Health minister Nila Moeloek discusses the future of Indonesia’s universal healthcare scheme

How is it faring in the midpoint of its 5-year plan?

Launched in the first day of 2014, Indonesia’s single national health insurance scheme’s (Jaminan Kesehatan Nasional) goal was to provide access for Indonesian people to quality heatlhcare with minimal financial strains. The five-year plan’s target is total coverage by 2019.

We interviewed Dr Nila Moeloek, Indonesia’s minister of health, to learn more first-hand information on the universal healthcare scheme of Indonesia, its current progress, as well as how the scheme is faring against the many challenges in the country’s healthcare landscape.

HCA: What are some of the major healthcare achievements of the Ministry of Health in Indonesia for the past years? How were these achieved and how does the Ministry plan to sustain this?

Among the recent achievements of the Ministry of Health in Indonesia are 1.) Indonesia was declared as a polio-free country by the World Health Organisation in 2014, and Indonesia was also the first country in the Southeast Asian region that reached TB Global targets last 2006.

HCA: What have been the biggest healthcare challenges for Ministry of Health for the past years? How has it addressed/is it planning to address these challenges?

The challenges for the Indonesia’s ministry of health can be divided into three settings. In the national strategic setting, challenges arise from the high level of disparity of health statuses between the socio-economic level, regions and urban-rural areas, as well as the implementation of the National Social Security System. For the regional strategic setting, roadblocks arise from the ASEAN economic community.

For the global strategic setting, Millennium Development Goals (MDGs) ended 2015 and is replaced with the SDGs starting from 2016. There are many countries that acknowledged the MDGs as the driver for reducing poverty and advancing community development. The acknowledgement comes especially in the form of political support. The Sustainable Development Goals (SDGs) covers 17 goals and 169 targets, considerably larger inscale and wider in outreach to resolve the interlinkages and intrications of development. In health sector, data shows that a healthy individual would like to have a stronger physical and intellectual capabilities, to contribute productively for the communities’ development.

The trade liberalization on goods and services in WTO context - especially in General Agreement on Trade in Service, Trade Related Aspects on Intellectual Property Rights and Genetic Resources, Traditional Knowledge and Folklores (GRTKF) are all global commitment forms that must be carefully responded.

With the global pandemic threats we experience today, Indonesia is actively implementing the Internasional Health Regulations to strengthen its core capacities. In the global fora, currently Indonesia is chair of the troika of Global Health Security Agenda – a platform of open and voluntary collaboration between coutnries which share similar concern on containing the spread of pandemic threat.

HCA: Please tell us about Jaminan Kesehatan Nasional. How is it faring two years after its launch?

Jaminan Kesehatan Nasional (JKN) is a single national health insurance scheme in Indonesia that conducted under the law # 40/2004, National Social Security System and the law #24/2011, Social Security Agency. The goal of JKN is to provide access for Indonesian people to a quality health care without any financial hardship. Through JKN Indonesia moving toward achieving Universal Health Coverage. JKN is implemented under social health insurance principles and the membership is compulsory. The target of total coverage is in 2019.

Up to January 16, the coverage of JKN is 158,669,787 people; it is more than 60% of population already covered by JKN. The structure of memberships comprised of: contributory (formal workers and informal workers) and non-contributory (poor people). The premium of poor people mostly funded by central government and a few funded by local government.On the other hand, contributory people should pay their premium monthly. The premium for informal workers is a nominal rate, meanwhile the premium for formal workers is a percentage of wages and it will be paid by both employers and employees.

JKN is administered by Social Security Agency (BPJS Kesehatan) and providing a broad benefit package that delivered by health facilities from primary healthcare facilities until tertiary healthcare facilities. Up to December 2015, there are 19,657 primary healthcare facilities and 1,815 secondary and tertiary healthcare facilities contracted by BPJS Kesehatan. The healthcare facilities consisted of both public and private facilities. The provider payment system that implemented in JKN are capitation for primary healthcare facilities and DRG payment which known INA CBG for secondary and tertiary healthcare facilities.

Premium pooling is the main source of financing in JKN. The program is utilized by people across the provinces; however, the utilization rate on catastrophic cases, for instance, cancer, hemodialysis, coronary heart disease was high. This adverse selection condition making a lot of spending in BPJS Kesehatan, the claim ratio is more than 100%, and based on the regulation, the deficit problem has been handled by central government.

HCA: What improvements do you foresee for JKN? What is your outlook for the healthcare plan 2-3 years from now?

Implementation of JKN is faced with two aspects which are health financing (premium pooling and provider payment) and health care delivery (supply sides). These two aspects should be improved together. For the financing aspect, the growth of membership should be watched and keeping increase as targeted and premium collection also should be completed as well. The level of premium should be reviewed and updated accurately. On the other hand, health care delivery should be strengthened, supply side should be improved, both quality and quantity and solving maldistribution problem to achieve equity of health access. The supply side comprised of health human resource, health facilities, medical equipment and supplies, drugs, etc.

In 2-3 years from now, the ministry of health is focusing on to strengthening health care delivery and to enhancing promotive and preventive health services. In order to provide better quality of health services, it is important to develop and implement the standard both medical and non-medical services and also the fulfillment of health human resources and medical supplies. And it must be available in all area in Indonesia for solving inequity problem.

In the meantime, concerning of sustainability of JKN, and considering the increasing of medical spending of some non-communicable disease (heart disease, chronic kidney disease, cancer, etcr), so it is urged to improve promotive and preventive programs. The ministry of health would intensify promotive and preventive program in respect to reduce morbidity rate, detecting and finding cases in early stage and to induce people in a healthy life manner.