conflict

authorized referee to decide the clinical privileges disputes due to different training modality between med specialistImproving the best and more morally justified ethical guidelines as complementary to Code of Med. Ethics or standard of care Giving medical opinion of ethical dilemma in clinical practice, med research and filtering the new med technologies. Enlightening the epistemological aspect of multicultural diversity of ethical issues during the legislation process and improving med. ethics education.

Ethicolegal Punishment Category of DRs

a. Being advised by his peersb. Reprimandsc. Should be supervised by special

program (unstructured)d. Reschooling (structured)e. Revoking IMAs membership

(desertification)

Future Role of MEHB-IMA & Med Disc Board

1. Developing bigger organizational function & structure and more executing

2. Improving the secretariat personnel/staff to give rapid responses of any ethical issues/problems/dilemmas in health care and medical encounters setting developing specific guidelines & casuistry-based jurisprudence to improve ethicolegal problem

3. Supporting any disciplinary proceeding referred from Med.Hon.Disc.Board (MKDKI) articles 68 Medical Practice Act No. 29/2004 or cooperation in provinces w/ no MKDKI

Future Role of MEHB-IMA & Med Disc Board

5. Sustaining capacity building upon its provincial members to prevent any de-professionalism leading to malpractice crisis/defensive medicine/DRs brain-drain /bad practice (malfunction DRs) locally/regionally

6. Improving the dual tiers of ethical proceeding7. Networking with any local and foreign medical

ethics/bioethics institution in research & education.

Professionalism as core content & health care reform

Professionalism Elements of ethicolegal systemHealth care legal reform

PROFESSIONALISMTrue professionalism means the pursuit of excellence, not just competenceProfessionalism is predominantly an attitude, not a set of competenciesA real professional is a technician who caresProfessional is not a label you give yourself. Its a description you hope others will apply to you

Maister DH: True Professionalism, The Free Press, 1997

Charter on Medical Professionalism

Fundamental Principles:Principle of primary of patient welfarePrinciple of patient autonomyPrinciple of social justice

Annals of Internal Medicine, Vol 136 Issue 3, 5 Feb 2002http://www.annals.org/cgi/content/full/136/3/243

ABIM's elements of professionalism

altruism, accountability, excellence, duty, honor and integrity, and respect for others

Professional Responsibilities

Commitment to professional competence

Commitment to honestly with patient

Commitment to patient confidentiality

Commitment to maintaining appropriate relations with patients

Commitment to improving quality of care

Professional Responsibilities

Commitment to improving access to careCommitment to a just distribution of finite resourcesCommitment to scientific knowledgeCommitment to maintaining trust by managing conflict of interestCommitment to professional responsibilities

Please visit : www.professionalism.org

Ethics/morality= natural law

Legal=Positive

law

Ethicolegal Perspectives

Ethico-legal

= moral principles

Liability

ProfessionalDignity

BonafideProfessionalism

competency

Maintain technicalexpertise

Self-regulationCollege CME/CPDProf organizationCode of ethics/peer reviewRespectable statusProf insurance/MDU/MPS

Discipline =accountability

Personal responsibility

Goal ofMedicine Patients

Safety

Elements of Ethicolegal SystemAgus Purwadianto, 2006

Reg certif

License

LICENSING OF DR/DENTIST MED PRACT ACT & MOH REG 512-07

Unit baruterstruktur

d/h SPTP

DegreeCertif

CompetencyCertif

Rekomen-dasi PDGI

FitnessCompetentSpecialist

AssocEthics Member

FK-FKG Collegium

Med Council

District Health Office

OthersProvisions

Task Certif PROV HO

Certain specialistProficiencyCheck Board

dynamic role of bureaucracy

>< rigidity cycle (ec seniority, rigid regulation) - rationality>< goal displacement ( public service, not doing routine jobs)>< skilled incapacity (specialization syndrome)Dual system of authority (>< excessive professional power of the expert)

Jack H. Knout & Gary J. Miller (1987)

Judicial review result

No 4/PUU-V/2007 regarding Med PractAct : is it against the Constitution ? 19JUNE 2007Decriminalizing the punitive-jailed penalpunishment of DR/Dentist withoutRegistration Certif, and Licensed Certifand the Name ID and not comply withCPD/CME as fine-penal sanctions +administrative punishment

Tranparent + legitimate Practitioner

ID name number :Registered number fr Med Council + certif of competency fr Collegium Licensed number fr Health Officer of District Level Recomm no fr Med Assoc + membership card

Task certif fr Provincial level Dep OHName of their associates

More transparent & simultaneously Draft of Amendment of Health Act by enacting

Health as Human Rights elaborating the Constitution,

Draft of Govt Regulation regarding Poor and the least advantage PEOPLE

MOH DECREE reg IMPLEMENTATION MANUAL reg TECHNICAL GUIDELINES FOR POOR PEOPLES HEALTH INSURANCES PROVIDER; VOLUME & PAYMENT MECHANISM OF MEDICAL FEE BASED ON LOCAL GOVT REGULATION

MENTERI KESEHATANREPUBLIK INDONESIA

HEALTH CARE LEGAL REFORM

More transparent & simultaneously Amendment of MOH Regulation using dynamic-

bureaucratic accountability & disciplinary based peer review of pre-licensing of health personnel practitioner

Empowering the local genius to implementing the self-regulating policy for implementing the district/province customs & consensus of ethicolegal system to balance the triad of medical/health goals-professional dignity-patients/people safety, eg : VILLAGE PREPAREDNESS POLICY USING LOCAL HEALTH PERSONEL & CADRE, medical delegation practice

MENTERI KESEHATANREPUBLIK INDONESIA

HEALTH CARE LEGAL REFORM

0.1 $ DRUG PACKAGE QUALITY DRUG BUT CHEAP FOR

PEOPLE

PROVIDE THE AVAILABILITY, EQUITY, ACCESSIBILITY

LABEL DISCLOSURE : MAX PRICE (Rp. 1000,-)

QUALITY CONTROLL : SAFETY & EFFICACY

MENTERI KESEHATANREPUBLIK INDONESIA

Regulation of Ministry of Health of Republic of Indonesia

Number 284/Menkes/Per/III/2007Regarding

Peoples DispensaryConsidering :a. That in a form to increase and enhance community

access in obtaining medicine and for increasingpharmacy services, it needs to open opportunity ofdevelopment Medicine discounter to become peopledispensary

Article 2Regulation of People Dispensary has aim to :

1. Giving guidance for drug store that has intention toincrease services and their business status to becomePeople Dispensary

2. Guidance for individual or small scale of business thatwanting to build People Dispensary

3. To protect community to obtain the better and truthfullpharmacy services

Article 33. To acquire People Dispensary License is free

expense

Regulation of Ministry of Health of Republic of IndonesiaNumber 548/Menkes/Per/V/2007

Regarding

Registration and License of Therapist Occupation

Article 3Paragraph 2 point d :

Recommendation from Organization of ProfessionParagraph 3

Recommendation as referred to paragraph 2 point d is given by Organization of Profession

beforehand by conducting competence test by concerned collegium or Committee of Provincial

Health Force (MTKP) or other Board in that province or closest province

REFORM TO OTHER HEALTH PERSONNEL REGULATION

Regulation of Ministry of Health of Republic of IndonesiaNumber 696/Menkes/Per/VI/2007

RegardingPrice of Generic Medicine

with trade name on

Government Health Services Facility

Article 3In case there is inanition of Generic Medicine, Government

Health Services Facility can use Generic Medicine with trade name.

Price of Generic Medicine with trade name as referred to paragraph 1 should be guided to stipulation of generic

medicine price.The highest rate of generic medicine with trade name

maximum 3 (three) times of generic medicine price.

Article 41. Doctor and Dentist on Government Health Services

Facility can give prescription of generic medicine withtrade name when generic medicine is not available.

2. Writing of prescription of generic medicine with tradename as referred to paragraph 1 should be followedwith writings of generic name from that medicine and on

the same prescription.

Article 14 MEDICAL PRACTICE ACT

(1) Total member of The Indonesian Medical Council shall be 17(seventeen) persons made up of elements originating from:

a. medical professional organization consisting of 2(two)persons;

b. dentistry professional organization consisting of 2 (two)persons;

c. association of medical education institution consisting of 1(one) person;

d. association of dentistry education institution consisting of 1(one) person;

e. medical collegiums consisting of 1 (one) person;f. dentistry collegiums consisting of 1 (one) person;g. teaching hospital association consisting of 2 (two) persons;h. public figure consisting of 3 (three) persons;i. Ministry of Health consisting of 2 (two) persons; andj. Ministry of National Education consisting of 2 (two) persons

Conclusion 1. Indonesian health regulation considered the concept

of professionalism, beginning from DR/Dentist practice Act, to other health personnel, although the society now become litigious to sue them of their liability and their peer group become more critical to their responsibility & accountability.

2. Health reform policy to support the poor & the least advantage people could be a panacea for their dissatisfaction of out of pocket health care system while going to the managed care system using the social security act and health insurance regulation, beginning with Min Service Standard.

Conclusion 1. Core content of professionalism can be improved by

implementing ethicolegal concept to deter and mitigate the professional misconduct by enhancing ethical & legal competence/capacity of the Med Ethics Hon Board and Med Disciplinary Board members at the provincial level as well as at District/City level, in line with the decentralization policy

2. The more transparent legal reform concerning professionalism using the competence + good professional conduct based health personnel, controlled also by layman person & enhancing disciplinary & ethically peer review and giving priority to health prevention and promotion, controlling the drug prices, and using local resources

Slide Number 1Scope of discussionSlide Number 3Slide Number 4Slide Number 5Slide Number 6HEALTH STATUS ACHIEVMENTS SCOPE OF POOR PEOPLE H. SERVICES YEAR 2005 2006Basic health facilities Slide Number 10DESENTRALISASI MSS INDIKATOR COVERAGE BY >90 % DISTRICT/CITY LEVEL IN INDONESIA 4 HEALTH SERVICES Local cost allocation Dr& Dentist situation Slide Number 162 Years Complaint to Med.Ethics Hon.Board(MEHB)-IMA (2004 2005)The Sources of ComplaintsThe Problem SpecialistType of ProblemsType of Problems (2)Slide Number 22Slide Number 232 years after- Issuance of Med Practice Act 2 years after- Issuance of Med Practice Act PUBLIC MISTRUSTMed.Ethics H.B. strategies Nat.workshop 2005 :Med.Ethics H.B. strategies IMA Nat Congress 2003 :MEHB-IMAs role in Ethical ConflictEthicolegal Punishment Category of DRsFuture Role of MEHB-IMA & Med Disc BoardFuture Role of MEHB-IMA & Med Disc BoardProfessionalism as core content & health care reformPROFESSIONALISMCharter on Medical ProfessionalismABIM's elements of professionalismProfessional ResponsibilitiesProfessional ResponsibilitiesSlide Number 39Slide Number 41dynamic role of bureaucracyJudicial review result Tranparent + legitimate Practitioner More transparent & simultaneously More transparent & simultaneously 0.1 $ DRUG PACKAGE Regulation of Ministry of Health of Republic of IndonesiaNumber 284/Menkes/Per/III/2007RegardingPeoples Dispensary Slide Number 49Regulation of Ministry of Health of Republic of IndonesiaNumber 548/Menkes/Per/V/2007RegardingRegistration and License of Therapist Occupation Regulation of Ministry of Health of Republic of IndonesiaNumber 696/Menkes/Per/VI/2007RegardingPrice of Generic Medicine with trade name on Government Health Services Facility Slide Number 52Conclusion Conclusion Slide Number 56