Essential health services for all in pandemic: A mission impossible?
The COVID-19 pandemic has overburdened the healthcare system in Indonesia and many other countries. The national COVID-19 task force has warned that unless there is greater awareness about and adherence to health protocols, the health system will collapse.
Thousands have lost their lives. In these challenging times, it is critical that even as we take steps to end this pandemic, we also continue our efforts to deliver essential health services to every individual without discrimination, i.e. ensure universal health coverage (UHC). Not only will this prepare our systems for future emergencies but also guarantee that people will not suffer due to health costs.
Indonesia has been on the pathway to quality health services for all since it introduced social security reform through two policies - the national social security system in 2004 and the Health Care and Social Security Agency (BPJS) in 2011. Next came the implementation of the national health insurance (JKN) program in 2014, which was the most significant step for us toward ensuring UHC.
The JKN program aims to provide comprehensive health care for the entire population through government support and improved access to quality services. During the first six years of its implementation, the government prepared several strategies to strengthen the program’s sustainability, primarily by improving the BPJS’ management. Since then, the scheme has gradually increased its membership, reaching 220 million people or 84 percent of the population in 2019.
Prior to the JKN, Indonesia’s healthcare systems featured fragmented programs and private insurance schemes for those who could afford them, along with basic state provisions for the poorest and non-profit organizations that supported the rest. It is the JKN that sought to support people who cannot afford insurance but are not eligible for government support either. It has succeeded, in its short years, in increasing healthcare utilization and reducing catastrophic expenditure.
Indonesia’s path toward UHC has not been free of barriers. Indonesia remains riddled with inherent challenges, which have made it difficult to implement a singular insurance plan. Our unique geography makes it challenging for populations in remote areas to access quality healthcare facilities, which has led to inequities.
The JKN has also incurred severe deficits due to low participation, too low premiums and high utilization of paying members. Moreover local governments have no responsibility for financing the deficit. This has created pressure for the central government, which has a limited budget to finance the deficit. As a result, preventive and promotive services are underprioritized and the situation becomes a risk for the JKN to sustain.
Studies have indicated that there is potential for the plan to take on more financing, specifically for preventive and promotive services such as immunization programs, which can strengthen health systems and prepare better for emergencies – an important lesson to take away from 2020.
The theme of UHC Day 2020 is “Health for All: Protect Everyone”. The UHC Day campaign will mark one year since the first cases of COVID-19 were reported in Wuhan, China.
In recent times, the BPJS has taken on another critical role. It has been tasked by the coordinating human development and culture minister to use its expansive database on hospitals, aid recipients and health workers to verify hospital claims for COVID-19 treatment. It is also preparing to support with COVID-19 vaccination drives for target beneficiaries.
Further, the JKN-Healthy Indonesia card has helped many Indonesians obtain health services free of cost and get medicine delivered in the pandemic.
To cope with the outbreak, the central and local governments have taken several concrete steps, including reallocating their budget to prioritize the response to COVID-19 involving measures such as contact tracing, surveillance, in-patient care and the provision of medical supplies and health care as additional support to the JKN.
With increasing demand for health care, the JKN plays a vital role in providing essential healthcare services to COVID-19 patients and controlling the price of pharmaceuticals and healthcare services.
However, as in other countries, here too, the pandemic has affected the economy adversely. Tax collection has declined, while the need for government spending has increased. This uncertain future should be analyzed carefully for JKN sustainability.
In this difficult situation, increased investment in preventive programs has to be prioritized. In fact, it is one of the four specific objectives of the JKN program to prioritize preventive measures, which can reduce the prevalence of diseases and lower the number of sick people. As Indonesia prepares for vaccination drives against COVID-19, this will be especially important.
Indonesia and other countries have invested their resources and energy to overcome the pandemic. This crisis has reminded us that the foundation of our health care systems needs to be strengthened and only if everyone, everywhere has access to quality healthcare services, including preventive programs and tools, can we truly take steps toward a healthier future for all.
We have seen that Indonesia needs huge investment to achieve equity in accessing quality health care services. Under the current circumstances, is this a mission impossible or possible?
The writer is a professor at the health policy and management department, School of Medicine, Gadjah Mada University, Yogyakarta.
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