Said to be the world’s largest single-payer national health insurance by targeted coverage, the national health insurance (JKN) was launched in 2014 a decade after the government adopted the program under the 2004 law on the National Social Security System (SJSN).

 

The program began with 112 million participants, less than half of roughly 255 million Indonesians at that time, who were registered by integrating the policyholders of separate insurance schemes. The program now provides coverage to 83 percent of the population today.

 

But the current figure still falls short of the government’s 2019 coverage target of 95 percent of the population, or around 257 million people. Experts have also said that the deficit-stricken program has much room for improvement.

 

Still, authorities and experts alike had expected a bumpy road since they started deliberating the program in the early 2000s, when only around 20 percent of the population had health insurance. Many had called the nationwide endeavor “ambitious”.

 

“In early 2014, there were both Indonesians and international partners who were dubious about how the launch of the JKN would go,” former health minister Nafsiah Mboi, who oversaw the launch, writes in “Indonesia: On the Way to Universal Health Care”, a commentary published in May 2015 in the Health Systems & Reform open-source journal.

 

Doubts hung over Indonesia’s efforts to launch the program, particularly because it is the largest archipelago and the fourth-most populous country in the world with a decentralized healthcare system. Integrating the numerous and fragmented health insurance schemes also posed a challenge, Nafsiah notes.

 

The evolution of Indonesia’s universal health care was influenced primarily by Dutch colonial policy that prioritized health insurance for government and military personnel. The health system of the colonial government also focused on diagnosis and treatment, Indonesian experts and authorities noted of the JKN’s development in “Successes and challenges for health in Indonesia”, an editorial published in the Jan. 5, 2019 edition of The Lancet.

Upon claiming independence, the Indonesian government gradually began to expand health insurance coverage to include soldiers and civil servants in 1968 and the formal sector in the mid-1980s. It then expanded coverage for poor and vulnerable groups starting in 2004, following the 1997 Asian financial crisis.

 

“Back then, we established the SJSN Law after a severe recession and financial crisis, so we were determined to reorganize the system,” said Hasbullah Thabrany, who chairs the Center for Health Economics and Policy Studies at the University of Indonesia and was part of the SJSN establishment team in 2002.

 

“I don’t see the same determination now, because it is perceived that there is no longer any danger threatening the people. Political will has declined,” he said.

 

While access to health insurance and services had improved when compared to the pre-JKN era, especially among the poor, Hasbullah said that service quality remained inadequate and out-of-pocket expenditure remained high. He said these failings might make people reluctant to continue participating in the program.

 

The National Health Accounts data shows that the proportion of household out-of-pocket payment to total health expenditure had declined from 54.8 percent in 2010 to 35 percent in 2016. As healthcare costs increased, however, such spending spiked from Rp 115.8 trillion (US$7.9 billion) to Rp 144.7 trillion.

 

Experts fear that the growing prevalence of non-communicable diseases in Indonesia could lead to “catastrophic spending” and put more families at risk of poverty. An estimated 100 million people globally have already been pushed into poverty for this very reason, they say.

 

Hasbullah called on the government to allocate more funding for the health sector. He also urged the government to begin taking a data-driven approach to policy making by involving key stakeholders, like healthcare providers, in improving service quality and ensuring that the program was sustainable.

 

“I see that many people consider the JKN to be a burden to the country and to the state budget. That is very wrong. If anything, we should be seeing it as an investment,” he said.

 

Senior researcher Athia Yumna of the SMERU Research Institute highlighted the urgent need for more partnerships with healthcare providers, including private healthcare providers, to provide equitable healthcare access, pointing out that resources and services were still concentrated in Java.

 

Data from the Health Care and Social Security Agency (BPJS Kesehatan) show that the number of primary healthcare facilities that had joined the JKN, including community health centers (Puskesmas) and private clinics, had increased by just 21.3 percent from 18,437 in 2014 to 23,430 in 2019.

 

Meanwhile, the JKN saw a 31.6 percent increase in the number of partner hospitals and primary clinics last year to 2,459, of which 61 percent were privately operated.

 

Asih Eka Putri, a founding member of the National Social Security Council (DJSN), which oversees BPJS Kesehatan, said that the agency was currently “restructuring”, which she said would attract private healthcare providers to the program.

 

Restructuring the JKN aims to resolve the “chronic structural deficit” that had plagued the program since 2014, by adjusting the benefits to new primary health needs and by developing standard classifications, she said.

 

The program’s persistent deficit has been attributed to premiums that have been set below actuarial assumptions, while claims growth has exceeded premium increases.

 

“There will be some measure of clarity and certainty [for private healthcare providers]. The in-patient class will be standardized and there will be – in the direction that we’re heading now – a single rate. There will also be clear coordination among executing agencies,” said Asih.