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The implications of the Indonesian presidential elections for its national health insurance

By Remco van de Pas
on July 4, 2014

The citizens of the Republic of Indonesia, a vast country with over 250 million inhabitants, have an important presidential election ahead of them on the 9th of July 2014. After 10 years of government under the current president Susilo Bambang Yudhoyono, next week’s election provides the voters with two distinct political options for the nation. Without going too much into the details of the electoral system, the choice will be between two candidates (and their vices). The first is Prabowo Subianto, a former commander of the special armed forces. The second is Joko “Jokowi” Widodo, the current governor of Jakarta. The candidates have distinct political views. Prabowo’s focus is on economic growth, rooted in nationalism, agricultural reforms and a considerable role tor the army to defend the national security. Jokowi’s view is to build a people-centered economy, with possibilities for small and medium sized farms and businesses to be involved in the economic development. Before analyzing their respective proposals regarding health and education, let us provide an introduction to the current health system, and list some priorities for the coming period.

The Indonesian health system is a complex system, which is not strange for an archipelago comprising around thousand inhabited islands. One of the major challenges is that the health workforce has not increased in sync with the growing population – the country is expected to be the third most populous country by 2043, after India and China, so this challenge is here to stay for some time. In addition, it also proves difficult to retain health workers to work in remote areas and islands, such as Maluku and Papua. The latter province is confronted with a serious, generalized, HIV-epidemic. Under decentralization of government, there has been a rapid expansion of nursing and midwifery schools. Each year 10.000 midwives and 34.000 nurses are “produced”. As accreditation and supervision by the central government over this newly trained workforce is limited, standards of medical education and quality control require attention. Not surprisingly, health staffs have not increased in quality as much as they have in quantity. A related problem is the dual practice (‘moonlighting’) by many doctors and other health workers. As salaries in the public sector are low, doctors often run private clinics in the afternoons and evenings. The government (reluctantly) allows this, as it is an incentive for health workers to stay in a remote area. However, absenteeism in public primary care clinics and hospitals is a concern, and many people think, rightly or wrongly, that the quality of care in government run clinics is lagging behind private facilities’ standards.

Last year, an IHP blog post reported how the government of Indonesia plans to move forward on the path to Universal Health Coverage (by 2019). In 2011, a national health insurance scheme (BPJS) was established by law, and its implementation started in 2014. Its main challenges are to have several schemes merged under one national scheme, that the richer part of the population contributes to the scheme (either via taxes or premiums), and the scale up of this social security system for health in a country where 70% of the labor force work in the informal sector. Moreover, decentralization has led to local free health care schemes, that are driven by regional and district elections, and promised by politicians to the electorate to mobilize support. It will require a comprehensive institutional and political reform to overcome this patchwork of fragmented schemes, each with different entitlements and separate from the state health care scheme. Fiscal policy and budget authority requires recentralization of authority, at least to some extent. It will be a daunting task for the new government to make such a national social protection scheme become a reality.

The two presidential candidates have different views on this. Prabowo’s view on health care mainly comprises compulsory service for doctors in poor areas upon graduation. He also wants to establish 12 years of compulsory education in state schools for the country’s youth. His opponent Jokowi wants to expand the national health insurance plan for the poor. He already has experience with this in Jakarta itself, where its “health card” is considered a moderate success. Now he wants to expand this to the rest of the country. In addition he proposes an education allowance program that would guarantee 12 years of free education.

The (politicized) polls give different views on the expected results of the elections. It seems that Prabowo is closing in on Jokowi as the electoral gap between the two candidates has narrowed to 3% in recent days. Both candidates had to establish complex coalitions in the national parliament to support their bid, so implementation of their respective agendas will be difficult regardless of the ballot results. This is even more the case for the health sector as the new financial system for social security is a national act, and thus mandatory for any new president to implement. The key issue will actually be how much the national insurance (BPJS) will cover of the payment arrangements for health care service providers (such as primary care doctors, but also nurses, dentists, and other health personnel). This is known as capitation. It will be the decision of the parliament (DPR) to agree annually on the health budget. This might become a problem because the coalitions behind both candidates are almost equally strong for the moment. The same will most probably also be true for the parties who are expected to support such a budget bill or not, it will be a close call.

While the Indonesian health financial framework requires reform, the country is also facing a demographic transition to chronic diseases. For people in the lower socio-economic quintiles, infectious diseases remain ‘a double burden’ of disease. Environmental related health issues such as emerging dengue epidemics also require particular investments. Basically the government needs to increase the investments in its public health system in an equitable, effective & sustainable way, and steer it away from expensive curative care to prevention of disease. It does not only require a president with a strong vision and political will, but also a strong societal movement to make that happen. That movement is growing in Indonesia, and many scoietal groups, such as the employers association but also regular citizens do support a national health scheme.

Lastly, the presidential elections take place the 9th of July, during the Ramadan period, and just before the final of the World Cup 2014. Would this influence the voter turn-out? Is this mere coincidence or very smart politics? As simple health systems researchers we refrain from commenting on this.

About Remco van de Pas

Remco van de Pas is a senior research associate at the Centre for Planetary Health Policy in Berlin and a lecturer in Global Health at the Institute of Tropical Medicine, Antwerp.

About Trevino Pakasi

Trevino Pakasi is researcher at the Center for Research and Integrated Development of Tropical Health and Infectious Disease (University of Indonesia)
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