The challenges to Indonesia’s ambitious national health insurance plan
In January 2014, Indonesia’s President ‘Jokowi’ announced a new compulsory national health insurance scheme that aims to make basic healthcare available to everyone by 2019.
Jokowi had campaigned on this policy, claiming he would pay for it by abolishing the fuel subsidies that accounted for a third of Indonesia’s GDP spending. A year after coming into office, he did just that. In its first year, 133 million people were signed up, an achievement met by the international media with relatively little comment, which is odd when one considers the scale of the undertaking: a developing country (GDP per capita just US$3,800) committing to the provision of free healthcare for all of its 250 million citizens, living across an archipelago comprised of 1,000 permanently settled islands, spanning upwards of 5,000km. In a country where the prevalence of poverty means that health issues can ruin families and livelihoods, where stories of selling houses and farms to pay for treatment for serious ailments are not rare, the potential impact on society is huge.
The most obvious effect will be found in the provinces, the Tier 2 and 3 towns and rural areas that surround them, simply because half of Indonesia’s population are still living below the poverty line where healthcare services are limited. But these areas are also the hardest to implement services – expect corruption, and a struggle to meet the demand.
Compared to their Southeast Asian counterparts, Indonesia’s healthcare services are still by the lack of hospital beds, physicians, nurses, and midwives available per 1,000 people. Healthcare coverage became an answer for the 250 million people who were uninsured.
How traditional beliefs impact health services
Indonesian traditions and cultural habits can be an impediment to the uptake of modern health services. The religious concept of pasrah (to surrender), for instance, discourages people from seeking medical attention and to instead leave their health in god’s hands. In Flores, going to a shaman is not uncommon. Alternative medicine and black magic treatments are often still preferred. Only when illnesses are life threatening would they consider going to see a doctor, and even then, the nuclear family must come to a consensus that treatment is the right option. Unlike the city, in rural areas death is celebrated more than life. Death ceremonies are enlivened with offerings of animals and rituals of keeping corpses in the house a few days before a proper burial is made. Age Sudarmarji, a former resident dentist in Flores faces these frustrations: “While the healthcare coverage gives people the benefit of taking care of their health at an affordable cost, trust towards modern medical approaches is still a major issue.”
Moreover, a lack of access to quality healthcare, social services, and lower levels of education in rural areas determine the mortality of women and children. According to a 2012 Unicef Report on Maternal and Child Health, “Under-five mortality rates are over 90 per thousand in three eastern provinces.” When going to a shaman fails to deliver results, the availability of better health services can push families on the poverty line to reconsider their options.
Implementation is difficult in rural areas, predominantly in eastern provinces, where there are fewer facilities and doctors. In Nusa Tenggara Timur, for instance, for every five clinics, there is often only one doctor available. Here a nurse – whose job is normally to assist a doctor – may have to run an entire clinic alone. A shortage due to extremely low wages (dentists get paid 500 Rupiah (about four American cents) per patient, whereas doctors earn 2500 Rupiah) earned. The distance to clinics, long commutes, and the lack of available beds are still alarming in Indonesia. Indonesia has one of the lowest bed-to-population ratios worldwide – just 0.8 per 1,000 citizens in 2012.
A legacy of distrust towards government
In the city, the challenges are different including a legacy of distrust of the government and a relatively high prevalence of existing healthcare coverage.
Though skepticism of government initiatives runs throughout the country, city dwellers have more choice owing to the higher prevalence of private companies. Indeed, many are avoiding the long awaited and promising BPJS (Badan Penyelenggara Jaminan Kesehatan/ Healthcare Agency) program due to fears of not getting the medical treatment they need or the quality of care they could get elsewhere. In the city, where time is a luxury and private health insurance companies are plenty, the public often opts for more expensive but speedy private services not only because they are deemed more reliable, but also because they aren’t keen on going through BPJS Kesehatan’s supposedly lengthy administrative process – a process that could easily be affected by corruption. Coupled with the lack of positive media coverage on the success of the program, the mandatory health insurance program hasn’t gained the widespread public recognition it deserves.
Implications of the increased healthcare coverage
Improved access to healthcare may benefit not only citizens but also the health and pharma industries, with payoffs including an anticipated increase in generic drug production capacity. It is suggested by the Indonesian Data Business Center, the healthcare plan will bring with it an economic contribution of 18.6 trillion Rupiah. (Approximately 1.4 billion USD)
The present healthcare plan provides a once in a generation chance to explore people’s relationship with health. It could boost the economy and people’s health outcomes, but only if it is designed in a way that helps overcome the distrust of government in cities and resolves conflicts with traditional beliefs.
Health through the Culture Lens is a weekly series exploring important cultural currents in health and pharma
- Article by Max Roche and Athina Ibrahim