Indonesia is the world’s largest archipelago with over 17,000 islands. It is also the 4th most populated country with more than 240 million people. With a population that large, Indonesia is made up of a variety of religions, ethnic groups and languages. Finding that it was lacking in healthcare infrastructure and coverage as well as in other areas, they began to make changes in the late 20th century. Life expectancy went up and under-five and infant mortality went down. But by 2010, around only 56% of Indonesians, mostly state employees, low-income workers and those who could afford private coverage had some form of health insurance.
So, in 2014 Indonesia launched Jaminan Kesehatan Nasional (JKN), a plan to implement universal health care with the goal of reaching 100% coverage and free basic care for everyone within a few years. The program is run by the Social Security Administrator for Health (BPJS) agency and every citizen is required to join the program. JKN exceeded its target for enrolling members in its first year (registering 133.4 million members compared to a target of 121.6 million). Currently, JKN covers more than 80% of the Indonesian population with plans to still reach total coverage. There are reports that customer satisfaction rates were 81%, awareness of JKN was 95% and that complaints had been resolved within 2 days.
The Indonesian health system has a mixture of public and private providers and financing. There is the central Ministry of Health which is responsible for the management of some tertiary and specialist hospitals, setting of standards and regulation, among others. Provincial government is responsible for the management of provincial-level hospitals and monitoring of district health services. District/municipal governments are responsible for the management of district/city hospitals and the public health network of community health centers, called puskesmas, and other subdistrict facilities.
People who are employed formally pay 5% of their salary, with 1% being paid by the employee and 4% being paid by their employer. Government workers pay 3% while the government pays 2%. Informal workers and the self-employed pay a low fixed monthly premium. Those enrolled in JKN are eligible to receive free health services ranging from dental check-ups to serious procedures like organ transplants. Despite all the new coverage under the JKN, out-of-pocket costs remain high. For those who can afford it, private health insurance is preferred due to the better run facilities and higher quality of care.
One of the areas of healthcare that has made great progress but still needs improvement is in maternal and infant care and mortality. Maternal and newborn care practices in Indonesia are strongly influenced by diverse local belief systems. Central among these beliefs is the role of fate or God’s will in the outcomes of pregnancy and delivery, including the idea that “little can be done to save the life of a pregnant woman or newborn.” Partly because of JKN, Indonesians now understand the medical benefits of maternal and neonatal care. Infant mortality rates have nearly dropped in half from 2000 to 2018. Maternal health has improved due to JKN providing unlimited access to prenatal, postnatal and antenatal services. However, rural woman are still more likely to birth at home or in understaffed facilities compared to urban woman who are more likely to give birth in a hospital.
While Indonesia has made great strides in improving their healthcare system and bringing coverage to the population, it still has a way to go. As of 2020, the cost of premiums has gone up. The JKN has been criticized for being over-ambitious, a lack of competency and not addressing the need for improved healthcare infrastructure in remote areas. There is a stark difference in the quality of care in urban and rural areas as well as between private and public hospitals. They have increased the number of hospital beds to well over 2,000 but they are still lacking. Public health facilities are overcrowded and have long wait times. There are also not enough doctors. However, Indonesia is still determined to make the JKN work.