Indonesia World Largest Universal Health Scheme

When Dr Selvy Anggeraini took over as the head of one of Jakarta’s busier government health clinics, she had a budget of 1 billion rupiah (US$72,500) to treat the 350 or so patients that came daily to seek care from one of her 14 doctors. Four years later, after the introduction of a generous universal health insurance program, her caseload has doubled, even though her budget has barely moved.

“The care is mostly free so now more people come,” says Anggeraini, whose district – home to 350,000 – spans some of the wealthier suburbs in the south to the working class districts in the north. And while Anggeraini is adamant the clinic cuts no corners to make ends meet, she allows that the clinic is stretched thin. “We have to make the same budget go further. It’s not enough.” 

Indonesia is one year away from completing a five-year roll out of what is already the world’s biggest universal health insurance program – one that makes Obamacare look practically third world in its ambitions. So far 185 million – about three quarters of the population – have signed up, availing themselves of generous benefits that until recently were unthinkable for most here.

Now Indonesians have access to services that are generous even by rich world standards: Free dental care, medicine, physiotherapy, as well as the full menu of emergency and chronic care up to and including organ transplants.

It’s a far cry from what was available before the insurance. The poor then either stayed sick or went into debt to pay for treatment, Anggeraini says. Most of her patients then would refuse referrals to specialists because they couldn’t pay.

“It was heart breaking,” Anggeraini recalls. “We didn’t feel like we were making people better.”

Trouble is, the government is having a hard time paying for its new benefit. Analysts say the government doesn’t cover nearly enough of what it costs to treat the poor, while the wealthy are not paying their fair share. Deficits are soaring, hospitals are having trouble getting paid and waiting times are lengthening. Unless the government raises premiums, or its subsidies or both the health care program risks imploding.

“This insurance program is unsustainable,” says Dr Ascobat Gani, a health economist at the University of Indonesia, who until last year was the scheme’s cost control manager. “We already have large enrollment but you have to secure the availability of services.”

Gani says hospital waits of a day or more for non life-threatening emergency cases are not uncommon. Patients complain of needing to make multiple visits over a period of days to see specialists.

Given rock-bottom premiums, there is little chance those bottlenecks will ease soon. The government covers the 25,000 rupiah (US$2) a month charged to the 100 million or so considered poor. Salaried workers and civil servants pay 5 per cent of their salary up to a maximum of 8 million rupiah. Few pay that amount though, says Dr Hasbullah Thabrany, chairman of health economics and policy studies at the University of Indonesia, who helped draft the 2005 law that forms the basis of the universal benefit.

The subsidy paid for the poor ought to be hiked by at least a third. Meanwhile salaried workers often don’t declare their full pay to cushion their levies or contribute only sporadically. Thabrany reckons contributions from salaried workers average little more than 68,000 rupiah per person per month.

With President Joko Widodo facing elections next year, and regional votes slated for June, there is little incentive for policymakers to hike premiums or catch fraudsters. “The problem is politics,” Thabrany says. “Cheap health care is popular.”

Just how much the Indonesian government pays into the program isn’t immediately clear. The insurance provider Badan Penyelenggara Janinan Sosial – or BPJS as it’s better known, doesn’t detail the full extent of government support.

According to its annual statements, income from premiums, payments made by customers to BPJS, and what it pays out in claims was roughly balanced at 67 trillion rupiah in 2016, the most recent year for which data is available.

But even though a big chunk of the insurance body’s income is in the form of that government subsidy for the poor – about two-fifths by Gani’s measure – the scheme is still in deficit. Last year the shortfall was 6.8 trillion rupiah. This year Gani reckons it will be 9 trillion rupiah – an amount by law the government must cover.

To be sure, an injection of funds into health spending was needed as Indonesia had lagged its peers. In the decade before the insurance was introduced a little over 60 per cent of the population had access to family planning, more than 40 per cent smoked, and nearly a fifth of women gave birth without a doctor or a midwife. There are 0.5 doctors per 1,000 people and most of those are in cities on Java. In Malaysia there are just over 1.5.

In remote areas the program has done little to improve a wretched situation. In February, more than 70 people died in Papua from measles and malnutrition.

Laksono Trisnatoro, a professor of health policy and administration at Gadja Mada University in Yogyakarta, says universal health care benefits wealthy urbanites more than their rural countrymen. Doctors gravitate to cities, and without doctors providers can’t file claims.

“Universal health insurance is a good idea but it’s the big cities that benefit,” says Trisnatoro. “How can you bill if you don’t have doctors or hospitals in the first place?”

But for one woman at Anggeraini’s health clinic those worries are a world away. Warsini, 42, has come to treat the fever of her five-year-old grandson. Other than a small registration fee that costs the equivalent of a small bottle of water, her visit will be free. And while she has waited for an hour, it is worth it. “I’m very happy to be able to see a doctor now. It’s a big relief knowing that if something happens we don’t have to pay.