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Indonesia's innovative healthcare scheme

System is expected to be the world's largest with 247 million covered by 2019, but critics have their doubts.

Last updated: 16 Jan 2014 11:04
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Bapak Untung, 51, is now able to receive specialist heart treatment in the capital Jakarta [Jack Hewson/Al Jazeera]

Jakarta, Indonesia - Andre Soni Asmara isn't sure of the exact cause of the sporadic pain he feels in his chest, or the frequent tiredness he experiences. For the past two years, he has suspected heart disease, which is hereditary in his family. His symptoms worry him, but he is more concerned for his son, Rizky.

Telling his story on the front steps of the specialist National Cardiovascular Centre in Jakarta, Andre fights back tears as he recounts the battle to save his four-year-old boy's life. Rizky was born under-weight in June 2009 and experienced heart failure shortly thereafter. He has needed intermittent hospital treatment ever since.

"He was turning blue when he was born, he needed round-the-clock care and had to have fluid drained from his lungs. I was worried sick," Andre says.

To fund his son's treatment Andre was forced to borrow 70m rupiah ($5,917) - more than three times what he earns in a year as a self-employed interior designer. "When I came to the hospital they refused me treatment [unless I met all the costs]. For ICU, it's 4m rupiah just for one day. I asked them, 'Can the poor not be sick?' If you're poor you can't be sick in this country because you can't afford it," Andre says.

The 44-year-old says the stress of meeting his son's medical bills has triggered his own health condition. "I've had to make a choice, and I decided I would be prepared to die so my son can have the treatment," says Andre.

Doubts voiced over Indonesia health scheme

Until now, he would rather not know the reason for the discomfort in his chest because he's unable to pay the cost of his own therapy. But this is set to change.

As of January 1, Andre is able to register for a new national health insurance programme managed by Indonesia's Social Security Organising Body (BPJS). The scheme is set to become the world's largest by 2019, when the government projects all 247 million Indonesian citizens will be covered.

'Sandwich people'

Indonesia's multiple existing health insurance carriers will be united under the BPJS umbrella, changing little for those who are already covered by insurance. But for 80 million Indonesians who, like Andre, are not deemed poor enough to qualify for the current Jamkesmas healthcare system and are not rich enough to buy private insurance, BPJS will mean affordable access to therapies for life-threatening illnesses.

One of the primary aims of BPJS is to provide coverage for those between the rich and extremely poor, whom policy analysts refer to as the "sandwich people". Now those who are self-employed or work in the "informal sector" will be able to pay contributions of between 25,000 rupiah ($2.10) and 60,000 ($5.10) rupiah a month to gain access to any service deemed medically necessary, from a routine checkup to open-heart surgery.

Integration of the service also means patients will have more choice in where they can access treatment, as long as they can afford to travel.

On the third-floor ward of the National Cardiovascular Center, 51-year-old Bapak Untung is being treated for acute decompensatory heart failure. He has suffered severely swollen feet, breathlessness and fluid in his lungs, exacerbated by the inadequate treatment he received from his local hospital in Bogor, 70 kilometres away in West Java. All he requires is a simple drug treatment to reduce the fluid in his lungs, but this was unavailable to him in his hometown.

Andre Soni Asmara was forced to borrow $5,920 for his five-year-old son's heart treatment [Jack Hewson/Al Jazeera]

After hearing about BPJS through a friend, he immediately took advantage of the access to specialist treatment in the capital, Jakarta.

"If this system had existed a long time ago, I probably would be better by now," Bapak says. "I think this programme is a bit late, but I'm very relieved it's here. Better late than never."

Long time coming

It's taken the government 10 years to set up BPJS - mandated by the Law on the National Social Security System passed in 2004, which ruled that all Indonesians must be covered by social insurance.

Critics claim government delays have been partly attributable to opposition from employers, for whom paying mandatory insurance premiums will increase labour costs. "President Susilo Bambang Yudhoyono's government has not been keen to implement because his cabinet is too neoliberal - they don't think it will be a good programme for business," says Hasbullah Thabrany, a health-policy expert from the University of Indonesia.

In an effort to expedite the Yudhoyono administration's glacial progress, in 2010 the government was successfully sued by the Social Security Action Committee (KAJS), which advocates for workers' rights.

"The central Jakarta Court decided that the government had failed and neglected [its duties], and the government was sentenced to implement the law as soon as possible," Hasbullah says, chuckling. "Maybe only in Indonesia do you hear about cases like that."

The professor welcomes the arrival of the scheme, but sees several obstacles in its rollout. He is primarily concerned by the lack of public information that has been made available about BPJS. According to Hasbullah, there has been a limited campaign through TV and radio advertisements, but public knowledge about the programme is poor.

The central Jakarta Court decided that the government had failed ... and was sentenced to implement the law as soon as possible. Maybe only in Indonesia do you hear about cases like that.

- Hasbullah Thabrany, University of Indonesia

In his consultations with the government, Hasbullah recommended an allocation of at least 1tn rupiah ($83m) for public education, and the "socialisation" of the programme, but he says the Department of Health has set aside only 20bn rupiah ($1.7m).

"I suppose with many people on the street, for example a taxi driver - a good example of the sandwich people, [who until now have not been able to get coverage] - they don't know about this, about the national insurance," he says.

"More than 50 percent will not be aware that they have cover. If you ask me to grade this, I would give it a grade C - a fail [in the Indonesian education system] for socialisation."

Enough money?

Hasbullah also anticipates the 19.9tn rupiah ($1.7bn) that has been allocated to the health ministry for 2014, will only meet 40 percent of the market costs of care.

Hasbullah says while the new system will push much of the burden of payment to employers and healthcare providers, and the health budget will be inadequate to maintain, let alone improve, the quality of care.

Defending the financing for the scheme, Deputy Health Minister Ali Ghufron Mukti said he was presiding over the largest health budget in Indonesia's 69-year history, and more funds would be allocated in the coming years.

"I think that we will spend more money in the future. It is necessary to increase our health infrastructure. So we are planning step-by-step, so if not today, then tomorrow or the day after tomorrow," he says, adding the process of spreading the word would be spread over five years.

"Indonesia is a big country, we cannot socialise the programme in one or two days. We have a roadmap, and we hope this roadmap will finish in January 2019," he said.

According to the Department of Health Indonesia's population is currently cared for by 85,000 general practitioners and 25,000 specialist doctors. While this meets adequate standards of coverage determined by the United Nations, there remain concerns over the regional distribution of doctors.

In Jakarta there is a high concentration of specialists, but outside of the archipelago's major cities specialist numbers are much lower and the quality of facilities can be hazardously poor. The task of coordinating the merger of Indonesia's half dozen existing state health insurance providers will also present significant challenges.

For Andre his optimism and relief that BPJS has finally arrived is tempered by his doubts about the healthcare programme's future.

After working as a journalist between 2000 and 2004, his work reporting on an endless succession of corruption scandals leaves him unsure whether or not the government is capable of presiding over the world's largest health insurance scheme.

"All the bureaucracy here is very bad. Unless you're rich, you can't take anything for granted," Andre says. 

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Al Jazeera
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