April 7th marks World Health Day, with the theme this year being ‘Universal Health Coverage: everyone, everywhere’. This is indeed a timely topic for Indonesia, with its ambitious goal to achieve full universal health coverage (UHC) through the national health insurance scheme, Jaminan Kesehatan Nasional (JKN), by 2019. UHC is a vital component in the global strategy to achieving the health-focused Sustainable Development Goals (SDGs). For the world’s fourth most populous country, and a population that is scattered across hundreds of islands, achieving UHC would be a massive step toward achieving the SDGs in Indonesia. Since the roll-out of the JKN in 2014 however, the journey toward better health coverage for all Indonesians has been far from straight forward, and there is still a long way to go if the target is to be met. With the 2019 deadline looming however, we need to consider if Indonesia can fiscally afford to achieve UHC, and if the health system is strong enough to support it.
Universal health coverage is based on the conviction that health is a human right, not a privilege. According to the World Health Organisation (WHO), UHC is about ensuring that all people can receive quality health services when needed, without suffering financial hardship. Currently, the WHO estimates that at least half of the world’s population is unable to obtain essential health services. To counter this inequality, Indonesia rolled out the JKN in 2014 as the world’s largest single-payer health care insurance program. It revolutionized health insurance in Indonesia, by streamlining the prior framework of individual insurance schemes for different social groups, into one program that could also offer insurance to those previously unable access insurance, such as informal workers. Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS), the social security agency responsible for implementing the JKN, has confirmed that approximately 70% of the population are now covered, which only leaves a 30% gap to be filled ahead of 2019. While in theory, the current coverage of JKN suggests that a reasonable proportion of the population can now access health services without considerable financial hardship, the reality of achieving more equitable access to healthcare is quite different. To achieve true universal health coverage, it will not be enough to report that 95% or more of the population have registered for the JKN. People must be able to actually receive the care that they need, and the BPJS budget must be able to support the receipt of that care.
A key issue in achieving full universal health coverage by 2019, is ensuring that patients can actually recieve the care that they are entitled to. While recent data from the WHO shows that over 90% of sub-districts in Indonesia have a health center, only 75% are equipped with basic amenities. In terms of personnel, 75% of health centers have a sufficient number of general practitioners, while only 57% have a sufficient number of nurses. The outcome is long waiting times and poor quality of care from overworked staff, in health centers that may not be able to provide the services needed by a patient. This is felt most acutely at the primary care level in Puskesmas, which have massive variation in the availability and quality of care, particularly in remote and rural areas. This is a massive problem because members of the JKN are required to access the Puskesmas as the first point of care to receive treatment or referral onwards. Inefficiencies in care that start at the primary healthcare level have ongoing effects for both the patient, and how JKN-reimbursed treatments are utilized.
If the continuum of a patient’s illness and treatment cycle is unsystematic and disorganized, this can result in the patient having to access a more costly curative services for something that could have been effectively managed earlier at the primary care level. Haemodialysis is one such example. As of 2014, over IDR 1.5 trillion was spent covering this treatment, making it the second largest expense to the BPJS budget. This cost is largely due to poor patient awareness and management of their illness, which results in requiring emergency care at end-stages of the disease. If the goal of full registration to the JKN is actually realized, it will be fiscally unsustainable for the BPJS to continue to outlay such enormous portions of the budget to reimbursing these sorts of treatments. Treatments such as haemodialysis can be delayed or avoided together, if patients are diagnosed at an early stage and can receive early intervention to effectively manage it. This cannot happen however, if the healthcare system is not functioning optimally, and patients are unable to access high quality care.
It is very possible that Indonesia can achieve universal health coverage by 2019. The key challenge is how to achieve this, while also addressing regional disparities in service quality and accessibility to ensure that people can receive appropriate, high quality care. This means more effective allocation of funding sources into human resources, as well as core programs at the Puskesmas level that focus on screening, patient education and management of early stage disease. Greater investment in the community-driven programs Posbindu and Posyandu, as well as structuring the implementation of the BPJS program, Prolanis, to encourage higher enrollment, will go a long way to making sure that patients can effectively manage their disease, without having to use expensive end-stage treatments as a first and last resort. An increased focus on promotive and preventive care is a vital supplement to the JKN to truly ensuring health for all.
*This articles has been published on the Jakarta Post, April 07, 2018
Madeleine Randell is an Australian public health research advisor. She is currently based in Jakarta, with the Center for Indonesia’s Strategic Development Initiatives (CISDI).