02.01.01. The public health system | Indonesia
02.01.01. The public health system | Indonesia
13 Apr 2022
Indonesia introduced universal health care through the National Health Insurance System (Jaminan Kesehatan Nasional (NHIS)) in 2014. Services covered under the NHIS can be provided by the government-owned health facilities and registered private providers (Agustina et al., 2019, pp.75,89).
The system was created by bringing together a number of existing, but still fragmented, health insurance and social assistance schemes under the umbrella of a single payer, the Social Security Agency for Health (Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS)) and covers a range of services from simple procedures to ‘open heart surgery […] and cancer therapies’ (Agustina et al., 2019, pp.76,89). Furthermore, reproductive, maternal, neonatal, child health as well as emergency services are fully covered, and medicines and medical supplies can be received without co-payment if the patient adheres to procedures. The system does not cover cosmetic procedures, self-inflicted injuries, and services provided outside pre-approved providers, unless they are emergencies (Agustina et al., 2019, p.89).
The system covers civil servants, private sector employees and provides for socio-economically vulnerable members of the community. Government subsidises for 109.5 million socio-economically vulnerable account for 61 per cent of those with insurance coverage. Civil servants, private sector employees and others providing independent contributions make up 39 per cent of those insured. (TNP2K, 2018, p.83).
By October 2018, the systems served 203 million members, representing the ‘largest single-payer scheme in the world’. In 2017, 223.4 million consultations were recorded, amounting to US$20.15 billion (US$ PPP) (Agustina et al., 2019, p.75).
As over half of members of the BPJS receive government subsidies and among those contributing independently, members often only pay during periods of illness, which poses challenges for the financial sustainability of the programme. It was reported that claims exceeded contributions by 600 per cent in 2014 (TNP2K, 2018, p.84).
The system in Indonesia consists of three main service tiers, these are:
Community health centres (Puskesmas)
The Puskesmas programme was introduced under president Suharto in 1968. By 1970, community health centres were established in all subdistricts (Agustina et al., 2019, p.77). The Puskesmas provide frontline primary health care. From there, patients with more complex needs can be referred to hospitals or other services. In 2015, 9,754 Puskesmas were in operation, covering 92% of subdistricts. However, particularly in the eastern part of the country, some subdistricts did not have Puskesmas. There are also concerns regarding quality. According to Agustina and colleagues (2019, pp.84-95), ‘only 74% of community health centres met preparedness requirements’. Quality standards were found to be better in urban than in rural areas (Agustina et al., 2019, pp.84-85).
Integrated community health service post (Posyandu)
The Posyandu were introduced shortly after the Puskesmas (1980), with a focus on preventive health services (Agustina et al., 2019, p.77). The Posyandu are staffed by a midwife, a nurse assistant, and a vaccinator and are facilitated by health volunteers (kaders) in each community. These teams visit hamlets or village subdivisions on a monthly basis and provide ‘basic reproductive, maternal, neonatal, and child health services’, although later on several Posyandu Lansia focusing on older people’s health have been set up. It is estimated that almost 300,000 Posyandu are held every month (Agustina et al., 2019, p.84).
The number of hospitals almost doubled between 2005 and 2015, from 1,268 to 2,488 (Agustina et al., 2019, pp.84-85). As outlined above, subsidised members can access third-class hospital rooms without co-payments, while self-employed members can access first to third-class rooms in accordance with their insurance plan. Those earning more than $300 a month are entitled to first-class rooms. BPJS members can upgrade their hospital room through payments or private insurance (Agustina et al., 2019, p.89). In the end of 2021, the government has announced the plan to erase this classing system in BPJS, and will only offer a standardised class, following the health equity principle. It will be implemented gradually starting in 2023 (Hasibuan, 2022).
The Ministry of Health further regulates geriatric services in Indonesia’s public hospitals (Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 Tentang Pelayanan Geriatri Di RS), 2014). By 2015, six hospitals on Java Island and one hospital in Bali, Sumatra, and Sulawesi islands provided older people with ‘integrated geriatric services’ (Pusat Data dan Informasi Kementerian Kesehatan RI, 2014, 2016b).
Data from the Ministry of Health shows that the number of private hospitals has grown more rapidly than that of public hospitals. However, private hospitals remain mostly concentrated on the Java islands where there are larger urban and peri-urban centres.
Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7
Hasibuan L. (2022). Siap-siap! Kelas 1,2,3, BPJS Kesehatan Dihapus, Ini Gantinya. CNBC Indonesia. https://www.cnbcindonesia.com/news/20220220094223-4-316764/siap-siap-kelas-123-bpjs-kesehatan-dihapus-ini-gantinya
Ministry of Health Regulation No. 79/2014 on Geriatric Services in Hospitals (Permenkes No. 79/2014 tentang Pelayanan Geriatri di RS), (2014) (testimony of Ministry of Health Republic of Indonesia).
Ministry of Health. 2012–2017. Ministry of Health Annual Health Sector Profile 2011–2016. Jakarta, Indonesia: Ministry of Health.
Pusat Data dan Informasi Kementerian Kesehatan RI. (2014). Situasi dan analisis lanjut usia (pp. 1–7).
Pusat Data dan Informasi Kementerian Kesehatan RI. (2016b). Situasi Lanjut Usia (Lansia di Indonesia).
Tim Nasional Percepatan Penanggulangan Kemiskinan (TNP2K). (2018) The Future of the social protection system in Indonesia, Jakarta Pusat: Office of the Vice President of the Republic of Indonesia. https://www.developmentpathways.co.uk/wp-content/uploads/2018/11/44293181123-SP-ReportFinal-ENG-web.pdf