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Criticism Builds of Indonesia’s Government-Sponsored Health Insurance Scheme
Posted on Mar 31, 2014 by Ailee Slater (G+)
At the beginning of 2014, the government of Indonesia began rolling out its brand new universal health scheme. Known as Jaminan Kesehatan Nasional, or JKN, the scheme aims to extend health coverage to 121 million Indonesians this year: nearly half the population of the country.
With a high rate of communicable disease and growing incidences of lifestyle disease too, the need for more comprehensive health care in Indonesia is clear. If JKN rolls out as planned, every person in Indonesia will be covered by government-sponsored health insurance by 2019, making JKN the biggest health care scheme in the world.
For Indonesian citizens with very low incomes, JKN may be able to provide medical care that was previously inaccessible. The nation’s health care system before 2014 did offer coverage to the poorest people in the nation, but many Indonesians who didn’t qualify for government assistance still found themselves financially unable to purchase private insurance, or to afford health services when an illness or injury arose. Hospitals would sometimes refuse to treat a patient who could not pay for their care up front, and patients who managed to come up with the necessary funds might find themselves in debt for years to come.
According to Indonesian policymakers, the new JKN scheme will work to eradicate health care inequalities and guarantee primary and emergency medical care to every person in the country. Indonesia’s Deputy Health Minister Ali Ghufran has said that along with offering health coverage to citizens, more health care workers will be placed in clinics around the country, and 150 new hospitals will be built this year.
Many are hopeful that the Deputy Health Minister will follow through with this promise to distribute more medical staff around the country. Indonesia is a nation composed of more than 246 million people living on at least 17,508 islands, and health care resources are not distributed equally: most doctors choose to work in urban centers, where they will receive higher pay and benefits, leaving many areas with fewer health staff or sometimes none at all.
With the rollout of the JKN scheme has come praise, along with a number of criticisms and concerns. Firstly is the question of money, and if the government has allocated enough funds to cover JKN in 2014 and the years to come. An expert in health policy at the University of Indonesia, Hasbullah Thabrany told Al Jazeera news that the JKN scheme cannot be implemented as planned with the US$1.7 billion that’s being used by the Health Ministry. Hasbullah anticipates that these funds will cover less than 50 percent of the costs of bringing health coverage to more than 100 million Indonesians.
Hospitals too are worried that the government hasn’t properly planned its finances, and that health care facilities will see an increase in patients without a concurrent increase in funding from the government. If payments from the government to hospitals are slow in arriving, clinics may again have to resort to asking patients for fees up front, or refusing to treat a patient who cannot pay. Patients with fewer financial resources may be asked to wait in long queues in order to access services.
Indonesia’s Medical Association agrees with concerns from hospitals that the government hasn’t set aside enough money to achieve all the JKN scheme goals for 2014. The Medical Association has said that if more money isn’t allocated to the program, quality of health care around the nation could fall: doctors may find themselves underpaid and overburdened with an influx of newly-insured patients.
The JKN scheme functions by paying doctors a set amount of money per patient, per month. Even if that patient does not visit her doctor during the month, the doctor will still be paid by the government simply for having the patient’s enrollment. The problem with this system is two-fold: the set monthly payment per patient is too low, and the payment doesn’t change even if the patient is in need of expensive health services. A doctor will be paid less than 70 US cents per patient, per month, and neither physician nor hospital has any way of recouping money from the government if a patient’s care proves unusually expensive.
Some of the challenges facing the JKN scheme are the result of Indonesia’s current, dysfunctional health care system. In 2012, the Jakarta Globe reported that just five out of the 1,800 hospitals in the country were internationally accredited, revealing a need for improvement in the nation’s standards of care and record-keeping processes. International accreditation is given to hospitals that meet criteria including: implementing processes to increase communication amongst caregivers; following up with recently discharged patients; and making necessary laboratory services and staff available to all patients.
Although Indonesia’s hospitals have been steadily improving, and more health care funds are now being directed toward rural areas, some health advocates say that the prevalence of non-communicable diseases has yet to be addressed. Conditions influenced by lifestyle, such as diabetes and cardiovascular disease, are becoming more and more common in Indonesia: a 2013 report by health care company Novo Nordisk found that 7.6 million Indonesians currently have diabetes, and projections indicate that number could increase to more than 11 million by 2030.
Despite these concerns about the state of Indonesian health and health care, President of Indonesia Susilo Bambang Yudhoyono has expressed his support for the JKN scheme. According to the President, this new health coverage system simply needs time to grow, and in the near future doctors can expect to see higher wages while patients can expect bigger subsidies. President Yudhoyono has also said that frequent evaluations of JKN during its first months will lead to general improvements in the scheme and keep the government on its way to implementing complete universal health coverage by 2019.