Prof.
Dr. dr. Fachmi Idris, M.Kes, president director at BPJS Kesehatan explains the evolution of the Universal Healthcare coverage program of Indonesia (JKN-KIS), the challenges inherent in its implementation, and the Indonesian government’s commitment to overcoming them.
Dr. Fachmi, can you briefly introduce the main activities and responsibilities of BPJS Kesehatan?
BPJS Kesehatan was created in 2014 as the successor to the former Social Security Institution of Indonesia (ASKES). The main purpose of BPJS Kesehatan is the successful and sustainable implementation of the Universal Healthcare coverage program of Indonesia (JKN-KIS), which is expected to cover all national citizens by 2019; today it already covers 178.2 million people or 70 percent of the national population.
You have been the President Director of BPJS Kesehatan since its inception back in 2014. Can you expand on the main focus areas during the implementation of JKN?
At the beginning, the main concern was the preparation of the national constitution and overall regulation structure that will support the development, implementation, and the sustainability of JKN-KIS.
BPJS Kesehatan is an instrument that fully serves to the successful realization of the universal healthcare coverage in Indonesia. Since our creation back in 2014 and before through ASKES, we have been working on the enlargement of citizens registered, the quality of the health services provided, and the sustainability of JKN-KIS moving forward. I am very proud of the results obtained so far but there is still a long way to go.
JKN-KIS is expected to cover the entire Indonesian population by 2019 and, as you mentioned, it currently covers around 70 percent of all the population. What is your action plan to catch up with the remaining 30 percent before 2019?
There are several public institutions involved in JKN-KIS such as DJSN (National Social Security Council), with DJSN being the one that designed and developed the strategic roadmap for JKN-KIS. There are clearly defined sections within this plan and one of those is targeting the challenge of increasing the membership base of JKN-KIS. Obviously, there are annual registration targets that are supported with specific initiatives.
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Hence, we have to carefully define the actions needed to reach the objectives within JKN-KIS’s strategic plan – in this sense, we have a supervisory board within BPJS Kesehatan that is closely following up on these ambitions as well as tracking the advancements.
Thus, we currently have segmented action plans to target each different social group: private employees, government employees, self-employees, and ‘poor’ segment. In addition, we are actively collaborating with other National Ministries such as Manpower and Planning in order to enlarge the reach of our operations and accomplish the registration targets established in JKN-KIS’s strategic plan.
The inclusion of all the segments is certainly a challenge and we are fully aware that we need to attract and register the non-poor segment in JKN-KIS in order to advance towards the financial sustainability of the model since JKN-KIS needs their premiums in order to be financially viable.
On that point, one of the main debates around JKN’s implementation is its financial sustainability, which will be more challenging in 2019 when it is expected to cover 260 million people. As president director of BPJS Kesehatan, what is your assessment of this issue?
JKN-KIS is a new program for Indonesia and, consequently, we are still fine-tuning the final scheme – the financial model is one these points under debate. It is important to mention that the current premium scheme is still below the actuarial that dictates the real cost of the healthcare service – which the government used as a benchmark but did not fully implement in order to enlarge healthcare access. Therefore, the financial deficit of JKN-KIS will continue to exist even if all Indonesians pay the premium established according to their segment. The point here that we are dealing with a significant gap between the premium and the actual cost of the healthcare services provided.
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JKN-KIS premium and the actuarial obviously vary according to the social economic segment. In order to ensure a better understanding of the current financial situation, let me expand on the economic numbers – premium versus actuarial – of two segments: the poor and self-employed.
Firstly, the established monthly premium for poor and near poor segment is Rp. 23,000 (USD 1.7) per capita versus the actuarial calculation that is Rp. 36,000 (USD 2.7) – there is a gap of Rp. 13,000 (around USD 1).
Secondly, the established monthly premium for the self-employed segment is sorted out in three different healthcare service levels. In the third class the established monthly premium is Rp. 25,500 (USD 1.9) per capita versus the actuarial calculation that is Rp. 53,000 (USD 3.9) – there is a gap of Rp. 27.500 (around USD 2.00). In the second class the established monthly premium is Rp. 51,000 (USD 3.8) per capita versus the actuarial calculation that is Rp. 63,000 (USD 4.7) – there is a gap of Rp. 12,000 (around USD 0.9). The first class is the only segment in which there is not any gap since actuarial exactly matches with the premium established.
The reason why the program continues, no matter the fact that it is systematically designed to be in deficit, is the strong commitment of the government in providing, at least, basic healthcare to the entire population.
What is the solution to resolving this financial mismatch?
There are three different solutions that were assessed to drive JKN-KIS towards its financial sustainability: increase premiums; reduce the pack of healthcare services, and capital injection.
The first consideration was to increase the premiums paid by society in order to minimize the economic gap between the premium and the actuarial. Nevertheless, this measure will directly reduce access to healthcare services since the financial capacity of a large part of the population cannot afford any increase in premiums. Consequently, this measure is not aligned with the constitutional objective of covering all Indonesian citizens.
The second option would be to reduce the pack of health benefits covered by JKN-KIS in order to decrease the actuarial cost. However, the current system is only covering basic care services, which are highly needed by the population. Again, this way would not be ethically viable and not aligned with our constitutional objective of covering basic healthcare needs.
Thirdly, the government injects more money in JKN-KIS in order to finance its implementation, regardless the deficit. This is currently the chosen option by the government and clearly shows the strong commitment of the President Joko Widodo in deploying universal healthcare coverage in Indonesia.
Finally, can you speak towards the role of innovation within JKN?
Innovation both in terms of medicines and technology must certainly be included in JKN-KIS since it enhances health services and ultimately, patients’ life quality. In this JKN-KIS, we have always fostered the inclusion of such technologies in our system based on cost-effective and evidence-based arguments that demonstrate that such innovative solution can create significant healthcare breakthroughs.
