Women support women: Ensuring health financing not only work for health facilities but also for women’s health

Nuzulul Putri

Women are the center of health services, both as users of health services and as providers of health services.

Although there are many criticisms of how global health indicators are not gender-sensitive, in fact, many health indicators use women as the denominator in their calculations. Of the 100 WHO Core Health Indicators at least 14 indicators specifically address women’s health, while other indicators use the general population regardless of gender.

Women are the driving force of the health system. More than 70% of the world’s health workers are women. Unfortunately, though they are drivers of the health system, women rarely have opportunities to play a strategic leadership role and they are frequently overshadowed by gender bias. Research I conducted in 2018 on women’s leadership in the health sector in Indonesia showed that male health workers in Indonesia have twice the chance of becoming top leaders in a health organization than female health workers. Women are often considered incompetent to become leaders with unclear reasons or justification.

Women support women and health financing 

As a child, I remember asking my mother why she and the women neighbors always put a glass of rice on the fence every night. My mother told me that it would help many people in my village to seek treatment. All rice will be collected every night, piled up in the village warehouse and every month will be resold. The money obtained will be managed by village leaders to help residents who need costly health treatment.

One day my mother told me that a neighbor had just given birth, the mother and baby were healthy, but her family had to spend a lot of money because she gave birth by Caesarean section. It was very difficult for them since the Caesarean cost millions of Indonesian Rupiah and they were informal workers who could not afford it. The rice money that had been collected in the village was eventually used to help the neighbors. At that time, there was no Indonesian National Health Insurance scheme (JKN), so all health care costs were borne by the sick. From that day onward, I understood how important it is for everyone to have protection in financing their health and how powerful it is for women to support other women.

The problem

Since 2014, Indonesia has made history in its efforts to achieve universal health coverage. Indonesia established JKN as an effort to ensure that all people have health protection. Differences in economic status, gender, ethnicity, and geography are trying to be bridged by ensuring that all people have guaranteed access to health services according to their needs.

JKN implements tiered health services where only patients with a certain diagnosis and severity can be referred for health services at the hospital. So, it is very natural that the use of JKN has been predominantly used by the community to access primary health services. In 2021, BPJS Kesehatan, the manager of JKN, noted that 49.7% of cases referred for hospitalization were for maternity, especially Caesarian, procedures. This shows how important the role of primary health facilities in JKN is and how they contribute to women’s health.

Until 2022, at least 26,417 health facilities have been contracted to provide health services under JKN. These health facilities provide health services to more than 220 million JKN participants spread across nearly six thousand islands in Indonesia. Of this number, 89.4% are primary health care centers (PHCs), almost half of which are private PHCs that must independently manage their operational cost.

Under JKN, PHCs are paid by capitation where they receive payments each month according to the number of participants registered as their patients, not based on how frequent the patients use their services. Consequently, the amount of their income is largely determined by the amount of the capitation rate and the number of registered participants. These two things become very problematic for private PHCs. Since 2014, the capitation rate has not changed even though health costs are getting higher. The number of participants for private PHCs is also much less than that of public PHCs, even though private PHCs do not receive financial assistance from the government like public PHCs.

Creating a solution

In collaboration with the association of private PHCs in Surabaya, my project discusses how payments for health services received by private PHCs under JKN have been able to help PHCs improve the quality of their services. PHCs are gatekeepers that will help determine whether a patient needs further treatment in hospital or not. Imagine how risky it is if there is a mother who should get advanced treatment in hospital because of difficult labor but cannot be referred or is referred too late. Two lives, that of mother and baby, are at the stake; therefore, the capacity of the resources owned by PHCs must be ensured to support their task of providing adequate primary health services. Without appropriate provider payments, there will not be enough resources for PHCs to carry out their duties, especially private PHCs who must finance all their own operations.

My project will document any evidence on how the existing payment system for private PHCs under JKN has impacted the primary health facilities. The project will also communicate the findings to health managers in primary health care to understand the complex terms of capitation payments. It will minimize the knowledge gap related to the capitation policy and improve awareness of this issue among managers of primary health care facilities and associations.

Women in the lead

When I work on projects and interact with health facilities, most managers who manage their finances are women. There was even an opportunity to discuss with a private association of PHCs; all participants who attended were women. Through the Samya Stumo Fellowship, I also had the opportunity to be guided by mentors who are experts in the field of health financing. What is remarkable is that two of my three mentors are women. They are active in conducting research, managing projects in health financing, and communicating them to stakeholders.

This reminds me of how women supported women through rice money in my childhood. At that time, women supporting women was more about helping get collective donations for health care costs. Now, for me it is more about how women in academia support women leaders in PHCs to become leaders who are experts in managing health organizations. It is also about how women leaders in PHCs support academics doing research for improvements in health financing. And most importantly, it is about how these women leaders support every woman in Indonesia to get better health services. All in all, this fellowship is helping me to be a woman who can support other women.