JUSTICE

1. JUSTICE Kuswandewi Mutyara

2. Justice • Distributive justice  in an attempt to suggest 'where we are' • Justice  requires a distribution of opportunity for care, and government is the appropriate instrument to guarantee equality of distribution. • Its mean  'that justice requires that everyone get the resources needed to be healthy', • we are “on the same page” • Justice as well as fairness is defined in the dictionary as “the treating of both or all sides alike without reference to one’s feelings or interests:”

3. Justice requires everyone has a claim to health care needed to provide an opportunity for a level of health equal, as far as possible, to other persons' health. Differentiate between justice among “known lives” (that is justice between people we personally or through friend are known to us) and justice for “unknown” lives: that is lives for whom we must make decisions but whom we do not know as individuals.

4. JUSTICE AND QUALITY • What ‘equal treatment’ exactly means in the context of the health care? • System here are several possible reference points: • equality in the formal access to health care services • equal chances to benefit from the services of the public health care system: this implies that everybody counts the same in cost-benefit calculations on which the design of the benefit package is based, • the right to achievement of the same result with respect to life expectancy and quality of life (health status), if medically possible: this is the most far reaching requirement which forces the government to engage in a maximum level of activity designed to even out congenital differences in health status.

5. POOR • The poor are people who are deprived of basic needs. • It is difficult to measure  many of indicator to measure • “hierarchy of needs” • Basics such as food and water must be available before health, housing, clothing etc. • According to UNDP (United Nations Development Programme) developing a Human Poverty Index

6. Human Poverty Index (UNDP) • % of people dying before the age of 40 years • % of illiterate adults • % of people with access to health care • % of people with access to clean water • % of malnourished children under 5 years.

7. some diseases are more prevalent among the poor, • some communicable diseases (HIV/AIDS, TB) are strongly associated with poverty, e.g. those linked to poor water and housing • higher prevalence of chronic diseases. • Higher mortality rates indicate that the poor have worse health status, although this is not always borne out by surveys which ask people to report their recent illnesses, as the poor often report less illness.

8. the poor tend to use the public sector more than private services • Higher use of services due to income and their distance from services (& time and travel costs)  the services in poor areas may be worse quality

9. the issues which need to be addressed in defining pro-poorhealth policies and strategies • How to improve the health status of the poor • How to ensure services of reasonable quality actually reach the poor and vulnerable • How to ensure people are not driven into poverty (or more severe poverty) by the costs of health care.

10. three main areas of policy can bedefined to improve the health of the poor • protecting them from ill health and reducing their burden of illness, • ensuring the poor have access to a range of curative, preventive and promotive health services which are of reasonable quality, are affordable and appropriate to their health problems • avoiding use of health services leading to worsening poverty.

11. OTHER Activities HAVE MAJOR IMPACT ON HEALTH AMONG THE POOR • Improving water and sanitation, education and incomes • Improving transport, housing and agricultural practices

12. POLICY ISSUES • ensuring the poor are covered by public health services • improving the access to and quality of personal health services • avoiding heavy expenditures by the poor on health care which exacerbates their poverty

13. HEALTH INSURANCE IN US (OBAMA administration)

14. TO LOWER HEALTH CARE COSTSAND ENSURE AFFORDABLE, ACCESSIBLE HEALTH COVERAGE FOR ALL • Health care costs are skyrocketing. • Tens of millions of Americans are uninsured because of rising costs. • Underinvestment in prevention and public health.

15. PROGRAMS • LOWER COSTS TO MAKE OUR HEALTH CARE SYSTEM WORK FOR PEOPLE AND BUSINESSES – NOT JUST INSURANCE COMPANIES • AFFORDABLE, ACCESSIBLE COVERAGE OPTIONS FOR ALL • PROMOTING PREVENTION & STRENGTHENING PUBLIC HEALTH

16. HEALTH INSURANCE IN SWEDEN • Small budgets cannot buy first-class medical care • The most persistent arguments for single-payer health insurance is that it will somehow give everyone gold-plated care at little or no cost. • “universal coverage”

17. CASE STUDY 1 In October 2003 Mrs. A., who lives in Malmo, Sweden, gave birth to a baby boy. She was signed out from the hospital six hours after delivering the baby. There are not enough beds, so delivering a baby “without complications” is an outpatient procedure. Budget cuts have eliminated beds and medical staff. The next day Mr. and Mrs. A. noticed that their baby was weak and did not want to eat. As is common in Sweden, they did not call a doctor. Instead they called the tax-paid “TeleMedicine” service. Nobody advised them to go see a doctor right away. The following day their baby died of pneumonia.

18. Case STUDY 2 In May 2006 another couple lost their three-year-old son to the budget-starved medical system. When Mr. and Mrs. B.’s son suffered from diarrhea and had been vomiting for almost two days, they took him to the emergency room at the nearby university hospital. A doctor ordered a supply of intravenous fluids, and the boy was sent on to the pediatric clinic to have them administered. When he arrived, the nurses had no time for him. Mr. and Mrs. repeatedly called on the medical staff to ask why nobody was coming to give their son the intravenous fluids he so desperately needed. Every time they got the same answer: nobody has time. They have too many patients and too little staff. Six hours later the three-year-old boy died of heart failure.

19. CASE STUDY 3 Mr. D., a multiple sclerosis patient, lives in Gothenburg, a city of 500,000. His doctor told him about a new medicine that is considered a breakthrough in MS treatment. But, when the doctor put in a request to have Mr. D. treated with it, the request was denied. Reason: it would cost 33 percent more than the old medicine, and that was more than the government was willing to pay. For most Swedes there are no longer any subsidies for prescription drugs. People with exceptionally high pharmaceutical costs get some subsidies, but they have to pay the greater share themselves. When the government denied Mr. D. the new medicine on the grounds that the subsidies would cost too much, he offered to pay the full cost of the medicine himself. He was denied the option to pay full cost out of his own pocket because, the bureaucrats said, it would set a bad precedent and lead to unequal access to medicine. In Sweden, there is no way to obtain access to medication outside the government-run system.

20. CASE STUDY 4 In April 2005 Mr. C., 61 years old, became concerned about an unusual feeling of fatigue. He went to see a doctor at the local government-run clinic. The doctor sent him home with some encouraging words. Mr. C. came back a while later with worsened symptoms.A gain he was sent home after a superficial examination and with more reassurance. Over the next year and a half Mr. C. visited this tax-paid local clinic a total of 14 times. He had no choice—all Swedes have to go through a government-run primary care physician at a tax-paid clinic in order to see a specialist. He developed blood in his urine. But the doctors refused even to take a blood test. They told Mr. C. and his son that they were denying him the blood test because of budget restrictions imposed by government bureaucrats. When, finally, Mr. C.’s son convinced the doctors to do one blood test, they found out that Mr. C. had cancer. He was referred to a regional hospital. There they established that his cancer, originally curable, had spread throughout his body. There was nothing left to do. He died shortly after.

21. HEALTH INSURANCE IN INDONESIA

22. Indonesia… • 2014  Introduce universal coverage • Ex: Asuransi  Kesehatan  Masyarakat  Miskin,  or  Askeskin,  was  targeted  to  the  poor  and  has  increased  access  to  care  and  financial  protection  for  the  poorest  implemented 2005

23. PROBLEMS • ???