JKN : An imperfect milestone Tommy Dharmawan  ;  A Physician in Jakarta

JAKARTA POST,  07 Januari 2014

                                                                                                                       

Santoso was a cardiac patient in a government hospital who routinely used Askes, the previous national health insurance.  In the first week of January he went to the hospital’s cardiac clinic, but to his surprise he only got half of his regular medication.  The hospital staff said this was because the insurance coverage rate for his medication was only enough to pay for half of the medication due to the implementation of the new national health insurance (JKN) on Jan. 1. Since then, he has visited the clinic twice a week to get his full package of medication, but this has also cost him more in transportation expenses. Eka, a cardiologist, is pessimistic about the JKN. He cannot make full prescriptions as most of the medication he usually prescribes is not on the national list of JKN accepted drugs. He said that many patients came by but he only received minimal payment.  The JKN is a part of the national social security system that uses a mandatory social health insurance scheme to fulfill the basic health rights of all citizens. President Susilo Bambang Yudhoyono officially launched the program last Dec. 31 in West Java; problems are abundant and it has been criticized as an immature health program.  To be fair, the JKN has some positives. First, it represents the implementation of human rights stated in our Constitution. No one in Indonesia can be rejected by a medical provider just because he or she is poor. No one in this country can become poor because of high medical costs.  The entire population should be covered by the program by 2019. In the first stage, according to Coordinating People’s Welfare Minister Agung Laksono, around 121 million people will automatically be registered, namely civil servants, military and police personnel, workers covered by the Jamsostek health insurance program and participants of the former government-funded Jamkesmas social protection program.  The government also said that it would allocate Rp 19.3 trillion (US$1.6 billion) to cover the premiums of those considered to be in the “impoverished” or “near-impoverished” categories.  Second, the health system will be more efficient. Patients must first go to community health centers or Puskesmas. If necessary, the Puskesmas will refer the patient to the district government hospital and so on.  Patients cannot go directly to the government hospital except in emergency cases. The medical expense system will change from the direct pocket of the patient to the third party, the Social Security Agency or BPJS Kesehatan. The other positive thing is that we will get accountability reports from hospital managements. Hospitals must therefore make on-time and accurate reports to BPJS Kesehatan, or they will not be reimbursed. Hospital staff are forced to become efficient and adhere to standard operational procedures in patient management. Easy access is another positive aspect. Agung said that about 1,700 out of 2,300 hospitals nationwide had signed agreements with the government to provide medical services for the program’s participants.  Indonesians not covered by this program yet can access services by filling the member forms online, with ease of use. The program will not use a reimbursement system. Participants only need to show their BPJS cards at hospitals.  The implementation of the JKN will also save trillions of rupiah. Sulastomo, a health economic expert, said the government had lost the opportunity to mobilize up to Rp 278 trillion ($23 billion) for welfare because of the seven-year delay. So, the longer we delay, the more Indonesia loses. Of course, there are some drawbacks. From the patient’s perspective, this program may not fulfill their medication needs, requiring them to pay more to get their full prescriptions, thereby involving more costs.  This makes the aim of the JKN questionable as medical providers also do not receive sufficient payment for services rendered because medication prices are far below the costs determined under the JKN.  The other drawback is that the national health budget accounts for only 2.2 percent of the total national budget and the budget allocation for the JKN is only Rp 19 trillion, not enough to cover all of the JKN’s expenses. It must be adjusted to the level mandated in the 2009 Health Law, which is 5 percent, or even up to 15 percent as per WHO standards.  The monthly contributions in the JKN is also very low. The contribution for informal workers is Rp 25,500; for third-class medical facilities Rp 42,500 (second class) and Rp 59,500 (first class).  The low budget from the government for the JKN will force the BPJS to cut expenses, eventually reducing reimbursements to hospitals and leading to low quality services.  The other drawback is late government campaigning of the program. Most patients and medical providers are still in the dark on details.  Lastly, this program has been implemented only a few months before this year’s elections, leaving the impression that the President is in a big hurry to stamp his legacy before stepping down.  We still need some time to wait for the full implementation of the JKN, but ready or not, the JKN has already started. We cannot stop the brilliant and optimistic idea of the JKN, to ensure the health rights of all citizens. We only can improve its implementation. ●