Wednesday, November 2, 2016

Indonesia - Health care and well-being in 71-year Indonesia

Healthcare card: Health insurance firm PT Askes’ director Sri Endang Tidarwati shows a health insurance card in Jakarta, in this file photo. The BPJS Kesehatan (Healthcare and Social Security Agency) scheme became effective on Jan. 1, 2014 (JP/-)

“Give me 10 young people and I will shake the world” is among founding president Sukarno’s famous quotes.

As we celebrate this nation’s 71st year of independence, we should reflect on multifaceted challenges of human development, from health and well-being perspectives.

Today, we can measure how the world views human development by looking at the Sustainable Development Goals (SDGs). Compared to its predecessor, the Millennium Development Goals (MDGs), the SDGs leap not only in sophistication in crafting the interlinkages between goals but also within each goal.

Take health as an example: its reach is not limited to the health goal itself but also to at least four other goals: poverty, food, gender and water and sanitation.

At the national level, challenges revolving around human development are more complex than ever. Indonesia is the fourth-most populated country in the world, with roughly 254 million people and more than 17,000 islands.

It is clear that distribution of goods and services is almost impossible to be done equally.

Even after 71 years of independence, challenges in provision of health care remain mostly unchanged. Lack of transportation, infrastructure, energy and isolation are the most common barriers to health sector development and services in villages, especially those on the borders — at Indonesia’s gateways.

In densely populated cities and semi-urban dwellings, perhaps there is more access. However, quality and affordability presents quite a substantial issue. Solving the challenges requires the government to set its sight not only within the health sector, but innovatively, also in sectors beyond health.

Compared to other developing countries, Indonesia has not fully met the standards of people’s well-being. About a quarter of the population is still left behind, compared to the 19 percent across Asia, a global report found. This is mostly caused by the widening inequality throughout the country.

Goods and services are not equally distributed between urban and rural areas due to poor transportation, insufficient infrastructure and information illiteracy.

As the first responders to community health and well-being, primary healthcare bears an enormous responsibility for solving health issues in parallel with maintaining and increasing health status of the community. In the new era, universal health coverage under the national health insurance (JKN) program has to be readily available for all, regardless of geography.

Be it in the mountains of Papua or in the big cities like Jakarta, Surabaya and Medan; primary healthcare is called to transform itself into an affordable, high-quality service.

For this transformation to happen, it calls for commitment from the government to side with the people and at the same time, to build public awareness on maintaining healthy lifestyles.

Against this backdrop of challenges and complexities, in May 2015 the Health Ministry launched the Nusantara Sehat (Healthy Archipelago) campaign, which deploys teams of health workers to peripheral areas in Indonesia that desperately need a nudge to transform not only their primary healthcare services but also their overall well-being.

Entering its fourth batch and making way to its 250th team by end of 2016, Nusantara Sehat has proven there is still hope in improving the country’s well-being through quality primary healthcare services.

Since the program was launched, 855 youth; early-career health professionals are on site, ensuring well-being is shared equally between roughly 2.5 million people.

These young people are not just health professionals but they are agents of change. Through its actions and innovations, Nusantara Sehat has showcased how health sector development can be an effective entry point to implementing sustainable development principles at the local level.

Despite the challenges, in hard to reach places such as the borders of Long Pahangai in West Kalimantan, Boven Digoel in Papua and Belu in East Nusa Tenggara, its innovations in community empowerment programs have helped reduce open defecation and child malnutrition, and helped build reproductive health awareness among teenagers.

Its presence in each of the communities embodies the optimistic spirit of independence and the visionary objective of the SDGs.

Such initiative shows that the youth are in a strategic position to push for transformation, beyond claiming demographic dividend. The key is empowering them to start taking action, engaging themselves in various fronts of development: health, education, energy, economy and others.

This way, the transformation is beyond sectoral: it is about transforming citizenship — from passive recipients of government services to concerned and engaged citizens.

Indeed, Indonesian youth are moving to realize Sukarno’s vision.

Rayssa A. Putri, a student at Global Jaya School, Bintaro, South Tangerang, Banten, is a student volunteer with Nusantara Sehat campaign. Diah S. Saminarsih is special adviser to the health minister on partnerships and Sustainable Development Goals(SDGs), and founder of the Center of Indonesia Strategic Development Initiatives (CISDI).

Commentary- Foreign boost might get Indonesian healthcare airborne

The condition of the country’s healthcare system couldn’t be more ironic. While it is dubbed as one of the potentially biggest markets in the world, Indonesia seems incapable of giving patients more than the most basic of care.

Barely having recovered from a nationwide fake vaccine scandal that affected more than a million children, a recent study by the University of Indonesia (UI) has uncovered potential fraud in the National Health Insurance (JKN) scheme’s hospital claims costing as much as Rp 7 trillion (US$526.7 million).
These incidents further call into question the government’s capacity to manage the healthcare scheme, which already covers 170 million individuals, one of the largest in the world. Hospitals and health facilities, which are still far from adequate in quantity, are still weak at delivery points and with little scrutiny from the government.

Although the meager care is a logical consequence of the scant system, it is hardly tolerable. The government should prioritize the expansion of healthcare provision as more people register for national insurance. The persistent lack of health infrastructure facilities, as a result of the domestic failure to keep up with growing demand for care, should no longer be accepted as an excuse.

The ideal is to have the government build the health infrastructure by establishing health centers in remote areas that are less attractive for the private sector. But as the government is grappling with financing its more than $400 billion worth of infrastructure projects, it may consider opening up the domestic healthcare sector to foreign investors and providers to accelerate expansion.

Indonesia has been seen as a promising market exactly because of the largely underdeveloped health system. It is among the 15 fastest growing markets globally, according to Oxford Business Group, which estimated that the country’s healthcare sector will be worth $50 billion by 2020.

In the earlier years of the JKN, rolled out by the Health and Social Security Agency (BPJS Kesehatan), it has already driven sales of medical devices, such as MRI machines, PET-CT scanners, most of which are imported. The market is still lucrative despite complicated import mechanisms.

The presence of foreign operators may increase the availability of services and spur competition in the sector. The problem of opening the domestic healthcare market to foreign investors, however, is more than just cutting red tape and rolling out the red carpet to investors.

The government should also improve monitoring of healthcare providers, especially hospitals and other medical centers in which malpractice frequently occurs and in which the fake vaccines were found.

Without a strong regulatory framework and effective monitoring system, the opening of the domestic healthcare market will only lead to further abuse of patients.

The UI study found that among the irregular claims from hospitals were an abnormally high number of babies delivered via C-section under the JKN, about 54 percent of 1.5 million babies delivered from January 2014 to July 2015. The unusually high prevalence of this procedure, which normally should be less than 10 percent of total child births, increased substantially the sums that had to be paid out by BPJS Kesehatan.

Even if more foreign providers are present, a lack of monitoring of the quality of drugs and treatments will prevent improvement in the quality of service, while costs will rise as a result of imported drugs and treatments. And how much will people have to pay for the government’s basic insurance if costs spiral out of control?

The government should encourage investors and providers that can accept the modest market that characterizes the country. These investors should have an interest in producing generic drugs and have the capability to expand services for lower- and middle-income patients under the JKN.

More also should be done to improve the JKN’s tariff system. With evidence of mismanagement, the BPJS Kesehatan should not rely on a reimbursement system to hospitals to support the health scheme. The agency should instead limit drugs and types of treatments that can be provided by hospitals and health centers under the insurance scheme. It can also start to directly procure drugs from pharmaceutical companies, rather than only accepting bills from hospitals.

Bargaining directly with pharmaceutical companies and other providers is a common practice in more advanced national insurance schemes in other countries.

In France, doctors and other health professionals in private practice are paid directly by patients. Health centers are still reimbursed by fees and charges set nationwide, while state hospitals receive annual operating budgets. In the UK, the National Health Service (NHS) directly carries out its own drug procurement.

These two pioneers in national health insurance schemes are not without criticism. Both are currently experiencing deficits amid an economic slowdown and ageing populations in the region.

The biggest disappointment is finding that the JKN is failing before it even gets around to extending healthcare to all of the country’s population. It is like firing up the gas in the burner but the hot air balloon still never being able to get off the ground.

Adisti Sukma Sawitri

You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

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