Footing the Bill

Providing affordable healthcare for a country’s neediest citizens is a thorny issue. Bhimanto Suwastoyo looks at the government’s attempts to work out glitches in health insurance for the poor.

In January, the Indonesian government launched a new scheme to provide free health services for the country's poor, estimated at some 76.4 million. The government replaced a less than three-year-old program managed by state health insurance company PT ASKES, saying the new program was an improved version that addressed the weaknesses of the old one.

However, many question whether this new program is the right vehicle to provide free health services to the poor, or if it will merely be a costly exercise in bad planning that will break down after a few years.

"Based on the considerations of controlling the costs of health services, improving quality, transparency and accountability, a change has been made in the management of the Health Insurance for the Poor program in 2008," Health Minister Siti Fadilah Supari said when launching the new public health insurance program, known by its Indonesian acronym Jamkesmas.

Supari said the major change was that it no longer used the services of PT ASKES and that the money for the program was now channeled directly from the state treasury to the bank accounts of 842 participating hospitals.

Under the old scheme, the government paid health insurance premiums for the poor to PT ASKES, allotting Rp 5,000 for each of the estimated 76.4 million low-income citizens who qualified.

The old program, the minister said when promoting the scheme in March, "was prone to and had the potential for corruption or irregularities".

Sarmedi Purba, who heads the Forum for Second Opinion Doctors, said the change was not merely cosmetic because it was no longer a health insurance scheme, where the state paid premiums for a set number of participants and ASKES paid for the medical service claims.

"The case now is that the government provides a certain sum of money for the hospitals to provide the services. It is no longer an insurance scheme but direct social assistance," Purba said.

Even back in 2005, Purba said, he foresaw that the Rp 5,000 insurance premium was not sufficient for comprehensive free medical coverage. Three years later, the figure not only remained unchanged, but had become the total cost allotted for one person per year.

Both Purba and former ASKES head Sulastomo said that with the Jamkesmas system, the country would never be able to provide comprehensive free health services for the poor and the program would always be chronically short of funds. .

Lily Sulistyowati, spokesperson for the Health Ministry, acknowledged that in 2007 the health service allotment under the old program was exceeded by Rp 1.7 billion, but promised that if an ongoing audit finds the costs warranted, the government will reimburse hospitals.

"Jamkesmas should return to an insurance scheme managed through an insurance system using the prudential principle .... Insurance companies have both the hard and software to insure health services, the government does not," Purba said.

For Sulastomo, unless the country launches an integrated health insurance program, also inclusive of higher income groups who can afford medical services, the program will fail.

"Only cross-financing between the rich and the poor can work. The state does not have the funds necessary to provide free health services to the poor," he said.

Another key problem is the qualifications, capabilities and integrity of the 2,664 "independent" officials to be recruited by the government to verify the administrative, financial and medical aspects of the Jamkesmas program across the archipelago.

"The commission is worried about the transition period, including the recruitment and forming of verification teams, the payment mechanism. Can the government really prepare those things in a such a short time, while the number of people needing health services is growing and the need is so urgent," said Taufan Tampubolon, a member of the legislative commission on health affairs.

The commission has also called for a review of the Jamkesmas program, saying the scheme violates a 2004 law on public health coverage because health insurance services for the poor should be managed by an independent entity, not the government.

Sulastomo said that Jamkesmas also had no real system of checks and balances because the verifications were done by the government and reported to the government.

"Organization-wise, it is already confusing .. anything that is not common sense and does not follow the principle of social health insurance will not be able to survive long.”

He also said that if the government wanted to go ahead with the scheme, it was imperative that the independence of the verification teams be assured. In the field, the transition to the new program does not appear to have affected the poor seeking free medical services.

"I have been an outpatient here for about two months now and I have not have had to pay anything for the health services. And I have had X-rays, went to see a gynecologist, had a heart examination, etc," said Sarti, 30, from Peserangan village in Cilegon, some 60 kilometers west of Jakarta.

As she squatted on the side of a covered path at Cipto Mangunkusumo General Hospital in Jakarta, Sarti said the only money she had to pay so far was for accommodation at a hostel run by the hospital – Rp 15,000 per day -- her meals and the trips home that she sometimes makes.

She has a yet unidentified womb problem that has bothered her since a miscarriage last year. "I often lose consciousness and suffer from grueling pain in the groin," she said.

Cunro, a slightly younger woman from Binuang village in Serang, not far from Cilegon, has also been an outpatient at Cipto Mangunkusumo for about two months, trying to find a cure for the painful and uncontrolled urinating that she has suffered since giving birth.

She takes a train to Jakarta every three days for treatment and sometimes stays at the hospital-run hostel.

"The hardest thing is the waiting. I am lucky that it was my husband who arranged for all the necessary letters and documents," Cunro said.

For outpatients, six documents are required, including a membership card for the old ASKES program, a reference letter from a local state health polyclinic, another from a provincial general hospital and a recommendation from a local social affairs and health office.

For hospitalization more documents are required, including a recommendation letter from a doctor at a local polyclinic.

Eka Yoshida, who heads health services for the poor at Cipto Mangunkusumo, said the hospital was obliged to provide health services for the poor.

She said the hospital still did not have a definite list of Jamkesmas participants from ASKES to work with. The list is prepared by provincial governments based on recommendations from district chiefs. ASKES verifies and compiles the final list and issues a Jamkesmas card to those on the list.

"And even after we receive the list, what will happen to those poor who are not on the list?" Yoshida said, adding that the public "was not yet educated enough about the prevailing health reference system".

Many poor people from the regions come directly to the hospital without any reference or recommendation from their local polyclinic or provincial general hospital.

"They do not have the proper documents, but they are already here and often in need of direct medical attention. We cannot refuse them," Yoshida said.

"We have to be flexible and therefore we also ask the authorities to be flexible with us, when we submit our invoices. At the current time, we cannot strictly adhere to the rules.”

Another problem faced by hospitals, Yoshida said, is dealing with bogus patients claiming free services.

"Not every patient claiming to be poor is honest. We have cases where patients come with highlighted hair, or with gold rings and bracelets, carrying an expensive cell phone, but they claim to be poor and want free medical services. If they have the proper documents, what can we do?"

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