Health Cards

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The Health Cards entitled recipient households (including all family

members) to free medical treatment at public health facilities. This included

visits to community health centers, contraceptives for women of childbearing

age, pre-natal care and assistance at birth, and patient and outpatient visits

at public hospitals. The implementation of the Health Card scheme involved

several stages (see Pradhan et al., 2002: 4–5; CIMU, 2002a: 17–18). Every

district (kabupaten) received an allocation of cards based on the BKKBN list

of pre-prosperous households. The Health Cards were delivered to districts

starting in August 1998, along with guidelines explaining the criteria to be

used for allocating the Health Cards to individual households. The offi cial

criteria were based on the BKKBN classifi cation of family welfare, but in

practice many local offi cials combined this information with various local

criteria in deciding how Health Cards should be allocated in their area

(CIMU, 2002b: 9–10).

The fi rst independent studies of the Health Card suggested that only

a small fraction of the poorest households were covered by the scheme,

at least in the fi rst six months of the program. The SMERU analysis of

the 1999 SUSENAS Special Module data showed that the Health Card

covered only 10.6 per cent of households in the poorest 20 per cent of the

population (Sumarto et al., 2001). In addition, mis-targeting resulted in

some leakage to the non-poor as the data revealed that the Health Card

was also distributed to around 3 per cent of the richest 20 per cent of the

population. In total, some 5 per cent of all households in the richest 80 per

cent received the Health Cards (see Table 3.9).

Researchers who have looked carefully at the Health Card issue have

identifi ed a number of factors contributing to the relatively weak coverage

of the poor and the mis-targeting that occurred (Soelaksono et al., 2003:

40–41). Firstly, there were clearly defi ciencies in the procedures used to

identify the intended recipients. In most provinces, the village midwives

or the staff from the local community health center, together with family

planning cadres and the heads of villages, identifi ed the households who

were to receive a card. However, according to fi eld surveys, the village

midwives did not always understand the criteria in the program guidelines

or appreciate the intended emphasis on poverty. Secondly, there was a lack

of correlation between the BKKBN household classifi cation and poverty

incidence according to consumption and expenditure data. Thirdly, there

were reports from a number of areas of recipients who sold their Health

Cards to others who were not eligible to receive cards but who were in urgent

need of health care (CIMU, 2002a: 17).

In addition, there were problems with the actual distribution of the cards

in some localities, as the cards were supposed to be delivered directly to

the recipients. Reportedly, the distribution did not always work smoothly,

especially since there were no specifi c funds to support this process. In many

instances, the head of the Puskesmas allocated the Health Cards only when

poor patients arrived at the Puskesmas seeking treatment. According to one

report, in Irian Jaya province (now Papua) some village heads were found

to have sold Health Cards to members of their local community (CIMU,

2002a: 17).

A fi nal problem contributing to poor coverage was a direct outcome of

the way that service providers were compensated for the workload arising

from patients using the Health Card when seeking treatment. This was

by a lump sum transfer based on the number of Health Cards allocated

to the district, not on the actual use of the Health Cards by the recipients

(Pradhan et al., 2002: 15–16). As a result, those responsible for distributing

the Health Card – the doctors heading the community health centers and

the village midwives – also had a certain fi nancial disincentive that worked

to discourage them from distributing the maximum number of Health Cards

in their area. Since most doctors and midwives also operated a private

practice, the more Health Cards that they distributed, the greater the number

of patients looking for free medical treatment, thus reducing demand for

their own private health service. Another problem was caused by delays in

the disbursement of JPS-BK funds (CIMU, 2002b: 14–15).

In a more detailed and considered study of the Health Card issue, Pradhan

et al. (2002) have argued that even though the coverage was relatively low

in the initial stages of the JPS-BK program, the 1999 SUSENAS data

nevertheless reveals that Health Card recipients were on average not only

poorer, but also had lower levels of education. Moreover, there was a high

proportion of female-headed households among Health Card recipients, and

a higher probability that recipients were working in the agriculture sector

compared to non-recipients. Despite the earlier fi nding of poor coverage and

targeting, there is evidence that the distribution of the Health Cards played

an important role in maintaining the use of health care services. (Pradhan

et al., 2002: 4). Figure 3.2 illustrates that the introduction of Health Cards

helped to prevent a further decline in the use of health care services between

1998 and 1999. Without Health Cards, the use of public health services

might have declined below 10 per cent in 1999. After the introduction of the

Health Card scheme, the utilization rate in 1999 remained at 10.5 per cent.

In fact, the proportion of households using public health care providers

increased slightly during this period, while the attendance at private health

care services declined. This suggests a substitution from private to public

health care induced by the introduction of the Health Card.

Table 3.13 also illustrates that the share of households possessing Health

Cards who received outpatient care was 15 per cent, which is greater than

the share for households without Health Cards (13 per cent). Health Card

owners also appear to have visited public health care providers more often

than those without cards. However, a large proportion of those with Health

Cards, around 85 per cent, are reported to have sought no health care at

all. There was also evidence that some who actually held Health Cards did

not use them when seeking medical treatment (4 per cent). There appears

to be a number of explanations for both these phenomena: the limited time

allocated at some public health facilities for treating those patients holding

Health Cards; a lack of access to a nearby public health facility; and the

perception on the part of some patients that they would receive a lower

standard of service and inferior quality medicines when using Health Cards

(Soelaksono et al., 2003: 18–19). Meanwhile, there was also evidence that a

very small number of patients from households who had not been allocated

Health Cards were reported to have used Health Cards. This seems to have

occurred when Health Cards were distributed at a clinic based on perceived

need, so that the surveyed head of the household was unaware that a family

member had received benefi ts under this program.

Table 3.13 Utilization of Health Card (percentage seeking health care

between December 1998 and February 1999)

Head of household Head of household

reported to have received reported not to have

a Health Card received a Health Card

Received outpatient care 15.10 12.91

Went to public provider 10.61 6.75

Went to public provider and 6.74 0.15

used Health Card

Went to public provider and 3.88 6.60

did not use Health Card

Went to public provider 4.82 6.48

Did not seek health care 84.57 86.77

Source: Pradhan et al. (2002: Table 2).