Ensuring Access To Health Care for The Poor and Marginalized

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.
PublishedJakarta Post, 9 January 2014

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