Dr. Hasbullah Thabrany, chairman at the Center for Social Security Studies Universitas Indonesia (CSSUI) and Senior Health Care Financing Consultant to the National Social Security Council of Indonesia, explains the evolution of the national healthcare insurance system since its creation in 1968 as well as the path of development to properly implement universal healthcare coverage (JKN) in Indonesia.
Dr. Thabrany, could you please introduce yourself to our international audience?
I studied health insurance when I was at the University of California at Berkeley, USA, where I did my master as well as my doctorate in public health. In 1995 I came back to Indonesia and, since then, I have been heavily involved with the development of the national health system while also working as a professor at Universitas Indonesia.
It is very interesting how the national health insurance has evolved since its foundation in 1968. It is worth mentioning that it was initially based on the social insurance system for all civil servants and their family members. For more than 40 years, the system was stagnant and covered only government employees. Thus, one of my main objectives when I came back from the US was to expand coverage to the entire population of Indonesia.
Expanding on this evolution, Indonesia suffered a financial crisis in 1998 which resulted in the reform of the health insurance system in 2000. In fact, the constitution was modified in order to position healthcare as a right for all citizens in our country and, as a result, Indonesia modified its social security bodies.
I am proud to confirm that I have learned a lot from every country that I have studied and visited. I introduced health insurance education in Indonesia from the US model, because no other country provides such education, in order to teach and create dialogue around the subject; educating healthcare professionals about this concept was crucial to ensuring the proper deployment of the social security system in the country. That is why in 1998 I created PAMJAKI (association of health insurances in Indonesia) to gather and put together knowledge about this topic.
Thus, the national health insurance has been intensively evolving since its creation and different stakeholders have been involved in the transformation to ensure a proper evolution. Currently, our new social security system encompasses health and pensions under the same law, which was finally implemented in 2014.
I have been intensively involved with this development and one of my main tasks during the development of social security reform to write academic papers and draft laws for the national health insurance as part of the National Social Security Reform.
As a key opinion leader within the healthcare sector, what are your conclusions about the implementation process of universal health care for all Indonesians (JKN) since it was initially launched in 2014?
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The Indonesian universal healthcare program is already covering approximately 70 percent of the Indonesian population, which represents about 175 million people by May 2017.
In addition, from the service coverage standpoint, JKN covers comprehensive healthcare defined as medically necessary. There are some financial constraints that force us to allocate our resources wisely; therefore, we certainly need more funding support to ensure the proper deployment of the universal healthcare coverage.
Nonetheless, there are other intrinsic factors such as drug quality and prevention that pose a challenge for the successful implementation of JKN. One of my main obligations is to reduce the impact of such threats to the universal health coverage deployment.
Therefore, we are motivating doctors to provide preventive care when treating their patients. In the procurement of drugs for government health care facilities, the main winning criteria is mainly just cost. Additional quality measures are needed for the tender. I am proud to confirm that the results obtained through JKN have been quite positive so far, but there is still a long way to go.
What should be the next areas to focus on by 2019 in order to ensure the successful deployment of JKN?
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It is already defined that in 2019 JKN should be fully implemented, which means that it should cover the entire Indonesian population. Nevertheless, the political side of such a program is going to play an important role in the accomplishment or not of the JKN goals. Indeed, public institutions have not properly understood that the universal healthcare program is not only about the coverage of the people but also about ensuring the quality of the health services delivered to the people at the right time and no catastrophic out of pocket expenses for example for expensive intervention or cancer drugs.
In this sense, I am highly promoting pharmacoeconomics in order to align financial restrictions with national health goals. As aforesaid, JKN needs more funds to accomplish the 2019 goal and there is already a constructive dialog around that.
In order to make the aforementioned assumptions clearer, I want to share a few figures. Just as a benchmark, in 2014 our health expenditure per capita was around USD 126 while in the UK it was nearly USD 4,000, which is way higher. However, the JKN’s expenditure per capita in 2016 was around USD 30; nearly 20 percent of the total health expenditure per capita that was USD 126. Hence, it is a clear indication that JKN’s expenditure is still too low.
In addition, many private hospitals are not joining the system because of the low hospitalization fees paid from the JKN. It is certainly an issue since more than 50 percent of the hospitals in Indonesia are privately owned and they are crucial to bringing care to patients.
Nonetheless, we are building up a healthcare database that will create positive impacts in the mid run since it will help physicians to determine the most cost-effective treatments according to empiric medical results. It will help to stipulate the best practices to treat chronic diseases, which is the current epidemiologic focus of the government.
You have an altruistic dream of everyone having health insurance and a pension in Indonesia. How do you think the country can get there with the enormous population and inequality that currently exist?
Inequality is a real threat in Indonesia but our objective is to bring healthcare to any patient regardless of his/her economic situation or location, which is a challenge in an archipelago country such as Indonesia. Our strategy is to leverage on technology to create healthcare breakthroughs that will overpass the boundaries of bringing high quality and effective healthcare treatment to the patients. With telecommunication, telemedicines, and computer technology, we can reach people even on a small island. We have several satellites that can be integrated into the healthcare system in the future.
We have seen really interesting trends worldwide such as digitalization that will reinforce this objective. We expect that such technological developments will also help the national government to reduce the cost of treatment and, consequently enlarge the patients’ market access to high quality and effective treatments.
Could you expand on how the Indonesian government and national policy makers are collaborating with other countries in the region that have already implemented similar programs to successfully deploy JKN in Indonesia?
It is a fact that the economy of our country has been growing more than five percent on a yearly basis during the last ten years and it is expected to maintain such growth in the mid-term. Thus, I expect that many of our neighboring countries will learn from each other to implement the best practices in each country. Indeed, we have intensive communication with ASEAN nations such as Vietnam and Thailand to share experience; such collaborations are helping us to successfully implement JKN.
As the middle class grows in Indonesia, the demography of diseases is changing, with less prevalence of infectious diseases, but an alarming increase in cardiovascular and lifestyle diseases. How can the government take a preventive role, therefore alleviating expenses on the healthcare system?
It is important to mention that cardiovascular diseases and cancer are the main causes of death in Indonesia and we have the public institution called BPJS Kesehatan that is responsible for paying individual healthcare services. This institution is responsible for enhancing the epidemiologic arena of chronic diseases as well as reducing the cost of treatment through prevention; it is currently mainly focused on diabetes and hypertension. There are already some programs designed to target these diseases through routinely, currently monthly, primary care clinics. Such programs aim to prevent diabetes and hypertension from severe complication carrying out early diagnosis practices as well as through life style education initiatives.
As a national and international key opinion leader within the Indonesian healthcare and life sciences industry, what main trends do see impacting healthcare in Indonesia and in the region in the next four years?
Universal healthcare systems are certainly a global trend and, in my opinion, there will be more countries implementing such policies in their nations. In fact, the Sustainable Development Goals, the commitment of Global World Leaders, has set that by 2030 all countries will be providing universal health coverage. The implementation of such universal healthcare programs will vary according to the specificities of each country. However, chronic diseases are a common healthcare challenge across the globe and, at some point, all nations will have to carry out education programs as well as care access initiatives to overcome that.
Specific to Indonesia, the national government will not be able to fulfill the national healthcare demand and, therefore, public and private partnerships are going to play an important role in the mid-term to provide healthcare quality and access.
