JAKARTA, Indonesia — In November 2014, Andri, a 33-year-old worker with a nongovernmental organization in Jakarta, began feeling weak and disoriented. Medical tests established that she had leukemia. Then she learned that her private health insurance would cover only a single annual session of chemotherapy.
The treatment she needed was too expensive for her family, as it would be for most Indonesians, said Andri, who for reasons of privacy asked that only her first name be used. “In the past, a lot of people died at home with cancer.”
Fortunately for Andri, she had fallen ill in a new era. In early 2015, she signed up for Jaminan Kesehatan Nasional (JKN), Indonesia’s newly rolled-out single-payer health-care program. It fully covered her monthly chemotherapy sessions at a top-flight Jakarta hospital. She is now in the second stage of her chemotherapy treatment, feels healthy and is deeply grateful to the Indonesian government.
In 2014, Indonesia, a sprawling archipelagic nation of 250 million people, began phasing in one of the world’s largest single-payer health-care systems. Two and a half years later, its government guarantees comprehensive health insurance for 165 million citizens and residents, with plans to expand coverage to the entire population by 2019. According to the office of the Social Security Administering Body for Health, which runs the program, more than 100 million health-care visits have been covered since its launch.
But the picture is not entirely rosy. Revenue is falling well short of costs, health clinics are overwhelmed by the rush of new patients, and fraudulent claims and bureaucratic dysfunction are rife. Some question whether a developing country that devotes only 3.5 percent of its gross domestic product to health care can realistically guarantee comprehensive coverage to each of its citizens.
“On the face of it, they’ve made much bigger promises than the government has capacity to deliver,” said May Tsung-Mei Cheng, a health policy research analyst at Princeton’s Woodrow Wilson School of Public and International Affairs.
When China began unrolling its universal health-care program in 2009, only certain high-priority conditions were covered, with the list gradually expanding as the country’s economy grew. Indonesia, which is substantially poorer than China, has imposed no such restrictions, covering routine procedures and complex, expensive operations alike. Aging Indonesian farmers have had kneecaps replaced. Heart transplants are funded.
In 2015, JKN’s first full year of operation, the program’s expenses exceeded government projections by more than $300 million. Costs will climb further when the government expands coverage to the country’s rural poor, who disproportionately lack coverage today. As it is, hospitals and health clinics complain that the state does not generally compensate them sufficiently for the care they provide to those with national health insurance.
As a result, the public’s experience has also been mixed, according to Hasbullah Thabrany, a professor of health economics at the University of Indonesia who is one of the chief architects of the program.
“Due to low or perceived low payments, providers have shifted their costs to members/patients directly with discrimination of services, charging out of pocket or creating long queues” for services, Thabrany said.
The abrupt influx of tens of millions of new patients, all with claims and other paperwork needing to be processed, has also contributed to the interminable wait times. On the day of her chemotherapy treatments, Andri had to get in line at the hospital at 2 a.m. to receive the required authorization for her 2 p.m. appointment. Moreover, her state insurance allowed her to consult with only one doctor a day, she said, so if she needed to consult with someone other than her oncologist, she had to repeat the process the next day.
Many others, less lucky than Andri, are placed on long waiting lists before receiving critical care.
Indonesian public-health experts are now calling for substantial reforms, beginning with boosting revenue. The government recently raised the amount wealthy Indonesians are required to contribute to the system, but the cap is still lower than experts think is necessary. “The costs must be increased to ensure better quality of care and to ensure middle class customers join happily,” Thabrany wrote.
Donald Pardede, a senior adviser to the health minister on health economics, acknowledges the need for urgent reforms and said that, in an ideal world, “sky-is-the-limit” benefits would be reconsidered. But government legislation says all citizens have a right to comprehensive health care, and he says it is unlikely to be revised. “The citizenry would cry out, so that’s unlikely to happen,” he said.
Pardede noted that the government is working with hospitals to help them cut fraud and waste, which he says will reduce health-care costs in the long run. Overall, he remains optimistic.
“If I was forced to choose whether things are better now or before, I would choose now, because we’re better allies to ordinary people now,” he said.
On a recent Monday morning at the Cempaka Putih Health Clinic in central Jakarta, the facility’s three floors were overflowing with patients and crying babies, and benches had been set up outside the building to accommodate even more patients. The administrative staff is packed into an attic, processing paperwork. Ati Sukhmanhsih, the clinic’s chief administrator, said that officials were hoping to move to a larger space soon to accommodate the huge volume of new patients with access to free health care.
For Sukhmanhsih, the crowding can be viewed as a positive.
“Before, there were many who were sick, who didn’t receive care,” she said. “Now, because of the JKN, they can come to the clinic and we can help them.”