Lenny Tristia Tambun & Dessy Sagita – The recent death of a newborn baby who was denied treatment by 10 Jakarta hospitals has raised questions about the readiness of providers to commit to the free health care program introduced by the governor, as well as the role of private hospitals in the scheme.

The Jakarta Healthy Card, introduced last November by Governor Joko Widodo as a way to ensure low-income residents would get free treatment at 17 hospitals citywide, should theoretically have allowed Dera Nur Anggraini, born on Feb. 10, access to the life-saving treatment she needed for a respiratory complication.

Instead, she was turned away at all the hospitals – state and private alike – where her father presented the card. Dera died last Saturday, aged just six days.

Hospital officials, backed by the Health Ministry and the Jakarta Health Office, have since denied that they refused to treat Dera because she was not a paying patient, saying they simply did not have room in their fully occupied neonatal wards to take in another patient.

Basuki Tjahaja Purnama, the deputy governor, acknowledged that while the Jakarta Healthy Card program was well-intentioned, its introduction appeared to have caught hospitals off-guard, leaving many unable to handle the increase in patients since the scheme was rolled out.

He pinpointed the problem on the number of recommendations issued by community health centers, or puskesmas, for patients to seek treatment at hospitals, even in cases where the puskesmas was capable of treating the patient.

"We're going to have to audit these recommendation letters from the puskesmas because right now the hospitals in the city are filling up fast," Basuki said on Wednesday at City Hall.

"I hope puskesmas [officials] aren't pulling some kind of scam, or sending the patients to hospital without first trying to treat them. That's why we need to carry out an audit."

Improving the system

Despite its sketchy implementation, Basuki defended the Jakarta Healthy Card program as valid under the 2004 National Social Security Law. He said that under the previous governor, Fauzi Bowo, a similar program called the regional health security scheme, or Jamkesda, was in place.

Like with the Jakarta Healthy Card, residents subscribed to Jamkesda could seek free or subsidized treatment at a hospital with a class III ward, as long as they had a recommendation letter.

The difference, Basuki pointed out, was that the letter in this case, called an SKTM, attested to the patient's financial condition and had to be issued by the head of their urban ward and approved by subdistrict authorities, not by a single authority like the puskesmas, thereby making it difficult for patients to obtain.

"Jamkesda was such an inefficient system that at the end the city administration owed Rp 300 billion [$31 million] to hospitals," the deputy governor said. "That's why we chose to replace it with the Jakarta Healthy Card."

While both schemes offer free basic care or subsidized advanced care at class III wards, the key difference is that 17 hospitals, including private ones, are signed up to the new scheme, compared to six state ones under Jamkesda.

This, Basuki said, was aimed at getting more private health care providers to sign up to the program. He said that with the city administration paying a larger monthly premium per patient for the Jakarta Healthy Card than Jamkesda, there was a financial as well as moral impetus for private hospital operators to get on board.

Willing, but overwhelmed

Private operators say they are willing to join the scheme, but the fundamental problem is in the lack of physical health care infrastructure to treat the 4.7 million people that city authorities hope to cover.

Melissa Luwiya, the operational director the Mochtar Riady Comprehensive Cancer Center Siloam Hospital in Semanggi, said the hospital had allocated 30 percent of its beds for the class III ward, triple the required figure of 10 percent for commercial private hospitals.

Even then, she said, "the ward is always full, and many times we have to turn down patients because there are no beds and sometimes we don't have enough nurses to care for the patients."

"We handle patients who use the Jakarta Healthy Card scheme, but we use the co-payment system where the patient must pay part of the cost," Melissa said. The Siloam Hospitals Group is owned by the Lippo Group, of which the Jakarta Globe is a part.

Separately, Marius Widjajarta, the chairman of the Indonesian Consumer Protection Foundation for Health (YPKKI), said the class III bed requirement stipulated by the Health Ministry had not been properly enforced.

"The problem is that, after announcing the regulation, the ministry never bother to check whether these hospitals have complied with the regulation," he said. The lack of monitoring, he went on, is often used by some hospitals to turn down patients on the pretext that there are no empty beds left in the class III wards.

"The ministry must conduct a regular audit and monitor these hospitals to ensure they're really complying with the requirement, otherwise we'll continue hearing stories about poor patients being rejected by hospitals," Marius said.