The
Constitution promises every citizen access to social security and emphasizes
the role of the state in providing universal social security coverage. On Jan.
1, citizens started to see the fulfillment of such promise, as the long-awaited
national health insurance (JKN) came into effect.
Dubbed the largest health insurance in the
world, the JKN will first cover approximately 120 million people automatically
entitled to primary health care and third-class coverage at partner
hospitals.
Among those, some 86.4 million are
underprivileged (formerly covered by Jamkesmas insurance), who are the
recipients of premium payment assistance (PBI), for which the government has
set aside Rp 19.3 trillion (US$1.58 billion) from the state budget.
Groups with assumed employment, who contribute
through individual (entrepreneurs and informal workers) or group (employees)
schemes, will also be covered.
As many have noted, the launch of the JKN sparks
new hope and anxiety at the same time. The government indeed has lots of
homework.
Information on the new scheme needs to be
disseminated to the public, health workers and hospitals, while it also needs
to ensure the readiness of hospitals and other health facilities. Data
(especially on poor people) needs to sort out, as does other technical issues
such as the registration process.
It must be noted though that in a country as
vast as Indonesia, disparity between regions, hospitals and health workers will
continue to create challenges in managing a massive health reform such as the
JKN. Decentralization will remain a stumbling block in enforcing existing
clinical and quality standards.
There are at least two issues that must receive
careful attention, in light of decentralization.
First is the excessive number of people to be
registered as poor people and its implication to local governments and
hospitals.
This will likely take place during the
transition from the regional level health insurance schemes such as Jamkesda
(and other local programs like Jamkes Aceh, Jakarta Sehat, etc.) to the
JKN.
According to statistics, (PPLS 2011, the most
recent Social Protection Program Data Collection of the Central Statistics
Agency, BPS), there a total of 96.7 million poor people, which means there is
an excess of more than 10 million people that would not be covered by the
JKN.
This group of people is expected to be covered
by the regional health insurance. The problem is that there have been ample
examples how regional governments or their local hospitals were on the verge of
bankruptcy because of the number of poor people using the former local health
coverage schemes had soared, compared to official data used to estimate the number
of initial recipients.
Garut and Sukabumi in West Java and Boyolali in
Central Java, are some of the mostly quoted regencies in such cases. The list
will be longer if we include eastern Indonesia’s regencies, which also suffer
from a lack of local capacity in managing health services and finances.
The central government must pay attention to the
regencies with lower fiscal capacity and a higher number of poor people to
ensure that the data discrepancy regarding the poor does not disrupt public
services or even lead to bankruptcy.
The role of the Social Security Agency (BPJS) in
conducting the payment process on time so that burdens do not fall on hospitals
and local governments is pivotal. Also, attention should be given to speed up
the provision of medical workers in such facilities.
Meanwhile, some local governments have expressed
hesitation to merge into this nationwide scheme right away because of this data
discrepancy. The local government of Surakarta, for instance, refused to
migrate and contribute to the JKN from its local budget (APBD) due to worries
over the jump in the number of people intending to register.
Similarly, the municipal government of Manado in
North Sulawesi decided to continue its local insurance because it did not want
to interrupt its program and its budget this fiscal year.
The Health Ministry needs to allocate a specific
period of time for a systematic transitional process to the local
administrations to completely merge their schemes into the JKN, hence, their
budgets can be better used to improve the quantity and quality of health
workers and facilities.
Second is the risk to the poor living in poor
and marginalized regions. The poor excluded from PBI living in poor regions are
in fact the poorest of the poor. They are similar to those not covered in
Jamkesmas and local schemes like Jamkesda.
Living in the regions with the worst off
economies, their local governments do not have much budget discretion to charge
the already limited budget for those beyond the number of poor people covered
by the central government.
For the poor listed as PBI, the risk is the
quality of services they will be receiving. They will only be able to access
low-quality hospitals because many poor regions in Indonesia lack health
workers and facilities.
On paper, the service types and quality should
be equal, regardless of the types of hospital, because the Indonesia Case-Based
Group (INA-CBG) system, a fee-for-diagnostic reimbursement system will be
applied.
However, one only needs to go to any public
hospital to see the reality. In the past, those lining up in the Jamkesmas and
local Jamkesda line were often more poorly served than those with Askes health
coverage and those with private health insurance.
With the JKN, the risk of discriminatory
treatment of service providers to the users could be repeated, given the low
premiums provided for the PBI. This poorest group is entitled to assistance of
only Rp 19,225, while informal workers are covered with premiums of Rp 25,500
up to Rp 59,500, and the formal workers are covered up to 5 percent of
wages.
In the long run, there must be an effort to
equalize the amount of premiums for the poor, so that the JKN is not perceived
as maintaining different classes of recipients.
The JKN must not be seen as just a mere
continuation of Jamkesmas, which was seen as an inferior program compare to
other health insurances. It must be plotted to gradually close the gap of
services for people of different socio economic status. This will need commitment
from the central government to allocate more for premiums for the poor, and at
the same time ensure that the BPJS’ investment is safe and financial condition
is healthy, to contribute more for this end.
These highlight the importance of public monitoring
and a reliable complaint mechanism system. Therefore, despite the presence of
the BPJS Supervisory Board tasked with internal monitoring, and the BPJS Watch
from the outside, it is important for the public and civil society to keep an
eye on the JKN’s implementation.
This is vital, especially to ensure that the
poor and marginalized are no longer treated discriminatively, which defies the
very purpose of having national health insurance: to ensure that the state
provides social security to every citizen, especially the poor and
marginalized.
_______________
Victoria Fanggidae
The writer is a
program and research manager at Perkumpulan Prakarsa (Center for Welfare
Studies), Jakarta, and a postgraduate from the University of Melbourne’s
Development Studies Program.
Published: Jakarta Post, 9 January 2014
vfanggidae@theprakarsa.org