No health without wealth?
Indira Puspita Prihartono
Jakarta-based physician and practitioner of hospital administration
Do you have the same right to health as everyone else in Indonesia? Do you think you would have equal access to the intensive care unit as someone without a job? In 1996, the World Health Organization stated in its constitution “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.“ But what is the highest attainable standard of health? Is it really the same for everyone?
Since 2014, Indonesia adopted a “universal” healthcare system through a social security administrator for healthcare, known as BPJS Kesehatan, and as of September 2017 it has encompassed approximately 70 percent of the total population.
But access and standards of healthcare is far from the same for everyone.
Recently, reports emerged of a baby who died in a hospital in West Jakarta because the family couldn’t provide the down payment needed for intensive care. The patient had a BPJS card but the hospital was a private hospital unaffiliated with BPJS, reinforcing the limits to the “universal” program.
The patient did receive appropriate emergency medical attention and intervention free of charge, however to be admitted into intensive care, the patient had to provide down payment or be referred to a BPJS affiliated hospital where vacancy in the intensive care unit is most often scarce.
This incident led to warnings from the Health Ministry of the prohibition of down payment requirement for hospital emergency care, regardless of health insurance status. However, national regulations may be difficult for some hospitals to abide. A few weeks later another incident occurred in a hospital in Cirebon, Central Java where another baby died. It was a BPJS-affiliated hospital but the parents who were active BPJS card holders were asked for down payment of Rp 1 million (US$73.88) for the required caesarian. The hospital denied reports that the reason was because they rejected the newborn’s entitlement to BPJS, as the infant was registered a few days before being born while the card would be active 14 days after registration.
Although prohibited, it is very challenging for private hospitals not to demand down payment for their services, given the cost of hospital treatment and procedures that can easily surpass most Indonesians’ annual salary.
Hospitals are complex institutions requiring numerous resources to function, which would not be possible without adequate funds. Continuous advancements of drugs and treatments along with the high value of the medical profession and skill account for the high-priced services.
BPJS has been criticized for not making things “financially easy” for hospitals to cater to patients entitled to the universal scheme. Healthcare providers consider BPJS’s prospective payment system which are based on hospital unit cost data are underestimated and insufficient. Through this system, healthcare providers must consider cost efficiency along with quality care in order to survive.
BPJS itself has had trouble collecting sufficient funds, being in outstanding deficit of Rp 5.8 trillion in the first semester of 2017. BPJS had gone through multiple revisions of its premium policy, now ranging from Rp 25,500 to Rp.80,500 monthly for each participant. Yet it’s easy for independent participants to disobey paying the premium.
Unfriendly payment systems for healthcare providers have made it especially more difficult for pricy private hospitals to cooperate. Since its implementation, BPJS has made efforts to collaborate with private hospitals, aiming to include all hospitals in the system by 2019; but as of now only 92 hospitals or roughly half of the hospitals in the nation’s capital are affiliated with BPJS.
Meanwhile patients’ complaints continue on BPJS’s limited hospital access and taxing tiered referral policy which dictates that patients must seek care from a primary healthcare center before being referred to class D, C, B, and A hospitals in respective order.
By regulation, hospitals unaffiliated with BPJS must provide emergency care to holders of the BPJS card, but the care afterwards in unaffiliated hospitals would not be covered. If the family or patient feels they couldn’t afford expensive hospital bills, the patient would then be referred to BPJS affiliated hospitals, susceptible to delayed care.
BPJS has gone through many challenges since its implementation, reaping praise and criticism. But clearly the “highest attainable standard of health” is not the same for every individual even in a “universal” healthcare setting. Some say you cannot put a price tag on health. As Mahatma Gandhi once said “it is health that is real wealth and not pieces of gold and silver.”
In this real world, one would still need gold and silver to pursue health. Still, in its pursuit one may also fail. Indeed health is no more of a right than it is a privilege. Having money in the bank allows one to enjoy services unobtainable by those who can only rely on national healthcare. Maybe it is not that the BPJS does not provide for equal services, but that the national healthcare program is responsible for more lives than the current situation can accommodate.
There is hope for a true universal healthcare system in Indonesia, one that would satisfyingly accommodate healthcare providers, insurance institution, as well as its participants, the people. It would need the effort, cooperation, and support of the nation, but it is possible.
As the highest attainable standard of health is the fundamental rights of every human being, as the WHO states, let’s not allow wealth determine the health of the people.
The writer is a Jakarta-based physician and practitioner of hospital administration. She is currently undertaking graduate study at the Faculty of Public Health, University of Indonesia.
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