Financial Protection Not Yet Optimal

KOMPAS/FERGANATA INDRA RIATMOKO

Several patients are accompanied by their family during a hemodialysis at Dr Moewardi Public Hospital in Surakarta, Central Java on Saturday (7/4/2018). Everyday, the hospital administers hemodialysis on 76 patients, mostly under the BPJS social healthcare insurance program. Patients can have the hemodialysis treatment two times a week for free. Those who do not have the BPJS need to pay Rp 900,000 per treatment.

The hemodialysis room at Dr Soegiri Regional General Hospital (RSUD) in Lamongan regency, East Java, was full of patients queuing for dialysis at around 2 p.m. on Friday (6/4/2018). Seventeen dialysis machines were being used to serve the patients. One special dialysis machine for hepatitis B patients was empty.

In the room, 70-year-old Mustaji of Madulegi, Sugio district, called for the nurse. He felt that something was leaking from where the machine was attached to his wrist. The nurse fixed it immediately and attached a tube that was connected to the hemodialysis machine.

Mustaji has had the liver disease and required routine dialysis for eight years. These days, he needs to undergo the procedure twice a week to clean his blood. Fortunately, as a National Health Insurance (JKN) recipient, he is not burdened by the costs of the procedure. “I hope the program will be continued, as it helps poor people like us,” he said.

Hamdan Lutfi, 56, of Paciran, also said that he received assistance as a JKN participant. Now, he is a Class I independent participant with a monthly premium of Rp 80,000 (US$5.84). This is much lower than what he pays for one dialysis procedure, which costs Rp 860,000 including medicines. “Who wants to be ill, anyway? Nevertheless, by participating in BPJS [the Healthcare and Social Security insurance program], I can receive many benefits at a low premium. You can only appreciate it if you’re ill like me,” said the man who once worked in Brunei.

For his dialysis treatment, Hamdan travels 45 kilometers on a motorbike from Paciran to Lamongan. “If I hadn’t registered with the BPJS, I have no idea where I would have gotten the money for the procedure. I need routine dialysis,” said Hamdan.

Implemented in 2014, the JKN program aims to provide healthcare coverage to all citizens. Through the program, the government intends to fight the stigma that people will go broke when they become ill. The people’s access to healthcare facilities is wide open. The JKN offers a wide variety of benefits. The hope is that the people can obtain high-quality health services without spending all their money.

Many have enjoyed the benefits of becoming a JKN participant. Mustaji and Hamdan are just two examples. They are no longer worried about soaring healthcare costs. Some 194.7 million Indonesians, including Mustaji and Hamdan, are registered as JKN participants.

The large number of participants, a wide range of benefits and financial protection for all participants are among the government’s lofty ambitions for the JKN program in its effort to provide universal healthcare in the country.

In a written statement, World Health Organization (WHO) Regional Director for South-East Asia Poonam Khetrapal Singh said that universal healthcare was a foundation of improving public health and welfare and a fundamental human right. It was important for a country’s welfare, as a healthy population would improve a country’s economic productivity.

Additional costs

However, in many cases, JKN participants are still required to pay for additional healthcare costs out of their own pockets, which are burden to the patients.

Pipin, 36, for instance, looked disheveled on Wednesday (4/4) in his rented house in Sukamaju village in Majalaya district, Bandung regency, West Java. He has suffered from an enlarged heart for a year. He has been recovering, but the condition never completely goes away. “I am always worried when he looks exhausted. I am worried that the illness will return,” said his wife Yuyun, 32.

It was not the only thing she worried over. Her husband’s huge medical costs – that she will need to pay if her husband’s illness returns – looms over her mind. As a Class III JKN participant, Pipin is eligible for medical cost waivers, and does not need to pay anything for his two-week treatment at Majalaya Regional General Hospital (RSUD).

However, he must go for a checkup once a month. The textile factory worker, who has a monthly salary of Rp 2 million, often has to pay for his medicines himself. “The hospital says that it does not have several medicines in stock, so I have to buy them at a pharmacy outside the hospital. Consequently, I have to pay for them with my own money. It costs around RP 110,000 a month,” said Pipin.

In Aceh, 39-year-old Erliani of Alue Nireh village in Pereulak district, East Aceh regency, is another example. Despite being a JKN participant, she still needed to pay a lot of money to take care of her 3-year-old daughter, Khusnul Hamidiah. Khusnul has problems with her kidneys, heart and lungs, and she also suffers from malnutrition.

When Khusnul was treated in 2016 at East Aceh’s RSUD Zubir Mahmud, Erliani paid Rp 1.5 million for her daughter’s IV fluid. After her daughter was referred to RSUD Zainal Abidin in Banda Aceh, Erliani had to pay Rp 300,000 as security deposit for a pouch of blood. The money will be returned when Erliani replaces the blood.

Erliani said she had difficulties finding donors to replace the blood. “Often, I have to pay for the medicines. The doctor gave me a prescription,” she said.

As she could not pay for the medicines, Erliani once brought her daughter home from the hospital mid-treatment. Erliani has 11 children; Khusnul is her tenth child. She has suffered from malnutrition since she was 9 months old. Erliani and her husband Muhammad Ali work odd jobs.

BPJS Kesehatan Banda Aceh head of insurance benefits referral Cut Novarita said the program covered all medical costs of JKN patients. Medicines not included on the national formulary could be provided to patients in accordance with their diagnosis and upon a recommendation from the hospital director or the medical committee chief.

“Patients must not be burdened with the cost of purchasing medicines,” said Cut. Patients experiencing such issues could report to the BPJS Kesehatan, which would follow up on all reports.

(ACI/SEM/AIN/ADH)