Papers (Part 1)

• Development of Highly Pathogenic Avian Influenza (HPAI) Policy in Indonesia from the Perspective of the Government and Smallholder Broiler Farmers Muchammad Gumilang Pramuwidyatama Wageningen University

  HPAI remained endemic in most of the regions in Indonesia. HPAI mitigation in Indonesia has been suggested to be pointed at the uptake of measures by small-scale poultry farmers. Thus, placing farmers as the key point along with stakeholders with whom farmers are in contact with related to poultry diseases management (e.g., technical supports, integrated companies, livestock, and animal health agency) is essential to develop HPAI policy. This study aims to identify HPAI policy implications based on (i) the preference of the government related to measures directed against HPAI, and (ii) smallholder broiler farmers’ motivation and socio-psychological factors that associated with farmers’ motivation to implement measures against HPAI on their farm.

  A systematic evaluation of 27 measures which involved a workshop with local government officials was carried out to identify measures directed against HPAI that are preferred by the government. In addition, interviews with 203 Western Java small-scale broiler farmers were done to identify farmers’ motivation and factors that are associated with their motivation to implement different measures against HPAI.
  Our results show that the primary aims of the government were to safeguard humans from HPAI transmission by mitigating HPAI in livestock. Both the government and farmers are more in favor to mitigate HPAI by applying preventive measures such as vaccination and biosecurity compared to control measures, such as stamping-out. Furthermore, improving the attitude of farmers is important to increase the uptake of biosecurity and vaccination; and offering activities or programs that incentivize farmers is important to increase the uptake of vaccination.

  In conclusion, HPAI policy should be emphasized to preventive measures rather than control measures. HPAI mitigation programs should primarily focus on incentivizing farmers complemented by programs aiming to improve farmers’ attitude. Furthermore, a collaboration between the government, integrated companies, and broiler farmers is essential to ensure the implementation of the policy.

• Did Democratic Politics Produce Better Health Care in Jakarta? Isfandiarni Soenarto Rosidin Vrije Universiteit Amsterdam Gerry van Klinken Royal Netherlands Institute of Southeast Asian and Caribbean Studies

  Democratization introduced a new politics of health reform to Indonesia. This paper assesses the extent to which these politics have actually affected health outcomes. Under the authoritarian New Order, government health expenditures were low (though high enough to cause significant health improvements from a low base). Health facilities were poor. Only the one-third of the population earning in the formal sector were insured for health, and that was by means of private contributions. The 1997 economic crisis and subsequent democratisation combined to make health care the subject of considerable political interest. Health insurance for the poor was part of targeted social assistance. Elections stimulated local government heads to offer cheap health insurance schemes.

  Assessing whether these politics – particularly in Jakarta – actually worked to reduce health expenses and improve health facilities for all citizens turns out to be difficult. Publicly available health statistics are not designed to answer questions that connect welfare politics with health outcomes. Statistics we extract from the economic census (Susenas) indicate that people are making more use of subsidised public hospitals, which offer cheap, good service. But the rich have benefited more from these subsidies than the poor. Meanwhile, the number of health resources (medical staff, infrastructure) has actually declined. Government financing for health has increased in absolute terms due to booming revenues, but it has not increased in proportion to other sectors, and remains below that in comparable other countries. It appears to have been directed at subsidising hospital attendance and not at expanding health personnel and infrastructure. This suggests that so far the reforms have been driven by short-term electoral logic, and not by the desire to build a sustainably financed universal health system for the future. Political pressures have so far failed to fundamentally challenge the assumption underlying the New Order approach that health is mainly a matter for the individual patient and the private market.

Papers (Part 2)

• Does Ex-Ante Moral Hazard Exist in Healthcare Indonesia? Isfandiarni Soenarto Rosidin Vrije Universiteit Amsterdam

  Jaminan Kesehatan Nasional (JKN), or a single-payer comprehensive universal healthcare program has been established since 2014 with the aim to provide health coverage for all Indonesians and the government paying the modest premium. This program is now facing financial difficulties to pay health bills and jeopardizing fiscal sustainability. It seems that people pay very little premium but they could receive high cost treatment. We argue people tend to have ex-ante moral hazard if there is no incentive to prevent their health once they are insured. Health insurance could determine the probability to access inpatient and outpatient care but its coefficient is underdetermined. Thus, understanding people’s behaviour towards health is crucial as it reveals demand for outpatient and inpatient cares, and hence it could affect JKN in the long run. This paper attempts to identify ex-ante moral hazard in health insurance program.

  We assume the heath behaviour of insured people is the same overtime so, due to data limitation, we only observe individual behaviour prior JKN era. We use Susenas 2014 to estimate demand for healthcare and unhealthy consumption. Our findings suggest health insurance with or without subsidy improves access to healthcare substantially, however, ex-ante moral hazard among insured people also exists. Unhealthy consumption has positive correlation with outpatient care after introducing insurance. We also find the probability of the insured people to consume more unhealthy food is significant higher than its counterpart. These results remain robust after controlling income, education, age, housing quality, employment status, having kids and living in urban areas. Moreover, among insured people, the subsidized members visit more frequent for outpatient care while the non-subsidized members spend more days for inpatient care. The latter is associated with elderly, wealthier and more educated people. To access inpatient care where the patients should deal with paper works, education plays important role for subsidized people. Having those findings, our main policy implication is price differentiation for basic and advance treatment is unavoidable so JKN as universal healthcare should focus on basic healthcare, health prevention and promotion supported by upgraded primary healthcare throughout Indonesia.

• The Impact of Urbanisation on the Changing of Disease Landscape in Indonesia Dicky Tahapary University of Indonesia

  Indonesia is a country in transition. The rapid socioeconomic development has led to a dramatic changes in lifestyle, as well as environment, not only in urban areas, but also to a lesser extent, in rural areas. These changes contributed to the changes of disease pattern in Indonesia, which host of more than 260 million people. Communicable diseases have previously been recognised as the main health problem in Indonesia. However, during the past few decades, non-communicable diseases (NCDs) problem has slowly surpassed the problem of communicable diseases.

  It is important to note that this health problem varies across Indonesia. In a more remote area, communicable diseases are still pretty much the main problem, while in urban area NCDs are the main problem. However, with the ongoing socioeconomic development and increase in infrastructure development, these rural areas are currently marching toward a more urbanised lifestyle and environment. These changes lead to the increase of NCDs on top of the still unsolved communicable diseases problem in many rural areas of Indonesia. Thus, these rural areas are facing a more complex health problem in comparison to their urban counterparts. Furthermore, access to healthcare facilities in these rural areas are still unfortunately limited.

  For example, the problem of obesity and type 2 diabetes is increasing in both rural and urban area, of which the rate of increase is even higher in some rural areas rather than urban areas. Thus, these rural areas are facing double problem of the still ongoing problem of communicable diseases and the increasing problem of NCDs. The lack of resources in these rural areas lead to a suboptimal management of both communicable diseases and NCDs, which then lead to a higher morbidity and mortality.

  Taken together, the government should put a more emphasize on increasing the awareness of NCDs problem in rural areas as well as providing an optimal health care to overcome increasing NCDs problem in rural areas. Preventive method by providing health education in term of NCDs prevention, especially to people living in rural areas, might potentially halt the increasing problem of NCDs in Indonesia.

Abstract

Keywords

• Governance
• Health
• Indonesia
• Politics