Indonesia’s health scheme dwarfs Obamacare. But there is a problem

  • When Dr Selvy Anggeraini took over as the head of one of Jakarta’s busier government health clinics, she had a budget of IDR1bn 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 programme, 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 programme – 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.
  • 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 programme risks imploding.
  • “This insurance programme is unsustainable,” says Dr Ascobat Gani, a health economist at the University of Indonesia, who until 2017 was the scheme’s cost control manager. “We already have large enrolment 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.
  • Just how much the Indonesian government pays into the programme 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.
  • 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. In 2017, the shortfall was IDR6.8tr. In 2018, Gani reckons it will be IDR9tr– an amount by law the government must cover.

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