Indonesia’s battle to bring healthcare to the masses

When Heni Karmila sought to find a doctor for her ailing mother using Indonesia’s new healthcare system, she faced a nine-hour wait in a line outside a crowded public hospital in Jakarta.
“The queue at the hospital is always very long, packed with young and old people, pregnant women, people who have had accidents, those in need of operations and even tiny babies,” the small business owner, 43, said.
The case illustrates the challenges for Indonesia as it seeks to roll out one of the world’s biggest universal healthcare systems.
The scheme aims to make healthcare accessible to the country’s entire population of 255mn by 2019, part of the government’s efforts to direct some of the benefits of strong economic growth into improved welfare.
Joining is compulsory, with most members paying a small premium.
Civil servants are automatically enrolled, private companies must sign up staff while the self-employed and those working in the informal sector are required to join themselves.
The poorest get care for free under the system, known as the JKN.
A total of 160mn people are so far members of the programme in the world’s fourth most populous nation, and it has been credited with helping many since its 2014 launch.
But it faces numerous challenges, from underfunding, to slow and patchy implementation, to cases like Karmila’s, where the system has become a victim of its own success in densely populated areas, leading to long queues.
Karmila, whose 72-year-old mother suffers from multiple ailments, said she also suspected that one public hospital was turning ordinary people away and instead reserving places for privately-insured patients, who bring bigger profits.
In the remote and poor east of the country, the problems are different - people may theoretically have access to healthcare under the JKN, but often there are not enough hospitals and doctors to provide it.
The most pressing challenge in recent months has been underfunding as patients flocked to use the system, prompting the agency that runs the JKN to warn it could run out of money as its funds may not cover claims from medical providers.
Despite resistance from lawmakers and the public, the government in April increased the premiums paid by some users.
Monthly premiums now range from 80,000 rupiah (around $6) in the top category of the JKN - which provides better services, such as private rooms in hospital as opposed to wards - to 25,000 rupiah (around $2) in the bottom category.
In the past, most Indonesians relied on private insurance of some sort while those deemed living in poverty got free public healthcare - but this left millions stuck in the middle, too poor to afford care but not poor enough to qualify for government assistance.
Under the JKN, all citizens should get access to health services provided by public facilities as well as those from a few private providers who have joined the system, although wealthier Indonesians are still likely to opt for private insurance.
There are currently no punishments for people who fail to sign up, but when the system is fully rolled out, they will face small fines. Irfan Humaidi — a spokesman for the healthcare and social security agency, which runs the scheme — admitted there were teething problems but insisted that overall the JKN was working well.
“There are so many people who have been benefited from the system,” he said.
One such person is Ramot Siagian who recently had a heart attack while visiting his daughter in Jakarta from western Sumatra island.
“We took him straight to hospital and he got treated using the JKN,” said his daughter Lia Siagan. An overhaul of Indonesia’s healthcare system was long overdue, as it lagged behind many others in the region.
Government spending on health in Indonesia is just 3% of GDP, lower than other countries in the region.
It has the equivalent of one physician per 5,000 people, compared to two in Thailand and six in Malaysia, according to the World Bank.
The quality of medical services is also criticised as poor compared to its neighbours, and horror stories abound.
Last year, two patients at a high-end private hospital outside Jakarta died when medics trying to anaesthetise them for routine surgery administered the wrong drugs due to a labelling mix-up.
Despite the challenges, the JKN has won much praise and its supporters are urging patience.
“Indonesia has just begun adopting a national healthcare system, so of course there are problems,” said Hasbullah Thabrany, a health expert from the University of Indonesia.
“But with commitment, it will survive in the long run.”