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JKN should shift focus from curative to preventive programs
The National Health Insurance (JKN) has run for four years and become the backbone of the country’s health sector. While the program, which is managed by the Health Care and Social Security Agency (BPJS Kesehatan), has successfully provided medical treatment to many, it has many drawbacks, including a perpetual deficit.
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Head of the University of Indonesia’s Human Nutrition Research Center Rina Agustina (Rina Agustina/File)
T
em>The National Health Insurance (JKN) has run for four years and become the backbone of the country’s health sector. While the program, which is managed by the Health Care and Social Security Agency (BPJS Kesehatan), has successfully provided medical treatment to many, it has many drawbacks, including a perpetual deficit.
A group of researchers led by the head of the University of Indonesia’s Human Nutrition Research Center, Rina Agustina, conducted a comprehensive study of the implementation of the program that was recently published by Lancet. The Jakarta Post’s Dyaning Pangestika and Adisti Sukma Sawitri recently talked to the lead author. The following are excerpts from the interview.
Question: How did the team come up with the study?
Answer: The paper, which is entitled Universal health coverage in Indonesia: Concept, progress and challenges, aimed to introduce our health coverage system to the world through evidence-based research.
This research is the only one that features scholars from multidisciplinary backgrounds. There are 12 authors from various backgrounds, such as economics, nutrition and public health. Most of the authors and contributors are from Indonesia, which makes this research the first that was dominated by Indonesian scholars. BPJS Kesehatan and Health Ministry officials were also involved as contributors.
What are the key findings of this research?
Indonesia is quite unique because our country is very diverse. We have 262 million inhabitants with 730 ethnic groups and languages, all scattered across 17,744 islands in this country. The problems are varied in each location because of lifestyles and differences in health beliefs.
This situation forced our healthcare system to find a more dynamic solution so it could adapt to all Indonesians’ needs.
We also faced a growing number of noncommunicable diseases (NCDs). The NCDs are estimated to escalate by more than 20 percent in the coming years. Death by diabetes, for example, increased by 63 percent from 2005 to 2016. Strokes also increased as well, making those diseases the largest contributing factors to the total number of deaths in Indonesia. These diseases would create a cost burden to our universal health coverage by 2020 and could possibly impose a burden of US$5.8 billion on the system.
Nutritional problems remain a challenge despite the existence of the JKN. Although the prevalence of stunting has reduced, our research showed that stunting still remained high at 33 to 37 percent over the last decade.
The prevalence of obesity among adults aged 18 years old and older increased to 21 percent from 2007 to 2016. Health care is supposed to address this issue by promoting a healthier lifestyle.
What are the challenges we need to overcome?
First, the system has yet to be successfully implemented because there is a missing middle group, a term that we use to describe people who work in the informal sector but are not covered by the JKN because of low enrolment in the system. This group, which mostly consists of young adults, is not poor. However, they decided to not participate in the scheme because they did not see it as something beneficial.
Only 52 percent of them enrolled for the program. Those who did not participate think it is such a waste of money because they did not get sick often. Some also think that the bureaucratic process takes too long and it made them hesitate to register for the JKN.
Second is our health service readiness. Our government is still focusing on a curative approach instead of prevention. Inadequate medical facilities remain an issue. Although 82 percent of public hospitals passed the test for preparedness in 2017, only 67 percent of community health centers passed the same test.
What is your recommendation to overcome such problems?
We have introduced a road map for the JKN to include by 2025 programs to make people’s lifestyles healthier and reduce the risk of chronic diseases.
From 2015 to 2019, we had to start improving the quantity and quality of health workers, disease control and the access to and quality of health facilities.
Between 2019 to 2025, we start working to implement the Universal Recovering Care, such as by reducing smoking rates, and start investing in sanitation and healthier lifestyles. The next phase is to implement the Universal Cost Care program by creating a policy to provide for healthier lifestyles, as well as affordable nutritious products.
The government recently proposed to cover the JKN deficit using revenues from tobacco excise. What is your take on this?
Personally, I think it is all right to use the money to help cover the JKN since the tax is also used in other countries to fund their health coverage. It would be much better if the government increased the tobacco excise.
However, some people might think that it is all right for them to smoke more since they assume it would help the government. This problem could be overcome by increasing health campaign promotions. Children should be educated to understand the dangers of smoking at an early age.
