Athia Yumna, research and outreach deputy director at the SMERU Research Institute, emphasized during an online discussion July 29 that sustainable financing was the key determinant to solving the national health insurer's long-standing deficit.

She recommended, for example, that the government impose a sin tax on cigarettes, shift the JKN subsidy from full to partial coverage, and boost public-private partnerships to expand fiscal space.

In addition, she said that having centralized procurement and supply management through greater use of electronic inventory systems and implementing the Health Technology Assessments — a health technology evaluation tool to inform policy making — would help make the JKN more efficient.

“[These are needed] so the JKN doesn’t end after just six or ten years, and it can continue to live on to our grandchildren’s generation,” she said during the discussion.

The national insurance scheme has been operating at a loss since it was launched in 2014, with officials forecasting a deepening trend from the Rp 13 trillion (US$ 893.53 million) deficit incurred last year.

The health crisis has only exacerbated the funding crisis, cutting the revenue of the Health Care and Social Security Agency (BPJS Kesehatan) that administers the JKN scheme.

Kalsum Komaryani, who heads the Health Ministry's health insurance and financing center, said at the discussion that the decline in revenue resulted from mass layoffs of salaried employees (PPU) and a decrease in contribution payments from non-salaried employees (PBPU).

She claimed, however, that BPJS Kesehatan was no longer in a deficit as of July as a result of a decline in spending due to fewer people visiting health facilities. Kalsum suggested that this was because people were afraid of contracting COVID-19 at health facilities.

COVID-19 patients are excluded from the insurer’s benefits and coverage plans.

“But 2020 cannot be used as our [benchmark]," Kalsum stressed. "It is possible that if COVID-19 subsides next year, [JKN claims] could increase or even rebound as the people who stayed away returned to health facilities, which in turn would [increase] spending. The BPJS would then be at risk of a deficit.”

Preventing the national health scheme from falling into financial ruin is critical to guarantee the provision of universal coverage for hundreds of millions of people in Indonesia. The JKN provided coverage to around 224 million Indonesians in 2019, or 82 percent of the 270 million-strong population at the time, according to current BPJS Kesehatan data.

BPJS Kesehatan research and development deputy Benyamin Saut reaffirmed some of Kalsum’s statements, including that the agency’s current revenue was “thin”.

Unlike the ministry official, however, he made no mention of a looming deficit, but warned of a possible JKN claims inflation in 2021 on the potential availability of a COVID-19 vaccine and post-pandemic impacts on health rates and statistics, for example the impacts of child immunization and contraception programs – or lack thereof – on the birth rate.

“We are now preparing a number of innovative solutions to anticipate a rebound [in claims], especially in the use of digital tools, restructuring the health insurance benefits and setting service classes for inpatient care,” he said.

The government has been taking measures to help the insurer prevent further losses when it raised the JKN premiums for a second time in a May presidential decree that took effect in July. The move caused a backlash among critics, who accused the government of subverting the law in connection with a previous attempt to hike the healthcare premiums, which was overturned by the Supreme Court.

Read also: Government accused of undermining rule of law in JKN premium hike

But Didik Kusnaini, the Finance Ministry's director of harmonizing budget regulations, noted in his presentation of the ministry’s projections that the social security fund for health care (DJS Kesehatan) – just one of several financing sources for the JKN – would suffer deeper deficits in the next two years if  the premium was not raised.

Didik also suggested using earmarked taxes, such as income tax or consumption tax for products like tobacco or alcohol, to help finance the national healthcare scheme. A 2018 presidential regulation currently allows the use of tobacco excise to finance the JKN.

Meanwhile, Health Ministry secretary-general Oscar Primadi told the discussion that the government would soon make “fundamental improvements” to the JKN by reviewing the insurance benefits according to primary health needs and by reworking the categories of inpatient coverage.

Read also: Government works to redefine primary health needs, JKN services

Oscar said the ministry was also promoting healthy lifestyles and behaviors through the People’s Healthy Lifestyle Movement (Germas) public campaign.

“With steps like these, we certainly hope to significantly reduce the burden of the catastrophic financing of the JKN program,” he said.

Promoting a healthy lifestyle among the public is part of a wider effort to unburden the national health scheme, as Indonesia has a high prevalence of non-communicable diseases. Heart disease, cancer and stroke were three of the most costly catastrophic diseases last year, according to BPJS Kesehatan's 2019 financial statement.

Public health expert Hasbullah Thabrany from the University of Indonesia suggested that incentives be given to regions that were better able to change lifestyle behaviors that contributed to increased incidences of non-communicable diseases, such as smoking.

“There needs to be a shift in the people's behavior. We need to make people aware that illness [leads to] long-term economic loss and that renders them unproductive,” he said during the discussion.

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