By Nuzulul Putri
Since 2014, Indonesia has undertaken an ambitious project in protecting its population of over 230 million through national health insurance – transforming into a giant single-payer healthcare system. This national health insurance covers healthcare treatment in health facilities from primary to tertiary.
Indonesia’s target was that all Indonesians would be protected with health insurance by 2019. Today, in 2021, Indonesia National Health Insurance has covered more than 220 million Indonesians, with almost 60% are considered poor and near poor, for whom the government pays the premium. The system has had a deficit since 2015 and has continuously reported deficit due to an imbalance between the contributions collected, the payment of participant benefits, and operational funding for National Health Insurance implementation.
The urgency to strengthen the health system to support universal health coverage (UHC) has livened up in Indonesia. Indonesia faces a reality that it is challenging to achieve UHC only by strengthening its health financing building block without strengthening other health system’s building blocks.
A published article that I wrote in 2019 as part of the Health System Global (HSG) Women Mentorship Program, highlighted the importance of strengthening the health system to support UHC, predominantly to minimize any health disparities in disadvantaged regions.
Why do people skip over free health services?
Amid the deficit of Indonesia national health insurance, in 2015, our team studied the phenomenon of populations living in border areas bypassing healthcare services in their home district covered by national health insurance, preferring to pay for healthcare services outside their district.
Our study found that health insurance coverage does not predict this health care seeking behavior, where someone already covered by national health insurance still chooses to bypass the health facility in their home districts in favor of seeking care in other districts. Our study reported that geographical issues, both in terms of distance and access, are the main predictors for people’s decision to bypass health facilities in the home district. This population prefers to use health facilities nearer and easier to access from their home, even though they need to pay for it. For this group of people, paying for transportation to access free healthcare services covered by the national health insurance in the home district is more costly than paying for healthcare services in other districts.
Since our respondents reported that they are satisfied with the health facility in the home district, there is a high possibility that the health facility in the neighboring district is also excellent. A previous study reported that health facility bypassing is positively associated with the destination’s better service quality. Hence, with comparable quality of healthcare service between the home and destination district, it is clear that the significant predictor for this bypassing behavior is the geographical barriers in utilizing health services under national health insurance.
As the largest archipelago country, it is no surprise that geographical access has become a problem for Indonesia. The government are aware that the most problematic issue is the maldistribution of health infrastructure. Hospitals and health workers are concentrated in Java islands where the major activities of this nations occurr. Remote areas, however, remain at a disadvantage. Mostly, healthcare services in this area are predominantly conducted by government-owned health infrastructures, while the private sector is still limited.
Reflections from HSR2020 on sustaining UHC
A session at the Sixth Global Symposium on Health Systems Research (HSR2020) titled “No UHC without the people: institutionalizing meaningful government engagement with the population, communities, and civil society” on Jan 27, 2021, taught us that managing UHC is not only about ensuring that all populations are protected, but is also essential to ensuring that the population is involved in maintaining its sustainability. The session clearly described how to stimulate any governance practices that will successfully empower multi-stakeholders (government, communities, and civil society) to work hand in hand to establish a co-owned health system. This co-owned health system, through building social partnership, is needed to sustain UHC.
Hence, the concept of social partnership offered in this session is needed to attract more stakeholders to help build the health system. The gap of health infrastructure maldistribution could be minimized by involving more stakeholders to equip these remote areas with better health infrastructure.
All in all, UHC means that all people can access health care services they need, whenever and wherever they need it, without being constrained by any financial hardship. It means that the government must not only become aware of health treatment costs but also ensure that their citizens do not get into any financial hardship to access health treatment.