Tulisan ini telah dimuat di The Jakarta Post, 5 Januari 2019
The National Health Insurance (JKN) is about to turn five years old. The program has made significant progress, as, for instance, coverage of social health insurance increased from 46 percent of the population in 2014 to 75 percent in 2018. The JKN has also improved equity in access to healthcare services, for the benefit of people living in low-or middle-income households.
Government subsidies through the “subsidized participant “or PBI scheme help the vulnerable group get both inpatient and outpatient services free of charge. Yet, a lot of work remains to be clone. Despite the narrowing gap of healthcare access between poor and non-poor, patients from both groups have still had to pay out-of-pocket(OOP) at healthcare facilities.
In absolute terms, higher-income patients spent more OOP than those from poorer households. However, relative to their household income, poorer patients face a higher risk of catastrophic health expenditure- when the costs incurred to access health care exceed their financial capacity. This has been exacerbated by poor geographical access in rural and remote areas, as well as a poor distribution of healthcare facilities.
As a result, the utilization ratio of health care services by PBI members is very low at only 3.8 percent. The claim ratio from this group was 47 percent in 2016; far lower than that of the formal workers group (116 percent) and informal workers group (281 percent). This indicates that, despite improving access for the poor, costs utilization has been concentrated in middle to higher income households.
Those figures justify the government’s decision not to increase the subsidies for PBI members. However, the situation has become more complicated.
While the health social fund has been depleted over five years, almost one quarter of informal sector workers have registered themselves as JKN members after falling ill.
Nevertheless, 28 percent of informal workers have not regularly paid their voluntary contribution.
Bleeding is deemed normal in the JKN’s first five years of operation, as is the face with health schemes in many other countries, since opening and widening access to health care for all encourages higher utilization. Yet, for the long term, comprehensive measures should be taken.
First, efforts to promote a healthy lifestyle and prevent diseases should be intensified. We need not start from the scratch. The Health Ministry and other stakeholders should arrange a priority list for the most bleeding medical cases, as ischaemic heart diseases, cancer, chronic kidney disease and cerebrovascular diseases.
This measure requires an improved disease-screening system. Most cancer patients seek hospital care only in the advanced stage. The reasons for this vary and include a low awareness of cancer symptoms and signs, a preference for herbal and traditional medicine, limited healthcare resources and a poor referral system.
Similar conditions apply to other chronic diseases, like kidney diseases and diabetes mellitus –that also entail a risk for the development of other lethal diseases.
Using this approach, the government should take the second measure: investing more funds in to reducing primary risk factors. Although Indonesia’s public health expenditure has increased after the launch of the JKN, its proportion of total health expenditure is only 40 percent. About 50 percent of the population has to pay out-of-pocket for healthcare services.
While the government needs to invest more, the impact of this will not be instant. It takes time to see a reduction of costs caused by high-cost diseases.
Therefore, it is critical for the government to change its mindset on investment in health – which is often considered a losing investment. Improving health is not a sprint but a marathon, with any environmental, social and political factors that may interfere. Many global studies show that greater investment in health – regardless of whether it looks detrimental – will yield benefits for people’s wealth.
The health funds should serve two main purposes in the next five years of the JKN: covering the shortfall in funding of the Health Care and Social Security Agency (BPJS Kesehatan) on the one hand and improving efforts to promote health and disease prevention on the other.
The BPJS Kesehatan deficit, which soared to Rp 10.9 trillion (US$754.5 million) in 2018, has been a major issue to tackle. The government decided to plug the deficit through the tobacco excise. However, how long can this strategy work?
Fund collection that is sustainable in the long term requires an innovative funding strategy. One way is an increasing unhealthy food tax, commonly called a public health tax.
In line with the first strategy to promote health and prevent diseases, the Health Ministry should identify unhealthy ingredients in food and beverages related to the high-cost diseases, then coordinate with the Trade Ministry and the Finance Ministry to formulate a comprehensive long-term health-related policy.
Furthermore, improving health promotion and disease prevention means that primary care should be strengthened, as its real role is that of the backbone of the health system. We have already discussed for decades the importance of primary care, without significant policies agreed upon and developed.
Many say primary care is the king, but where is the crown? Poor facilities, an unfair distribution of resources and low wages of healthcare staff working on primary care are several issues that highlight the missing crown.
Strengthening primary care, therefore, is the third main strategy in the second five-year term of the JKN. Several basic approaches have already been taken by the Health Ministry and BPJS Kesehatan, including determining care standards and developing performance-based payment systems in primary care. However, these are still insufficient to complete the puzzle.
Primary care facilities should also feature adequate human resources, medicine supplies and facilities. In 2017, about 33 percent of community health centers, or Puskesmas, were not ready to provide high-quality services, especially in rural and remote areas.
The problem is aggravated by the poor distribution of healthcare personnel, due to a lack of incentives to work in rural and remote areas. The current performance-based payment system in primary care could improve healthcare staff salaries.
However, another problem arises, since such a system drives healthcare staff to focus on curative measures in clinics, such as unnecessarily holding referral cases and increasing medical contacts.
Another indicator of a successful Puskesmas is the integrated chronic diseases management program or Prolanis. It requires more systematic measurements to help patients increase their quality of life rather than merely involving as many people as possible.
If all measures are implemented, it will not only bring back the crown of the king to primary care, but also spare people unnecessary healthcare costs that may impoverish them.
We hope 2019 is a good start for Indonesia to improve the JKN.
The writer; a lecturer and researcher at the School of Medicine of the University of Indonesia, is pursuing his PhD at the Erasmus University Medical Center Rotterdam, the Netherlands