JKN after five years: Where will we go?

9 mins read

Tulisan ini telah dimuat di The Jakarta Post, 5 Januari 2019

jkn after five years - jakpost

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

Ahmad Fuady

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