NO HEALTH WITHOUT WEALTH?

Do you have the same right to health as everyone else in Indonesia? Do you think you
would have equal access to the intensive care unit as someone without a job? In 1996,
the World Health Organization stated in its constitution “the enjoyment of the highest
attainable standard of health is one of the fundamental rights of every human being
without distinction of race, religion, political belief, economic or social condition.“
But what is the highest attainable standard of health? Is it really the same for
everyone?

Since 2014, Indonesia adopted a “universal” healthcare system through a social

security administrator for healthcare, known as BPJS Kesehatan, and as of September
2017 it has encompassed approximately 70 percent of the total population.

But access and standards of healthcare is far from the same for everyone.

Recently, reports emerged of a baby who died in a hospital in West Jakarta because
the family couldn’t provide the down payment needed for intensive care. The patient
had a BPJS card but the hospital was a private hospital unaffiliated with BPJS,
reinforcing the limits to the “universal” program.

The patient did receive appropriate emergency medical attention and intervention free
of charge, however to be admitted into intensive care, the patient had to provide down
payment or be referred to a BPJS affiliated hospital where vacancy in the intensive
care unit is most often scarce.

This incident led to warnings from the Health Ministry of the prohibition of down
payment requirement for hospital emergency care, regardless of health insurance
status. However, national regulations may be difficult for some hospitals to abide. A
few weeks later another incident occurred in a hospital in Cirebon, Central Java where
another baby died. It was a BPJS-affiliated hospital but the parents who were active
BPJS card holders were asked for down payment of Rp 1 million (US$73.88) for the
required caesarian. The hospital denied reports that the reason was because they
rejected the newborn’s entitlement to BPJS, as the infant was registered a few days
before being born while the card would be active 14 days after registration.

Although prohibited, it is very challenging for private hospitals not to demand down
payment for their services, given the cost of hospital treatment and procedures that can
easily surpass most Indonesians’ annual salary.

Hospitals are complex institutions requiring numerous resources to function, which

would not be possible without adequate funds. Continuous advancements of drugs and
treatments along with the high value of the medical profession and skill account for
the high-priced services.

BPJS has been criticized for not making things “financially easy” for hospitals to cater
to patients entitled to the universal scheme. Healthcare providers consider BPJS’s
prospective payment system which are based on hospital unit cost data are
underestimated and insufficient. Through this system, healthcare providers
must consider cost efficiency along with quality care in order to survive.

BPJS itself has had trouble collecting sufficient funds, being in outstanding deficit of
Rp 5.8 trillion in the first semester of 2017. BPJS had gone through multiple revisions
of its premium policy, now ranging from Rp 25,500 to Rp.80,500 monthly for each
participant. Yet it’s easy for independent participants to disobey paying the premium.

Unfriendly payment systems for healthcare providers have made it especially more
difficult for pricy private hospitals to cooperate. Since its implementation, BPJS has
made efforts to collaborate with private hospitals, aiming to include all hospitals in
the system by 2019; but as of now only 92 hospitals or roughly half of the hospitals in
the nation’s capital are affiliated with BPJS.

Meanwhile patients’ complaints continue on BPJS’s limited hospital access and taxing
tiered referral policy which dictates that patients must seek care from a primary
healthcare center before being referred to class D, C, B, and A hospitals in respective
order.

By regulation, hospitals unaffiliated with BPJS must provide emergency care to

holders of the BPJS card, but the care afterwards in unaffiliated hospitals would not be
covered. If the family or patient feels they couldn’t afford expensive hospital bills, the
patient would then be referred to BPJS affiliated hospitals, susceptible to delayed care.

BPJS has gone through many challenges since its implementation, reaping praise and
criticism. But clearly the “highest attainable standard of health” is not the same for
every individual even in a “universal” healthcare setting. Some say you cannot put a
price tag on health. As Mahatma Gandhi once said “it is health that is real wealth and
not pieces of gold and silver.”

In this real world, one would still need gold and silver to pursue health. Still, in its
pursuit one may also fail. Indeed health is no more of a right than it is a privilege.
Having money in the bank allows one to enjoy services unobtainable by those who
can only rely on national healthcare. Maybe it is not that the BPJS does not provide
for equal services, but that the national healthcare program is responsible for more
lives than the current situation can accommodate.

There is hope for a true universal healthcare system in Indonesia, one that would
satisfyingly accommodate healthcare providers, insurance institution, as well as its
participants, the people. It would need the effort, cooperation, and support of the
nation, but it is possible.

As the highest attainable standard of health is the fundamental rights of every human
being, as the WHO states, let’s not allow wealth determine the health of the people.