Indonesia’s healthcare struggles to modernise

The flow of Indonesian patients going abroad or to the country’s large urban centres for medical treatment ranging from simple checkups to complex surgeries reflects both the challenges and opportunities facing the country as it tries to forge a more modern and efficient healthcare system.

A basic lack of trust in the country’s medical system is perhaps the biggest reason some 600,000 Indonesians now visit overseas hospitals every year, according to a 2015 report from the consultancy firm Roland Berger.

Ajay Mulani, the director of an English school in Jakarta, typifies the kind of scepticism most Indonesians have toward the country’s local medical profession, after his three-year-old son was diagnosed with cancer in early 2016.

“It was the biggest shock of my life. I was devastated and confused,” he told Global Health and Travel (GHT). “The doctors wanted to puncture my son’s spine to confirm the diagnosis, but I wasn’t comfortable with it because I thought something could go wrong.”

His bad experience with local doctors, who once misdiagnosed his father as having gallstones, is not uncommon in this country of 260 million and has led many Indonesians to conclude that “any major procedure shouldn’t be done in Indonesia,” he explained.

Wanting to give his son the best care possible, Mulani decided to take him to Singapore, where the attending doctor used a finger prick to take a few drops of his son’s blood for testing, and the speed as well as the simplicity of the procedure amazed Mulani.

“My son didn’t cry at all, while in Jakarta he cried a lot because a nurse took the blood sample from the vein.”

Thanks to cutting-edge technology, the test results were available within minutes. While obtaining the same results took a couple of hours in Jakarta.

AJAY MULANI WITH HIS SON DURING ONE OF THEIR VISITS TO SINGAPORE

Although new medical specialities, modern drugs, and the latest technologies are now gradually being introduced to Indonesia, stories such as Mulani’s highlight the still undeveloped nature of the country’s healthcare sector, explained Rhenu Bhuller, partner and senior vice president of healthcare at Frost & Sullivan.

This lack of “trust, access and availability” in Indonesia’s healthcare system is driving patients to leave the country in search of better healthcare.

In addition to a desire for quality treatments, another factor pushing outbound medical tourism has to do with the country’s geography as well as the easy access to flights connecting Indonesia with neighbouring countries. As an archipelago made up of about 17,000 islands, Indonesia’s geographic features simply make it easier for certain patients to travel overseas than to facilities within the country.

“If you live in areas like Medan, it may be cheaper to fly to Malaysia for treatment than to take a flight to Jakarta,” said Bhuller noting that the latest medications are widely available in Malaysia, where the costs of procedures are cheaper or comparable to those in Indonesia.

Manpower and infrastructure in short supply

Behind this massive loss of faith in Indonesian healthcare lies a chronic dearth of both medical professionals and adequate facilities to serve the people’s needs, a problem that is now one of the most pressing issues facing Indonesian healthcare, according to industry stakeholders and analysts.

Indonesia is “still an underserved healthcare market,” Romeo Lledo, president of Siloam International Hospitals, the largest operator in Indonesia, told GHT.

According to Lledo, the shortage of both doctors and hospital beds, and the fact that most specialists tend to concentrate in big cities like Jakarta or Surabaya, explain why domestic medical tourism is also widespread.“In our hospitals in Jakarta, about 40 percent of the patients are medical tourists from other areas of the country,” he said.

A country-by-country comparison shows just how far behind most other nations in the Asia-Pacific region Indonesia is in terms of medical resources.

For example, the country has only 0.3 doctors and 0.6 hospital beds for every 1,000 people, according to Health at a Glance Asia/Pacific 2016, a report by the Organisation for Economic Co-operation and Development (OECD) and the World Health Organization (WHO). In comparison, Singapore has 2 doctors and 2.1 beds, while the numbers are 1.3 and 1.9 in Malaysia.

SOURCE: ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT (OECD), 2016.

Data from the country’s Ministry of Health also show that Indonesian medical workers are unevenly distributed across the country, with nearly 50 percent concentrated in Java and Bali, according to Ernst & Young.

Cardiologists, oncologists as well as endocrinologists and orthopaedists are the specialists most in demand, Bhuller said. The growing urgency to address such shortages is captured by the rising incidence of chronic illnesses among Indonesians. In 2014, cardiovascular diseases, cancer and diabetes accounted for 56 percent of total deaths in Indonesia, according to Frost & Sullivan.

The scarcity of medical staff translates into long wait times and overburdened physicians who often don’t have enough time to communicate adequately with patients and end up having to delegate some of their duties to nurses, said Lledo.

Perhaps echoing the feelings of many Indonesian patients, Mulani said one of the improvements he’d like to see is for Indonesian doctors to make bigger efforts to provide patients with as much detailed information as possible about their condition.“In Singapore, the doctor guided us at every step, and his assistant was available 24 hours a day to explain what to do in case my son experienced any problems.”

The government commits to universal health coverage

Despite this grim picture, there is reason to be optimistic.

For starters, the overall health of the average Indonesian has improved dramatically over the past two decades. Rates of maternal mortality, for instance, have fallen by 56 percent over the last 10 years, while average life expectancy increased from 49 years in 1960 to 69 years in 2013, according to McKinsey & Company.

Looking to the future, the current government has shown a strong commitment to broadening healthcare access for all Indonesians.

In January 2014, it launched a national health insurance programme, called Jaminan Kesehatan Nasional (JKN), with the goal of achieving universal healthcare coverage by 2019.

While still in its infancy, the programme has been credited for making medical services financially accessible to large swathes of the population who were previously unable to receive care.

In the past, many Indonesians could only pray when dealing with a serious medical problem, “but now it’s different – they can afford the treatments,” Donald Pardede, director for health financing and health security at Indonesia’s Health Ministry, told The Wall Street Journal in October 2015. 

Partly as a result of JKN, the number of Indonesians covered by either public or private health insurance grew from 63 percent in 2012 to 68 percent in 2015, according to Yoshihiro Suwa, a Jakarta-based analyst with Roland Berger.

Rather than benefiting the poorest, however, those who are gaining the most from JKN are informal sector workers, like street vendors, noted Suwa. This is because medical services had previously been out of reach for this category of worker as they were too poor to pay for care out of pocket but were not indigent, which meant they could not qualify for public healthcare subsidies prior to JKN.   

Strong headwinds against universal health coverage

Despite JKN’s benefits, critics point to a number of limitations that are hampering the development of universal health care in the country.

“I think the programme is not fair for Indonesians living in remote areas, such as Papua or central Kalimantan, because right now it’s used mostly by people who live in big cities,” said Yaslis Ilyas, public health expert at the University of Indonesia.

Such concerns reflect the disparity in resources between urban and rural areas, as patients in underdeveloped regions have not been able to benefit from the new programme due to a lack of medical facilities, according to a study conducted by Gadjah Mada University in 2014, as reported in The Jakarta Post.

“Although people in rural areas pay the same premium as those living in cities, they don’t get the same access,” stressed Ilyas.

INDONESIANS WHO LIVE IN JAKARTA ARE AMONG THOSE WHO ARE BENEFITING THE MOST FROM JKN.

JKN is also proving to be financially unsustainable.

“Premiums are very low and benefits are huge, so the programme cannot support itself,” explained Ilyas, who sees either a significant increase in premiums or a drastic cut in benefits as the only effective way to balance the system.

Substantially raising premiums or lowering benefits, however, could place a heavy burden on many patients in a country where some 28 million people live below the poverty line and 40 percent are at risk of falling into poverty, according to data from the World Bank.

And while premiums for using services at first-rate hospitals were raised in April 2016, they covered only one part of the deficit incurred by Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS), the social security agency that runs JKN, said Mundiharno, BPJS’ planning and development director, to The Jakarta Post. For 2016, BPJS is projected to have a deficit of about IDR7 trillion, or US$525.5 million.

Given that most JKN members are non-contributory participants, one way BPJS could raise revenues is to expand the pool of contributory workers, especially middle and high-income Indonesians who can afford to pay the highest premiums, argues Suwa.

AS OF JANUARY 13, 2017, ABOUT 172 MILLION PEOPLE ARE COVERED BY JKN. THE MAJORITY OF THEM RECEIVE PUBLIC SUBSIDIES FROM EITHER THE CENTRAL OR THE REGIONAL GOVERNMENTS.

SOURCE: BPJS 

But affluent Indonesians prefer private insurance over public schemes, largely because they tend to visit private facilities that offer better services and shorter waiting times but may not accept JKN patients. Wealthy Indonesians also typically visit specialists rather than general practitioners, but specialist consultations can be booked only through referrals from general practitioners working in public centres, according to JKN’s rules. 

“Middle- and upper-class patients don’t want to line up the whole day in a public clinic to see a primary care doctor,” said Lledo.

This means that JKN will be unlikely to keep Indonesian medical tourists from going overseas for care. “I believe that people who have money will keep flying out for medical treatment because the national insurance scheme is more beneficial for those who have financial problems,” said Mulani.

In order to make JKN sustainable and more attractive for people with disposable incomes, Suwa believes that the government will have no choice but to subsidise the programme with more public funds. This will lead to enrolling more private hospitals under JKN and covering the treatments of non-contributory members.

“Even in developed countries, there is no universal healthcare coverage that is financially sustainable without government subsidies,” said Suwa.

With Indonesian government spending on healthcare as a percentage of GDP currently one of the lowest in the region, additional public funding of JKN in the years ahead would be in line with analysts expectations for future increases in public healthcare spending.

The private sector has a crucial role to play

For Indonesia’s public health sector to succeed, however, it will need to continue relying on the support of private actors to fill the large gaps in healthcare expertise and infrastructure across the country.

“I don’t think the government has managed to address the shortage of specialists, but I see growth and positive strides in the private sector,” said Bhuller, who also noted that private hospitals were upgrading medical equipment and attracting specialists from overseas, especially Indonesian professionals practising abroad, as well as expanding their capabilities outside Jakarta.

Siloam, for instance, is planning to build a number of new facilities throughout the country. The group, which already operates 23 hospitals, has 40 projects in the pipeline, 16 of which will be completed by the end of 2017, according to Lledo.

In addition to raising capacity, industry stakeholders are also making serious efforts to raise the bar for medical services in the archipelago, led by Siloam, which was the first provider to focus on quality. In 2006, the hospital received accreditation from the Joint Commission International (JCI), the gold standard in medical accreditation. Since then, the government has required all major public hospitals to obtain the JCI imprimatur.

Similarly, the Mayapada Healthcare Group is benchmarking itself against overseas providers, such as the National University Hospital and Changi General Hospital in Singapore, to improve its operations and achieve “internationally recognised standards,” Roger Finnie, chief operating officer of Mayapada Healthcare Group, told GHT.

Not content to focus only on urban centres, Siloam is also using telemedicine to provide physicians in rural areas with the support of specialists practising in major hospitals. Its general practitioners are trained to communicate online with specialists in Jakarta who can guide their less experienced colleagues in making diagnoses or even stabilising patients through emergency procedures, said Lledo.

“Telemedicine helps to determine whether the patient actually needs to travel for treatment or can receive it on the spot,” explained Bhuller. “This cannot replace the need for specialists but helps prioritise the most urgent cases.”

TELEMEDICINE IS ACTING AS AN EFFECTIVE TOOL TO CONNECT INDONESIAN PATIENTS AND GENERAL PRACTITIONERS IN RURAL AREAS WITH SPECIALISTS WHO ARE CONCENTRATED IN BIG CITIES. 

A work in progress

While the enourmous task of building up a modern healthcare system will tax Indonesia’s finances and capabilities for years to come, the country is on an upward trajectory.

One piece of unfinished business is the funding of universal healthcare, but Indonesia is not alone. Smaller countries have achieved universal health coverage, yet still struggle to make services affordable for the whole population.

“The issue of funding is not unique to Indonesia—health policymakers in established universal health coverage markets, such as South Korea and Taiwan, have long grappled with ballooning healthcare expenditures and are still looking for various means to resolve this issue without jeopardising the stability of the ecosystem,” according to Universal Healthcare Coverage in Indonesia, a 2015 report by The Economist Intelligence Unit.

Lledo acknowledges that, although Indonesia has a long way to go, it is on the right track to achieve universal health coverage.

“I think JKN is a very successful programme considering the size of the Indonesian population,” he said. “Currently, there are about 170 million JKN members and the majority of them are low-income people for whom the programme is a blessing because as long as they pay the monthly premium, their healthcare needs are fully covered.”

This story was originally published in the 2017 March issue of Global Health and Travel magazine