Another health reform: What do we really need?
Christian Suharlim and Novita Gemalasari Liman
The Jakarta Post
Early this month, Indonesia's new President Joko 'Jokowi' Widodo launched a new health services card, Indonesia Health Card (KIS). Officials have asserted the KIS is better than the national health insurance (JKN) launched in January. Is it?
Government leaders stated that the KIS provides more coverage compared with the current JKN, such as free contraception, Human Immunodeficiency Virus (HIV) tests and coverage for newborn babies and traffic accident victims.
Some emphasized that the KIS provides not only curative treatment, but also disease prevention, especially through education. Contrary to what the public believes, these services are not new.
Prior to the KIS, children received routine immunizations from community health centers and schools, people received free contraception and HIV tests from government programs and communities received health education from an abundance of anti-smoking and reproductive health campaigns.
Furthermore, the JKN system included newborn babies of PBI beneficiaries (payment assistance) and had been covering traffic-accident health expenses jointly with state-owned insurance firm Jasa Raharja.
The new Health Minister Nila Moeloek mentioned that KIS beneficiaries include people with social welfare problems (PMKS), such as the elderly, drug abusers, sex workers, orphans and people with disabilities. This is justifiably the only new addition to the existing JKN system.
The KIS is basically the JKN: old song, new tape. There is no dualism of service and any claimed improvements have been around for quite some time.
Some people might argue that the KIS is only a political ploy to build Jokowi's public image and political capital. However, by rebranding our health programs, we could hope for better execution of them.
By putting the 'Jokowi' label onto the health system, he automatically takes charge and responsibility of the multiple wrinkles of implementation, thus increasing the JKN/KIS's value and accountability.
Furthermore, communities feel entitled to receiving the KIS as a fulfillment of past political campaign promises, which will make them feel invested in the program, thus improving the feedback mechanism.
Despite possible benefits of renaming the JKN the KIS, Jokowi overlooked the improvements we really need: a working financing system and a solid physical infrastructure.
For the past 11 months of implementation, inadequate financing and payment rates has caused hospitals to drop out of the JKN. Out of 1,500 private hospitals in Indonesia, less than 40 percent are still part of the JKN.
Furthermore, 900 public hospitals operating under the JKN have a generally lower quality of care compared to their privately managed counterparts. Without improvements in the financing system, the JKN ' now the KIS ' will have neither improvements in accessibility nor quality of care.
With the current financing system, we are executing a failing health system producing a clear discrepancy in health equity.
Jokowi's KIS will provide substandard care and second-rate treatment, while people need to pay out of pocket for appropriate care in the private sector.
The current premium of Rp 19,500 (US$1.60) for the poor is deemed inadequate. Hasbullah Thabrany of the University of Indonesia has calculated the appropriate price of the JKN premium: Rp 50,000 per month, covering medical and surgical expenses.
By having a good financial flow, we would improve the private hospital participation rate and create a healthy competitive environment between public and private hospitals ' ensuring good quality care.
Furthermore, we would stimulate the creation of new hospitals to improve access to underserved areas ' improving physical health infrastructure.
Although Jokowi's incremental improvement of the Indonesian health system might not justify the rebranding, not all is lost. With the new accountability system in place, this is the best time for Jokowi to include health financing professionals in developing and navigating the complexity of the KIS, of what we hope would eventually become the world's largest single-payer health-care system.
Christian Suharlim is a post-doctoral researcher at the Harvard Center for Health Decision Science and a former employee at the Health Ministry. Novita Gemalasari Liman is a physician in Barru, South Sulawesi and a research associate at the Suharlim Foundation.
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