Indonesia's universal health scheme: one year on, what's the verdict?

* Transforming institutions

A year after the government launched a health insurance project, professionals have opposing views. Is it too ambitious to succeed?

Some say the JKN scheme has struggled to reach those living in the hardest to reach parts of Indonesia. Photograph: ZUMA/Rex Features

Indonesian healthcare has traditionally been fragmented: private insurance schemes for those who could afford it, basic state provision for the very poorest, and NGOs in specialised areas providing support in between.
However, in January last year, Indonesia’s government launched an ambitious project: to establish a compulsory national health insurance system with the aim of making basic care available to all by 2019. The scheme, Jaminan Kesehatan Nasional (JKN), was implemented by the newly-formed social security agency Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS). It sought to improve the situation for citizens stuck in the middle of healthcare provision – too poor to afford health insurance but deemed not poor enough for government help.
Under JKN, all citizens are now able to access a wide range of health services provided by public facilities, as well as services from a few private organisations that have opted to join the scheme as providers. JKN care aims to be comprehensive, covering treatment for everyday concerns such as flu through to open-heart surgery, dialysis and chemotherapy. Private insurance continues to play a role by providing for excess or additional coverage of services not included in JKN.
Those in formal employment pay a premium equivalent to 5% of their salary, with 4% payable by employers and 1% payable by employees. Informal workers, the self-employed and investors pay fixed monthly premiums of between 25,500 IDR (£1.34) and 59,500 IDR (£3.12) in a tiered system of first, second and third-rate care depending on the contributions they choose to pay.

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Students in the village of Andong, Indonesia. In some rural areas, minimal public transport is a challenge for the healthcare system. Photograph: Agoes Rudianto / Barcroft Media/Agoes Rudianto / Barcroft Media

However, more than a year on, the JKN scheme has been subject to intense criticism. Academic studies by the Gadjah Mada University Centre for Health and the Paramadina Graduate School of Diplomacy have concluded that it will be impossible for all Indonesian citizens to access health insurance by 2019, as the BPJS had projected. “The plan is too ambitious,” says Yaslis Ilyas, a public health analyst at the University of Indonesia and critic of the project.
The issue of unequal access lies at the heart of the debate – largely a result of problems with the administration of the scheme. “Personnel have low competency and the JKN management has been ineffective,” Ilyas believes. “In addition, the population of jobless people and those working in the informal sector in Indonesia is very high.”

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The scheme has been less effective in areas where visiting a clinic or hospital involves long and sometimes expensive journeys to urban areas. This lack of infrastructure has meant that the scheme has been far from universal during its first 15 months.
For those citizens who are unemployed or work in the informal sector in Indonesia, NGOs have historically been the ones to plug the gaps in healthcare provision. The John Fawcett Foundation, for example, an NGO treating preventable blindness, works in the poorest and hardest-to-reach parts of Indonesia.
It is these areas that have struggled to gain access to healthcare through the JKN scheme so far. “Communication and transportation are definitely big problems for healthcare access under JKN, especially for those who live in remote areas or islands,” Ilyas explains.
Some local people, especially in cities, are also sceptical about the programme’s benefits. “JKN has definitely not been entirely successful. It has been extensively advertised in the media, and many people are talking about it, but anybody with money would not use it,” says Kiki Handayani, 38, who has lived and worked in both Bali and Jakarta over the past few years, and whose father enrolled in the JKN scheme last year.

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“It’s easy enough to register – you provide ID, employment details and a photograph, then you receive a card. But many people complain that it does not provide the service promised,” Handayani adds.
However, Irfan Humaidi, speaking for BPJS Kesehatan who supply the new healthcare service, robustly defends it. “In the first year of the social health insurance implementation, BPJS achieved a membership of 133.4 million when the target was 121.6 million, and BPJS has already paid the claims submitted by hospitals [as a result of the scheme],” he says.
“Based on an independent survey, customer satisfaction is 81% and awareness of the new social health insurance system is 95%. Complaints have been resolved within 1.5 days on average. Just a year after implementation, we have made many important achievements for the nation,” he adds.
And despite the criticisms, many still have high hopes for the programme. “Our staff are very optimistic about the BPJS scheme,” said Mary Northmore-Aziz, founder and chair of the Bali Smile Foundation, an NGO that helps people with craniofacial disabilities obtain healthcare. “They know it’s a big undertaking but seem very optimistic about its impact on their lives. A husband received good quality heart care for free in our local public hospital. Others are delighted that their families will be covered, so private arrangements won’t be needed.”
While the JKN scheme is, in principle at least, an improvement for some sections of Indonesian society, it still has a long way to go if it is to become truly universal by 2019. (http://www.theguardian.com)