1

REGULATING the PROFESSIONAL :The Dilemma in Medical & Health Practices

for the Poor in Indonesia

Soenarto Sastrowijoto & Nur Azid MCenter for Bioethics & Medical huamities

School of Medicine, Gadjah Mada UniversityYogyakarta, Indonesia

2007

2

Background :In Indonesia Morbidity & Mortality rate and Human Development index rank is Lower compare to ASEAN Countries.The history of medial / health care system and judicial product = Colonial – Orde Lama – Orde Baru– Economic Crisis – Reformation Era, related to health statusMedical / health care system, based on

Welfare stateSocial (security) state Free market / Market driven direction.

The medical health services / education / financing is not developed integratedly.Act and regulation related to medical health / education / financing

3

Objectives of the study

The identify feasible regulatory mechanisms and strategies to address iatrogenic health problem in medical & health practice. To describe and analyse the existing regulatory mechanisms, ethical codes and legislation with direct implication for medical & health practice.

4

Questions of the study

Is the medical & health practice could be covered by the existing rules and regulation ? Which type of ethical consideration and cases of ethical problems are handled by relevant regulatory body / court, argument’s constitutes, and the outcome ?

5

Methods :

Desk – study of documents (Act and regulations, text books, articles, internet, newspaper, and Court), and Key individuals, professional associations, Center / Provincial / Districts MoH offices, NGO; and All will be analysed, based on the relevancy to the objectives of the study.

6

Results :

Five levels Hierarchy of Law and Regulation in Indonesia

1) the Constitution of the Republic of Indonesia,

2) Act or Government Regulations replacing Act,

3) Central Government Regulation, 4) Presidential Regulation, 5) Provincial and District Regulation.

7

The Extent of the Regulation

1. Regulating Capacity and distribution of Health Care Practitioners (HCP)

2. Regulating Competency of HCP3. Regulating quality of Healthcare

service4. Regulating Financial system5. Regulating the Ethico - legal Aspects6. Regulating Penalties

8

Some Type of ethical cases

1) Unpaid insurance on doctors’ fault 2) Advertising3) Patients’ miss-management (including miss

diagnosis and treatment)4) Quarrel between doctor and employee (nurse

and midwife)5) Neglecting patients’ who are unable to pay

approval or court request6) Sexual harassment

1. From The Medical Ethics Honorary Committee(MKEK, 2005)

9

Type of ethical cases……..cont

1) Wrong medical intervention 2) Failure on certain medical intervention3) Leaving operation instrument in

patients’ body 4) Illegal abortion 5) Medication error 6) Miss-diagnosis

2. From the Newspapers

10

Ethical cases in the Court

1. Obgyn, Private Hospital (2002)2. Surgery, Private Hospital (2004)3. Surgery, Private Hospital (2004)

Why ? Small number

11

1) Obgyn, Private Hospital (2002)Failure to install contraceptive devicepregnantInformed Consent sufficiently givesCurettage – careless – neglecting patient

Court : granted the plaintiff's demands

12

2) Surgery, Private Hospital (2004) Patient injury Information was gives not directly by the surgeryThe right of the patient To have second opinion – rejected.Alleged negligence

Court : granted the plaintiff’s demands

13

3) Surgery, Private Hospital (2004) Necrotizing ileocolities Medical standard procedure – fulfilled First and second operation – no causal link Courts : - refused defendant’s exceptions

- Denied plaintiff’s demands completely

14

• Act related to Health system

1. National Education systemNo. 20, year 2003

2. Medical PracticeNo. 29, year 2004

3. Decentralisation / Provincial –District autonomy (2004)

15

• National Education system, Act (2003)

In developing standards in Post (Medical) Education, - college of medicine/surgery –coordination with Professionalism Assoc, School of medicine, Teaching Hospital, Department of Education, and Department of Health.All kind of higher education and training vocational & professional, under / managed by the university system. The needs and demands of the society, particularly the poor (disadvantaged group)- no consideration.

16

• Medical Practice Act. No. 29. 2004

1. Medical Profess standards of Education / Training

- generals – school Med. Assoc - Post graduate – college of medicine / surgery

2. Medical / health service legislation CertificationRegistrationLicensing

Regulating – Medical Practice Nursing & alternative

(not covered)

17

• The integration of Health system development

Population HEALTH status

HEALTH Servicessystem

HEALTH Education

System

HEALTH Financing

system

18

Formal Providers

19

DISSCUSSION

MMR and IMR – higher comp. to ASEANThe Number of Health Professionals

( Doctor-Sp ; Nurse; others)- Very limited – the number of

Population

20

Health Financing (Economic) Systems

Goverment

Private

Goverment

Private

Govt

P

1.

2.

3.

Welfare – State

Market – driven – system

Social – security system

21

Medical / Health Practice, and New Regulation (Needs)

Privatepractice

Govt.

The Rich

The Poor

HealthInsurance

System

FamilyMed. / Healthcare

Primary

PublicMed. /health

ServiceMDs

New Reg.

22

The current Act & RegulationsPrimary health care

(Private & public)GP / FM – RegulatedNurse - Medical care

- Nursing careAlternative health care

The Poor choice !Secondary health care

The condition is the same for the PoorMost / many Medical / Health practice(particularly Private sector) – the choice of the Poor – without license.How to monitor/ Control / Develop : A Dilemma

Not covered by Regulation

23

Primary care - Nursing / Medical Second care - Generalist / Specialist

Tertiary care - Specialist / sub specialist

Professional Training

JobOrganization

Professional OrganizationGrey Area

New Regulation

24

RECOMMENDATION

Health sector reform in services, education, and financing should be considered, developed integratedly.New Act and Regulation is needed, even though need time.Privilege Regulation in transition (Provincial & District level), as Model development should be developed urgently.