Health insurance : It’s the politics, stupid! Panji Hadisoemarto  ;  The writer, a doctor of science candidate at the School of Public Health, Harvard University, is a lecturer at Padjadjaran University’s School of Medicine, Bandung

JAKARTA POST,  02 Januari 2014

                                                                                                                        

Ready or not, the next big thing for the health of Indonesia’s population is here: national health insurance (JKN).  Many, though, feel we are not ready to implement JKN. Predicted problems to implementation abound: insufficient coverage of the poor, maldistribution of health service facilities and physicians, below break-even point reimbursement rates.  The list could grow longer. And because the start of JKN coincides with the political year of 2014, many warn that the plan is prone to politicization. Here is what I don’t get, what’s wrong with politicizing JKN, unless “politicizing” means something bad, inherently bad?  The fact is, JKN, like all other public health policies, has been and will always be political. Public health is politics. And if there is anything from the past that we can learn to assure smoother implementation, and revisions, of JKN, it’s the politics.  First lesson: Rome wasn’t built in a day. The seed of JKN was planted 13 years ago by the late president Abdurrahman Wahid when he proposed a new National SocialSsecurity System (SJSN) as a response to the failure of previous efforts to resolve persistent poverty in Indonesia. What followed next is history. It took four years for the SJSN Law to be passed and another seven years until the Social Insurance Providers (BPJS) Law was passed. The Constitutional Court revoked some parts of the laws; enactment of the latter was questioned even by lawmakers. To date, many of the regulations required by the two laws have not been passed.  It may take a while before JKN reaches its most ideal shape, so don’t be disheartened if things don’t go right the first year or the first decade. Seriously, history has seen progress toward universal coverage take up to half a century. Second lesson: It takes two to tango. Sure, put the blame on the lack of political will on the government side but it is not the only party responsible. Other interest groups could, and should, be actively involved to move JKN forward toward its most desirable shape and outcome, too. They are legislators, NGOs, academics and healthcare workers, to name the most important groups.  Do they have the political will to move this forward? I bet they do. But it takes more than a strong will to move this forward. More important is that all parties involved practice their political skills and mobilize their resources to move this forward. Third lesson: There are winners and there are losers. JKN undoubtedly touches the interests of many. Take the premiums as an example. Larger premiums would provide more capacity for the BPJS to finance all the services covered by JKN, and it is a very extensive list. On the other hand, that would mean larger wage cuts for employees, plus the government has claimed that there is insufficient fiscal capacity to pay for the ideal premium subsidy for the poor.  At the current rate, on the other hand, the quality of services may suffer due to insufficient hospital and doctor reimbursements.  A win-win solution may not be reached, but everyone will have to deal with it. A consensus was reached that we needed JKN, though. We did agree, politically, on the aims of having JKN, too. And it is something worth applauding. For its implementation, on the other hand, there is still a long way to go for the political process to take place. JKN still needs fixing. In doing so, struggles between the political actors over the contents of subsequent policies will continue and will lead to conflicts. I am more than eager to see active participation from all interests to shape the policy. And to anticipate that, in the context of the upcoming election, it is the best time to talk about leadership. A strong leadership is essential to manage the politics of JKN and to assure that JKN actually reaches its aim, which is to guarantee the right of every person to equitable access to health care. Not just any health care, but quality health care that is able to increase the health status of the people. A strong leadership is required to bring all interests together to serve the ultimate goal and to make compromises.  Undeniably, we don’t have unlimited resources to spend on JKN alone and no one policy will make everybody happy. So the leadership will face hard choices, and I can’t resist writing that that choice may include some forms of rationing.  Of course, I would prefer the leadership that would have the vision to use the momentum of JKN implementation to reprioritize health as one of the main drivers of development. Meaning, a leadership that recognizes that money put on the health of Indonesians is an investment, as opposed to spending.  So what I would like to see is more public discussion from our future leaders about what they have in mind about fixing JKN. Meaning, please politicize JKN. Please use JKN to increase popularity. Please use JKN to gain votes. I think that bringing JKN onto the central stage of the debate in the upcoming election is important to foresee the future of JKN under the new government.  But, please, I don’t want to see promises; what I want to see is a clear vision and detailed plans on how they are going to fix JKN. Later, of course, we will have to make sure that the elected leaders put the money where their mouths were.  ●