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. ●

Will everybody smile? Ahmad Fuady  ;  The writer is a general physician and lecturer at the faculty of medicine at the University of Indonesia (UI) and is preparing his doctoral program focusing on health economics and policy in the Netherlands

JAKARTA POST,  03 Januari 2014

                                                                                                                        

For Indonesians, welcoming this New Year also means welcoming national health insurance (JKN) with its evident problems.  Implemented via social security providers (BPJS), hopes and worries are mixed together. The JKN is certainly an Indonesian’s dream. However, we are still wondering whether the system will provide the finest universal health coverage and satisfy all stakeholders.  Some problems include rushed regulations as New Year’s Day approached, an unfinished financing and payment system and the availability of providers. The delays have resulted in uncertainty for nearly all stakeholders.  Providers remained uncertain how they will be paid by this system, until the Health Ministry issued regulation No. 69/2013 near the end of the year. However, its categorization of “mild”, “moderate” and “severe” ailments entitled to coverage of medical rehabilitation, for example, still lack explanation.  Further, some costs are set higher than prior costs in the Indonesia Case-Based Group (INA-CBG), the diagnostic-based reimbursement system applied in the healthcare plan — but some are cheaper.  Some reimbursement is delivered according to working diagnosis, regardless of a patient’s other medical problems. The cost paid by the system may be much lower than that required for treatment, leading to scepticism of poorer quality hospital services. Moreover, the poor dissemination of information to hospitals, particularly in rural areas, leaves confusion because of different information and unanswered questions. Medical cases may be treated by various types of medicines and therapeutic modalities. For example, two patients may have similar diagnosis, spondylitis tuberculosis (an infection of tuberculosis on the backbone), but physicians may consider different treatment. One patient may receive medicine only, but the other one receives psychotherapy, or even bowel training and physiotherapy, because of complications of mental and physical conditions.  In the above reimbursement system, the payment does not consider any additional diagnosis and peculiarity of the case.  Further, physicians cannot prescribe medication outside the nationally set drugs, leading to “missing” medicines actually allowed in prior benefit packages.  This would lead patients to visit private providers, leading to the inefficiency of the JKN.  How about existing providers? At the level of primary care, the government targets coverage of about 3,000 for each general physician. This means we need at least 80,000 physicians but the available medics are extremely low. Yet, primary care is the backbone of national health insurance, so we require adequate, qualified primary physicians to become proficient first contacts and gatekeepers of health services.  Payment for primary-level physicians is another concern. With a government allocation of physicians at Rp 4,000 (US 33 cents) to Rp 6,000 per capita of the 3,000 potential patients, a physician could gain Rp 12 million to Rp 18 million per month. Assume that 10 percent of the allotted patients, or 300 of them, fall sick and need primary treatment each month, while each visit costs Rp 30,000; the physician’s income will be only Rp 3 million to Rp 9 million per month. Is this acceptable for a competitive salary? It depends much more on the physician’s approach. They should try to reduce visits below 10 percent through excessive health promotion and prevention strategies. It is easy to say, but terribly hard to practice. Altering community behaviour from being curative medicine-minded to a healthy lifestyle with various prevention methods is like climbing a mountain. Some costs, including that of chronic, non-communicable diseases, may be impossible to reduce, but controlling the diseases may be helpful. It is complicated to conclude whether a current physician’s incomes are worthy or not.  Yes, national health insurance is not well-prepared because of political pressure leading to rushed preparation. However, we should not step back. The government should be open to criticism and revise unfavourable regulations, while physicians should keep trying to provide the best quality care. Putting smiles on the faces of all stakeholders may be impossible in the current situation. People from Sabang to Merauke require adequate numbers of primary-level physicians with an excellent quality of service. The government, as a consequence, has to apply innovative strategies to produce primary-level physicians and deploy them across the country, to enable as equal access as possible to their services. The payment system should be evaluated within the first three months to remodel the system if required.  The BPJS and the JKN are not the end results of health coverage, but improvements day by day are imperative. ●

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.  ●

Birth of Indonesia’s ‘Medicare’ : Fasten your seatbelts Hasbullah Thabrany  ;  The Writer is chair of the Center for Health Economics and Policy Studies, University of Indonesia, and was a former member of the Presidential Task Force for the National Social Security System

JAKARTA POST,  02 Januari 2014

                                                                                                                       

After an almost 10-year delay, the law on the national social security system will be implemented on Jan. 1. This Law No. 40/2004 is equivalent to the Old Age, Survivor, Disability and Health Insurance Act or the Social Security Law of the US. Both laws were enacted after severe financial crises that alerted the countries to the crucial need for a social security system to overcome financial catastrophes.  While the US law covers four programs, Indonesia’s national social security covers five programs, namely health insurance, occupational injuries, provident funds, pension and death benefits. There are some differences between the laws of the two countries. The US Social Security Law, without health insurance, was passed just three years after the 1932 Great Depression.  Indonesia’s law was enacted six years after the 1998 financial crisis and two years after the amendment of the 1945 Constitution. Further, the health insurance part of the US law was added later in 1965, creating its Medicare program.  But Indonesia’s health insurance covers only the elderly using a pay-as-you-go funding mechanism. In Indonesia on Jan. 1, the health insurance part will for the first time cover Indonesian citizens and foreigners residing in Indonesia for more than six months. Another difference is that the entire US social security system is administered under a single agency, the Social Security Administration under the federal government. Meanwhile, the administration of our social security is under two different quasi government agencies under Social Security Providers (BPJS), one catering to health coverage and the other in charge of the other four programs. The Indonesian model follows the similar separation of short-term and long-term programs of social security in Taiwan, the Philippines and South Korea.  Another unique feature of the Indonesian system is that since the beginning, in 2004, the Cabinet of President Susilo Bambang Yudhoyono seemed reluctant to pass the Social Security Law. The government, however, bowed to pressure following a lawsuit and widespread demonstrations mobilized by the Action Committee for Social Security (KAJS), which comprised 66 labor unions, student associations and NGOs. Indonesia’s national health insurance (JKN) program is administered separately by BPJS Kesehatan, previously PT Askes Indonesia, in a program similar to that in the US, Canada, Taiwan and Australia. It represents a single payer health care to meet basic healthcare needs, meaning all medically necessary treatment, of the entire Indonesian population.  The JKN covers comprehensive benefits, from influenza to expensive medical intervention such as open-heart surgery, dialysis and cancer therapies.  The program covers medical necessities and hotel-type services. JKN funding comes from mandatory contributions from all workers and a government subsidy for the poor and near poor. Hotel-type services are limited to a first- or second-class room and board for those who pay 4.5 to 5 percent of their monthly wages. The poor and the near poor needing hospitalization, covered by the government subsidy, are entitled to a third-class room and board.  The BPJS Law No. 24/ 2011 prescribes that on Jan. 1, the JKN will start by integrating the administrations of four current public health insurance plans. To undertake the JKN, the world’s largest national health insurance plan, PT Askes (currently a parastatal company) has been transformed into a public, non-government entity named BPJS. While PT Askes was tasked to make money or profit from the sick for the government, the BPJS must ensure that every contributor gets necessary medical care. From the New Year, public health insurance will first cover about 120 million people.  An additional 10 million to 20 million people may enroll during 2014, most likely those suffering from chronic diseases or catastrophic diseases such as renal failure and cancer.  Many have criticized the fact that the scheme is not supported by adequate number of healthcare providers. However, the current utilization of healthcare providers shows that, for example, the average bed occupancy rate of all hospitals has been only about 60 percent. Similarly, many offices or clinics are under-utilized.  Meanwhile, our healthcare system is suffering from a shortage of specialists and low-quality care resulting from severe underfunding. In the last 40 years, Indonesia spent only about 3 percent of its gross domestic product (GDP), much below other large countries such as China and India that spend more than 5 percent of their GDP on health. Despite all the preparations by the government and the BPJS, there are still potential problems — mainly low contribution resulting from unfair intervention by some employers and employee associations.  Some employers’ association representatives lobbied the government to set a low-ceiling for wages and thus low health security coverage contributions; while employees, citing their low wages, refused any cuts for social security.  Similarly in 2014, the government is only willing to contribute Rp 19,225 (US$1.57) per person per month for the poor. Although the amount is much higher than the 2013 allocation, the figure will not meet average market costs to provide good care by the private sector.  The government’s contribution was being criticized as discriminatory; as the President also issued a decree on financing supplemental health insurance for high-ranking officials at Rp 1.6 million per person per month, about 80 times more than the government contribution for the poor. Following such criticism the President revoked the regulation on Monday.  Fearing insolvency caused by current contribution levels, the Health Ministry set low reimbursement levels. Although private healthcare providers are not mandated to contract with the JKN, the low reimbursements will create low interest among private providers, leading to overcrowded clinics and beds at state providers. Currently, state hospitals nationwide supply about 50 percent of beds.  Further, the fact that the BPJS will issue BPJS membership cards will create a perception of non-inclusiveness by healthcare providers. The BPJS should issue a JKN card, as commonly practiced around the world.  The low payments to healthcare providers and the exclusivity of the BPJS will discourage quality medical services. The JKN needs quick monitoring and rapid fixing to ensure sustainability. So, let’s fasten our seat belts to anticipate some turbulence in the first stages of Indonesia’s universal health coverage.  ●