E40: Floating Hospital & A Sinking Healthcare System
Credits: Doctorshare
Launched in 2014, Indonesia’s Healthcare and Social Security Agency, locally known as BPJS Health, administers universal health care to millions of Indonesians through a heavily subsidized scheme. Although policy makers have good intentions, it's running an approximately US$1.49 billion deficit causing some health providers to be on the brink of collapse after being owed millions of dollars. Covering the program’s budget is not the only thing out of reach as BPJS services remain unattainable for many Indonesians that are outside of the main islands. Some private citizens have taken it upon themselves to provide healthcare for these areas. One non-profit organization called Doctorshare is risking their lives to serve patients in remote parts of the country. With sit down with healthcare special staff to the former Governor of Jakarta, Basuki Tjahja Purnama (Ahok) and current program head of non-profit DoctorSHARE, Stanley Saputra, to discuss the BPJS Health financial crisis and the current healthcare situation in remote areas of Indonesia.
Listen to the full episode with the link at the bottom of the article. Here are the main takeaways from the episode:
How BPJS Health Was Established
BPJS Health, which administers the National Healthcare Service, was launched in early 2014 by President Yudhoyono in after years of preparation.
What Is BPJS Health
BPJS Health is a universal health care program that covers millions of Indonesians through a heavily subsidized scheme. Premiums for low-income participants are fully covered by the government while the majority of others pay heavily subsidized monthly premiums. Employers split their premiums between the employer and employee, and independent workers pay on their own.
Millions of Indonesians have used the coverage for everything from basic check ups to heart surgery with no copay or charges except for the subsidized monthly premiums. BPJS Health has been providing lifesaving healthcare to many individuals who otherwise would not be able to afford it or would go bankrupt in the process due to the high costs incurred.
Currently BPJS Kesehatan has covered 30-40% of Indonesian population.
Program's Unsustainability
With early success, challenges for BPJS Health quickly emerged. A payment shortfall and low participation has plagued the system, and the ones that do participate, often do so only when they need the services. As a result, many hospitals are partially reimbursed by the government forcing them to decide whether to pay outstanding bills or pay staff salaries. Some have chosen to ask the staff to be patient and wait to be paid. Muhammadiyah hospital just this month testified in a parliament hearing that BPJS owes it Rp300 billion or USD$21 million and that is struggling to provide its services as a result.
BJPS spends huge sums on chronic diseases with little investment on disease prevention or the promotion of healthy lifestyles.
The program overall is suffering from a serious deficit. The deficit continues to grow and is threatening the entire health care system. It currently stands at Rp. 21 trillion or approximately US$1.49 billion.
Several private hospitals are still resistant to join the BPJS program due to their slow reimbursement schemes and the fact that the government’s rates are set well below the hospital’s operational costs.
Premiums for the poor are fully covered by the government while the majority of others pay heavily subsidized monthly premiums. Currently, BPJS charges around 25,000 rupiah or around USD$1.65 for the lowest tier to Rp80,000 or USD$5.75 for the highest tier premiums. In a move to slow the massive deficit, the government has decided to double the current premiums beginning in January 2020.
Although many people can afford to pay for the coverage, many fail to see the need to participate until they are actually sick.
What needs to be fixed
Stanley explained that there are two main issues. First is the management of BPJS Health itself and second is the society. “Not many people in Indonesia are health-literate. They seek medication when they are sick. They are not aware of illness or disease prevention,” he said.
Stanley also said the enrolment fee is too low, “For the three different classes of services available, the first class should be at least around Rp300,000, second class should be Rp200,000, and third class (lowest) should be around Rp100,000.”
“Another issue I think is that the government is too focused on establishing hospitals, providing doctors, without realizing that they are focusing on, which is the higher risk groups, but very little focus on the awareness of prevention with the low risk group in the continuous care. The issue is both in education about health and treating diseases,” Stanley adds.
Affordability vs Accessibility
There are more than 26,000 health facilities that are under BPJS, which includes community health centers, hospitals, dentists and opticians. However, it’s far from enough for Indonesia’s growing population.
The problem in remote areas is that local people lack access to hospitals. The local government is giving free medication in their regional hospitals without requiring them to register with BPJS Kesehatan.
Accessing health facilities outside of Java, especially in the middle and eastern part of Indonesia such as Maluku, North Maluku, and Papua, continues to be a major problem as they lack health facilities. Stanley adds “It’s even more devastating in the eastern part of Indonesia, they do have hospitals, but they are not well equipped to be categorized as a hospital.”
Another challenge for people living in remote areas is transportation. Individuals might be a participant of BPJS Health but that doesn’t mean that they can afford the transportation cost to even reach the basic healthcare providers, which can take days in some areas.
Private Organization Filling The Healthcare Void
Some private citizens have taken it upon themselves to provide care to these areas. One such organization is DoctorSHARE established by Dr. Lie Darmawan. The non-profit organization is made up of volunteer doctors and provides healthcare to people in remote areas such as Maluku, North Maluku, Papua and other parts of Indonesia.
The group has three privately-funded floating hospitals and have spent an enormous amount of energy preventing malnutrition, stunting and tuberculosis which continue to affect many Indonesians.
DoctorSHARE has been filling the government healthcare void and has been a lifesaver for many Indonesians.
DoctorSHARE has served over 10,000 patients in 2018 and more than 50,000 patients since it was established in 2009.
Episode Description
Podcast hosts: Shawn & Tanita
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