Expediting COVID-19 health budget

Timboel Siregar Advocacy Coordinator of BPJS Watch and General Secretary of All Indonesian Workers’ Organization-Indonesian Workers’ Society Confederation (Organisasi Pekerja Seluruh Indonesia-Konfederasi Rakyat Pekerja Indonesia – “OPSI-KRPI”)

IO – The Finance Ministry’s Fiscal Policy Agency (BKF) has admitted that of the IDR 87.5 trillion allocated for the health sector, the portion realized as of mid-July was only around 7.2%. Obviously, the budget realization is very small, and not appropriate, given the rapid daily increase in numbers of COVID-19 patients and the tribulations of hospitals struggling to treat them. 

The breakdown of the budget allocation is as follows: 

a. COVID-19 handling expenditure IDR 65.8 trillion. 

b. Medical workers’ incentive IDR 5.9 trillion 

c. Death compensation IDR 30 billion 

d. National Health Insurance (JKN) premium assistance IDR 3 trillion

e. COVID-19 task force IDR 3.5 trillion 

f. Tax incentive for health sector IDR 9.05 trillion 

At IDR 65.8 trillion, COVID-19 handling expenditure budget is the largest. Health Minister Decree (KMK) No. HK.01/07/MENKES/238/2020 which serves as the legal basis to cover treatment costs for COVID-19 patients is still problematic in its implementation, which contributes to the low level of realization. 

The reasons are multiple. First, many COVID-19 patients are still unaware of the KMK No. 238, so they paid for themselves or use their private insurance. This is due to the decree’s lack of familiarization. 

In the third dictum of the KMK, it was stipulated that COVID-19 designate hospitals can submit COVID-19 patient cost waivers for those treated since January 28, 2020. This means that the hospitals are the one to file a claim. If a patient doesn’t ask for the cost to be covered, the hospital will likely not claim the costs from the government. 

Currently, the KMK No. 238 has been refined by KMK No. HK.01/07/ MENKES/446/2020 on Technical Guidance for Reimbursement Claim for Treatment of Patients with Specific Emerging Infection in Hospitals Providing Covid-19 Medical Treatment. I would encourage the government to disseminate the information on the two KMKs so that the public is aware that COVID-19 treatment cost is borne by the government. 

Considering that the funds have been made available since January 28, 2020, COVID-19 patients who have paid for their own treatment can ask the hospital to file a claim so that the costs incurred can be reimbursed. 

Second, in its implementation, there are hospital claims that cannot be verified by the Healthcare and Social Security Agency (BPJS Kesehatan) due to various reasons. At present, I am assisting a recovered COVID-19 patient who intends to recover the cost but is facing difficulty. One reason the claim document from the hospital cannot be produced is because the hospital is obliged to first reimburse the patient’s treatment cost in advance. Thus, they see the need to clarify with the Health Ministry because they see inconsistencies with KMK No.238. The hospital has treated around 200 COVID-19 patients. 

In my opinion, the requirement shouldn’t be too strict. BPJS Kesehatan just needs to verify the claim document so the Ministry of Health can reimburse the hospitals. When the hospitals receive the funds, they can reimburse the patients. The Health Ministry only needs to ensure that the funds are duly received. 

I have been handling the case for almost two months and the patient is confused because of the uncertainty. Just imagine, the hospital has treated 200 COVID-19 patients who likely paid for themselves. Of course, in addition to the said case, there are other things that cause hospitals being yet unable to receive payment claimed from the government. 

Third, technical problems on the ground have caused many disputes between hospitals and the government. The government is slow in coming up with provisions regarding the dispute resolution because KMK No. 238 does not regulate the mechanisms and a body to settle the dispute. It wasn’t until July 8, 2020 that the Decree of the Director General of Health Services No. HK.02.02/111/2928/2020 on Technical Team for Claim Dispute Resolution at Hospitals Providing COVID-19 Services was issued. 

I am of the opinion that the Health Ministry is slow in responding to COVID-19 funding dispute which resulted in the hospitals experiencing many problems with claims which can potentially disrupt their cash flow, affecting their operation and treatment for COVID-19 patients or patients with other health conditions. 

In my view, those three factors are behind the reason why the realization of the IDR 65.8 trillion budget is still low to date. 

With regard to medical workers’ incentive, the realization of the IDR 5.9 trillion budget is also still low: up to July 1, 2020 it was only IDR 408 billion (6.9%). The disbursement of medical workers incentive funds is governed by KMK No. HK.01.07/ MENKES/278/2020 which has been replaced by KMK No. HK.01.07/ MENKES/392/2020 on Provision of Incentive and Death Compensation for Health Personnel Handling COVID-19. The slow disbursement might be due to the bureaucratic and rigid procedures of KMK No. 278 which only apply to COVID-19 referral hospitals. 

The still low distribution process for medical personnel incentives is due to procedures in KMK no. 278 which are bureaucratic and strict and only for COVID-19 referral hospitals. 

In KMK No. 278, the process of verifying the incentive document filing is long-winding, where it has to go through primary healthcare facilities, health offices in district/city and province before reaching the Health Ministry. From the Ministry, the document is then submitted to the Finance Ministry. On the contrary, in the new KMK No. 392, the process of verification is done by provincial health offices and directly submitted to the Finance Ministry. 

In KMK No. 392, hospitals that can file incentives claim for their health workers are not only COVID-19 referral hospitals, but also any other hospitals handling COVID-19 cases. 

It is hoped that through KMK No. 392, implementation can be carried out easier and faster, so that the budget allocation for medical workers incentives can be improved. 

With respect to JKN premium assistance, the realization of the IDR 3 trillion budget allocation is also potentially low, given the budget is used to subsidize premium-paying Class 3 participants who contribute IDR 16,500 per person per month in premiums. Currently there are about 21 million people in this class. 

The realization of the IDR 3 trillion budget began and extends from July 2020 to December 2020. For premium-paying Class 3 participants who neglect to pay their JKN contributions (or are non-active), the subsidy will not be given. As per May 31, 2020 the total number of JKN self-paying participants who missed their contribution stands at 16,215,342 people (53.71%), dominated by Class 3 participants. 

As purchasing power declines due to COVID-19’s devastating impact on the economy, the increase in JKN contributions as of July 1, 2020 will only increase the number of Class 3 participants failing to meet their premium payments, resulting in a potentially low budget realization. 

Amid the pandemic, it is hoped that the government can accelerate the process of budget disbursement, especially in COVID-19 Handling Expenditure and the Medical Workers Incentive items, so that hospitals’ cash flow will not be disrupted and health workers can receive the incentives they need to financially support themselves and their families.