Jakarta, IO – The reform era created momentum that led to four amendments to the 1945 Constitution. In the second amendment, healthcare is provisioned for as a constitutional right of all Indonesian people. Article 28H(1) stipulates that every citizen has the right to live healthily and receive healthcare services.
To assure this constitutional right, Article 34(3) states that the state is responsible for providing proper health care facilities and improved access to health care through social security systems. Article 28H(3) further ensures that all people have the right to social security, allowing them to fully develop themselves as human beings with dignity. In this regard, article 34(2) mandates the state to implement social security instruments to empower those who are vulnerable and underprivileged to live with dignity, in line with the idealistic spirit of the 1945 Constitution.
Thus, it is crystal clear that the state must provide and guarantee health care services for all Indonesian people, regardless of their socioeconomic status, religion, ethnicity, and so on. To implement the constitutional mandate, Law 36/2009 on health explicitly defines health as a healthy state – physically, mentally, spiritually and socially – which allows everyone to live productively, socially and economically. And social security is the key instrument to achieve this.
Law 40/2004 on a National Social Security System (SJSN) and Law 24/2011 on a Social Security Agency (BPJS) mandates the state to provides five social security programs for all Indonesian people. They are national health insurance (JKN), occupational accident benefits (JKK), death security (JKm), old-age benefits (JHT) and a pension scheme (JP).
The JKN program is managed by BPJS Kesehatan, and the JKK, JKm, JHT and JP programs are managed by BPJS Ketenagakerjaan, which also oversees unemployment benefits (JKP) as stipulated by Law 11/2020 (Job Creation Law). There implementation of SJSN is based on nine principles, including mandatory participation and mutual cooperation.
JKN for all
The JKN program has been running for nine years. Since it was implemented January 1, 2014, the program has helped the community access health services at first-level health facilities (FKTP) and hospitals. All participants – government subsidy recipients, privately-employed workers, independent workers, civil servants/military/police personnel, non-workers – can enjoy the same quality of medical services, but with ward types divided into Class 1, 2 and 3.
According to 2019 data, JKN had been accessed 433.4 million times, with an average of 1.2 million visits to health care facilities per day. Visits decreased to 362.6 million times (993,692 visits per day) in 2020, due to the Covid-19 pandemic, as participants worried that they might contract the coronavirus if they visited health care facilities. But it went back up again the following year, to 392.9 million visits (1.1 million visits per day). It is estimated that the number of visits will increase further in 2022, as the pandemic has been brought under control.
Other than common medical procedures, JKN benefits also include health screening, regular tests for patients with diabetes and cervical cancer. Several costly diseases, known as catastrophic illnesses, are also covered by JKN. Catastrophic illnesses are generally caused by several factors – metabolic, environmental and lifestyle. Of the eight types of catastrophic illness, four are the most expensive, namely heart disease, cancer, stroke and kidney failure. The total cost for these eight illnesses hit Rp17.05 trillion in 2020, with a total of 17,872,458 cases. This was down from Rp20.27 trillion (a total of 19,999,026 cases) in 2019, in relation to the pandemic. (TABEL)
Given the large volume of funding for catastrophic illnesses, the government must continue to control expenses through direct promotive and preventive measures, at the individual and community level. This aims to increase public awareness of the importance of prevention and early detection of catastrophic illnesses, so that they can be handled and treated more rapidly and precisely.
Apart from catastrophic illnesses, caesarean (C-section) surgery also incurs steep expense, amounting to Rp3.96 trillion in 2019 (724,502 cases). While funding for catastrophic illnesses was down in 2020, that for C-section surgeries actually increased, to Rp4.21 trillion (770,796 cases). This high cost raises suspicions of alleged fraudulent practices committed by unscrupulous hospitals to skim off funds from BPJS Kesehatan. Non-government watchdog BPJS Watch revealed that it once handled the case of a pregnant woman in North Jakarta who was strongly advised to have a C-section, paid for by JKN, but she refused, because she preferred to endure a normal delivery. After a lengthy wrangle, the woman finally managed to have a normal childbirth with the cost paid for by JKN. There are many similar cases reported elsewhere.