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ince the 1980s, complaints about suspected malpractice and negligence on the part of physicians and hospitals have become commonplace - plastered across front pages of newspapers and brewing a storm of questions with no clear answers for the root causes and their solutions. In 2005, the first draft of the hospital bill was submitted to the House of Representatives to regulate what had become a big part of the medical industry; it remains a bill today. The issue resurfaced recently when a young mother was dragged off to jail for emailing complaints about a hospital's service to her friends. The Jakarta Post's Rendi A. Witular and Arghea Desafti Hapsari look at the issues concerning health management in the country.

Indonesians almost lost their reform-minded Finance Minister Sri Mulyani Indrawati in a tragic manner when early this year a specialist at a top Jakarta hospital diagnosed her with a cardiac abnormality during a medical checkup.

The doctor later prescribed various drugs for her. She sought a second opinion from her sister, a physician, and later from a colleague - cardiac specialist and Health Minister Siti Fadilah Supari.

It later turned out the diagnosis was completely wrong, but no punishment was ever meted out to the doctor by Supari or the Indonesian Doctors Association (IDI), despite their vested authority to do so.

Around the same time, housewife Prita Mulyasari was jailed by prosecutors for alleged defamation through emails, in which she complained of the services she had received at Omni International Hospital in Tangerang, Banten.

It was not until the ensuing public outcry that prosecutors released her. The case is currently being tried in court.

Idealists in the medical profession have long voiced concerns over a rising number of breaches of ethics by medical workers and hospitals, but to no avail.

"If you ask me how we unwind this mess, I just don't know where to start," says University of Indonesia medical expert Iwan Dharmansjah.

"Since the early 1980s, we've struggled to change things. The problem has now grown too complex to resolve."

He says the root cause of the problems are the combination of a lack of government supervision, overly powerful pharmaceutical companies, a high degree of "esprit de corps" in the medical profession, compounded by the country's abysmal health insurance system.

Today's new laws on health, medical practice and consumer protection provide considerable legal guarantees for patients.

But enforcement is another story; interpretation of the laws are sometimes so varied they favor the medical practitioners over the patients, according to community health expert Hasbullah Thabrani.

"The Health Ministry has the resources to supervise hospitals, but somehow they don't use them," he says.

Supari has even said she had no authority to revoke private hospitals' operating licenses over violations, in response to the Omni case.

However, the ministry's director general of medical services, Farid Husain, says the ministry has all the power to revoke and issue operating licenses to all types of hospitals.

Even so, hospitals and doctors are rarely inspected by the ministry or regional health agencies, for various reasons, ranging from lack of regulations to high costs of supervision.

In the case of complaints, the government insists that patients file them with the medical practitioners' association, or the IDI. The body, one of the country's top lobbies, runs the so-called Indonesian Disciplinary Council for Physicians.

However, collegial solidarity has led to very few instances of doctors being punished, according to Iwan.

IDI chairman Fahmi Idris denies the allegation, saying the IDI would never cover for members who have violated laws and the medical code of ethics.

The legal option is to file a lawsuit, but besides being too costly, constraints include the difficulty of finding doctors willing to testify against colleagues charged with negligence.

The situation has worsened with the absence of medical service standards that can be used as a benchmark for proper medical treatment.

"In countries *with a developed health system*, patients can easily sue doctors," says Kartono Muhammad, a former IDI chairman.

"But here, the courts don't know how to proceed with such cases because there's no standard of medical procedures to work on."

Complicated procedures, coupled with a long-held distrust in the judicial system, have forced patients to seek out-of-court settlements; but largely to the advantage of doctors and hospitals, says Kartono.

To date, there is still no clear-cut procedure for filing a complaint.

Farid Husain, responsible for hospital supervision, suggests that patients go to the IDI's disciplinary council, the local health agency or to the Health Ministry directly.

But a group of complaints that have remained mostly unnoticed revolve around the questionable use of drugs and facilities, which are hard to prove and difficult to resolve.

Pharmaceutical companies are the primary suspects in such allegedly unethical practices.

Abundant cash, networking and influence have led several companies to collude with doctors and hospitals to sell their products.

A common perception is that these companies "buy" doctors long before they leave medical school.

Indonesian Pharmaceutical Association (GP Farmasi) chairman Anthony Ch. Sunarya denies there is any collusion between doctors and drug companies.

"We have our code of ethics. If such a practice does occur, then the doctors and hospitals should also share the blame, because it takes two to tango," he says.

The Health Ministry, however, refuses to regulate such practices.

"It's *a matter of* ethics; it's the IDI's responsibility, not the government's," says Farid Husain.

IDI chairman Fahmi says the allegations are a result of the country's poor insurance system.

"We've signed a deal with GP Farmasi on what can and cannot be done," he says.

"In the end, the problem lies in the system. If the insurance system worked, there would be a list of medicines covered by the insurance companies; this is what we're all looking forward to."

An adequate insurance system, provided either by the government or the private sector, could also help monitor, indirectly, the use of drugs and facilities, frequently deemed to be irrational; because at the end it will be the insurance companies that are burdened with any unnecessary costs, rather than the patients.

The government only has an insurance system for civil servants and people living below the poverty line.

"Because the government has no insurance scheme for middle-income people and those living just above the poverty line, many of these people are at risk of falling below that line just to pay inflated medical bills," Iwan warns.

The chronic concern has fallen on deaf ears, he adds.

"We're facing an ethics crunch here," he points out.