Indonesia searches for the “missing middle” as UHC deadline looms

Over 100m people are still not covered.

Indonesians working in the informal economy are giving local regulators a headache as the deadline for the country’s ambitious universal healthcare coverage (UHC) plan draws closer.

The so-called “missing middle” covers a wide range of individuals, from the homeless on the streets to sophisticated freelancers and self-employed workers, said Diah Satyani Saminarsih, M.Sc, Special Advisor for The Minister of Health for Partnership and SDG.

Diah shared that the UHC program now covers around 150 million out of Indonesia’s population of 250 million. Out of this number, 100 million are covered by the government, while 50 million are paid independently.

“One problem is that we still miss what we call the ‘missing middle’’. It creates a huge gap in the income of the health sector,” she said.

“If you dig into the data, right now 80% of the population has been hospitalized at one point or another, mainly due to catastrophic illnesses. This puts a huge economic burden on the UHC. Indonesia needs many more healthy patients to cover for the expenses of unhealthy people,” Diah added.

Healthcare spending to spike
Although the current number of sick Indonesians is already staggering, data from International SOS show that there isn’t much cause to be optimistic in coming years. Non-communicable diseases (NCDs) are estimated to account for 71% of all deaths in Indonesia from 2012 to 2030 and will cost the country US$4.47 trillion or US$17,783 per capita, said Richard Jones, M.D., Technical Adviser, International SOS.

“Indonesia will experience a tsunami of NCD-associated medical expenditures in the next decade. We have a lot of data on healthcare, and what we could be doing with data is the future of healthcare. If we are able to identify people who might be at risk early on, we can look at a population-based approach rather than a reactionary approach,” Jones said.
In order to address the expected spike in healthcare spending, Diah stressed that it is imperative that private hospitals get onboard with the UHC system at the soonest possible time.

“Care is not enough if it is only given by public hospitals. Private hospitals and clinics need to be part of the whole system. As long as everyone is still bickering about whether to be in or out of the system, I don’t think the universal health coverage will be much more effective than it is already now,” she said.

She cited instances in which some private hospitals outright refuse to treat publicly-insured patient and only accept cases with private insurance. There are also cases in which private hospitals accept cases under JKN but provide different care for those on private and public insurance.

“This is against the law. There should be no discrimination of care. All of us need to work together. WE need to understand that when we provide healthcare, a lot of people are at stake, it’s literally about life and death. While we sit here talking about profits, people are dying. It is not just the responsibility of the government, but of everyone who works in the healthcare sector,” Diah said.

“We still have a long way to go. We still have three years. In order to achieve UHC by 2019, the government is expanding its budget to include those who may not be eligible to paid for by the government. This is to make up for the missing middle,” she added.

Private hospitals speak up
Luckily, private hospitals seem quite keen to join Indonesia’s UHC plan. Zamzam Noerzen Djaelani, Director, Awal Bros Hospital, says that private hospitals make a key distinction between markets in metropolitan areas and peripheral areas, particularly those outside Java. In big metropolitan areas, he says, most patients are usually backed by private insurance. In the outskirts, though, many patients rely on JKN for their healthcare needs.

“Because there is great demand for JKN (Jaminan Kesehatan Nasional) in peripheral areas, I think private hospitals are very keen to join the system. There is a very slim market; it’s either we go with the system or we do not have enough revenue,” said Zamzam.

However, policymakers need to address the price of services under JKN, which Zamzam argues is too small for private hospitals.

“Prices particularly for surgery and obstetrics are too small to provide sufficient care for the patient. Private hospitals are forced to use generic drugs and cheaper equipment, as well as pay lower medical fees to practitioners. That is more of the problem we have in private hospitals. Maybe the government should consider some tariffs,” Zamzam said.

Another point that policymakers could address is the payment system for specialists, who are currently being paid on a per-service basis. Zamzam floated the idea of having a fixed monthly package for practitioners, which may vastly improve the quality and consistency of care across the archipelago.

“The system is only as strong as its weakest link. I think your hospital system is fantastic, but it suffers from sustainability issues, as well as inconsistent procedures and policies. I think the government should tap more private enterprises to improve the system,” Jones noted.

Diah acknowledged that there is a need to improve standard operating procedures in hospitals and clinics across the country. In particular, she cited the need to cut down on paperwork. Policymakers also need to standardize processes at puskesmas, the colloquial term for government-mandated community health clinics located across Indonesia.
Diah also did not close the door on the possibility of using private insurance to top up JKN.

“That is still under discussion; a key leader here is Bank Mandiri. I say we give two or three years more before we see any substantial improvements in this,” she said.

Tech key to boosting services
One of the best ways to standardize processes and improve care across the archipelago is through the use of technology, said Romeo Lledo, President Director, Siloam Hospitals.

“To a certain extent, if you cannot find the medical record and the doctor is already there, that’s where guesswork comes in. That’s why patients get irritated because people keep asking the same questions, and that’s also where errors happen because the patient’s history is not available,” Romeo added.

“I think technology will play a really important role. One thing that we’d like to do is that as we expand, a patient in Jakarta, when he travels to Bali or to the east, they go to one of our hospitals and all his previous data can be extracted by the attending physician. Connectivity is very important,” he said.

Christopher Norton, Director, PwC South East Asia Consulting, added that big data can be used to ramp up preventive care across the archipelago, rather than being completely reactionary.

“I think one of the big things is how do you look at data on a macro scale in such a way that it can impact public policy. How do we look at health IT from a public policy perspective, as well as from an individual perspective? The big thing is medication management, discharge monitoring,” Norton said.

Jones of International SOS added that there is already a lot of data available on healthcare, and what policymakers could be doing with this data is the future of care in the region.

“Prevention is better than cure. My analogy is that rather than saving people when they are in the river, we should move upstream and prevent them from falling in in the first place,” Jones noted.