Disease Prevention Efforts Sacrificed

KOMPAS/RIZA FATHONI

Activists declare a citizens\' movement to call for the processing of administrative documents to receive services from the Health Care and Social Security Agency (BPJS Kesehatan) at Cipto Mangunkusumo Hospital in Jakarta on Wednesday, Sept 19, 2018. The government is seeking other funding sources to cover BPJS Kesehatan’s deficit, including from the regional cigarette tax.

JAKARTA, KOMPAS – The government’s decision to use part of the regional cigarette excise income to cover the financial deficit of the Health Care and Social Security Agency (BPJS Kesehatan) has not been well received.

The measure will reduce the government’s support for health promotion and disease prevention, which means the long-term program to prevent people from being sick will be impacted. So far, efforts to promote public health and prevent diseases have not received enough funding from the government. At present, the public health efforts in regions still rely on the local cigarette excise. A strong public health effort could effectively prevent people from falling sick, but such an effort is not free.

The chairperson of the Association of Indonesian Public Health Experts, Ede Surya Darmawan, said in Jakarta on Wednesday that he appreciated the government’s plan to provide additional funds to help the BPJS cover its financial deficit. However, the approach taken by the government should be more systematic.

Initially, as stipulated in Health Ministry Regulation No. 40 of 2016, the proceeds raised from the regional cigarette excise were used to fund public health services related to the promotion of a healthy lifestyle and the prevention of diseases, rather than on curative services.

Activities that can be funded from cigarette excise include the program to reduce risk factors for infectious diseases, non-communicable diseases, including immunization, increased health promotion, family health, nutrition, environmental health, occupational health and sports. Cigarette excise funds are also intended to control the consumption of cigarettes and other tobacco products and for health services at first-level health facilities.

However, the regulation on the use of cigarette excise funds was then amended with the issuance of Health Ministry Regulation No. 53 of 2017. In line with the amended regulation, the cigarette excise can also be used to fund the National Health Insurance (JKN) program. Funding for the JKN accounts for about 75 percent of the allocation of health services. The JKN program is carried out by the BPJS Kesehatan as the operator.

Unbalanced

Health promotion efforts are unbalanced. The funds allocated to curative programs are far larger than those spent on disease prevention. Health promotion and disease prevention programs are also partly financed by health operational assistance and special non-physical allocation funds. However, at present the public health units (Puskesmas) have been preoccupied with serving the patients in the JKN programs.

Ede is worried that, with the government’s decision to use most of the cigarette excise for the JKN, people may consider smokers to be instrumental in helping the JKN program. "This may increase the number of smokers, because they feel they can help." In fact, however, smoking-related illnesses have been a burden on the JKN," he asked.

Meanwhile, the chairperson of the Association of Health Services, Krishnajaya, said Presidential Regulation Number 72 of 2012 on the national health system categorized the financing of public health services as a public good, which should be the responsibility of the government. Meanwhile, the financing of individual health efforts is a more private matter, except in the case of the poor, who should have theirs financed by the government.

Health offices in the regions have arranged a number of programs to promote public health services with the funds from the cigarette excise. The change in the allocation of funds from the cigarette excise will certainly affect their programs.

"The health offices are complaining about the change. Health promotion efforts are again sacrificed. As the facilitators in the regions, the health offices are powerless," Krishnajaya said.

Krishnajaya expressed hope the government would solve the JKN’s deficit by tackling the root of the problem. There must be another way to get the funding for the JKN program, rather than diverting funds allocated for public health services.

Presidential decree

President Joko “Jokowi” Widodo said at the State Palace that he had signed a presidential regulation on the JKN. The Presidential Regulation (Perpres) is primarily aimed at improving the JKN program, including efforts to cover the social security fund deficit in order to improve community health services.

Regarding the deficit, Article 100 of the presidential regulation states that 75 percent of the funds collected from the regional cigarette excise will be directly deducted by the central government to fund the JKN program.

The cigarette excise is collected by the central government. Regional administrations receive part of the cigarette receipts.

According to Article 31 of Law No. 28 of 2009 on regional taxes and levies, a minimum of 50 percent of the cigarette excise receipts must be allocated to public health services and law enforcement. However, based on the new presidential regulation, 75 percent of the funds will be transferred to the BPJS’s bank accounts.

"Whatever the name is, health services for the community must be carried out as well as possible. Thus, the deficit should be partly covered by the cigarette excise receipts," said the President.

In Banyuwangi, Finance Minister Sri Mulyani said the BPJS Kesehatan program should be redesigned. The government also continues to seek other measures, including a cost efficiency program and finding other funding sources, to reduce the BPJS Kesehatan deficits.

"The Finance Ministry, the Health Ministry, the hospital union, the local governments and doctors\' professional organizations must meet to jointly redesign the BPJS. This is necessary to make the BPJS sustainable not only in the medium term but also for the long term," he said.

(ADH/LAS/NTA/GER)