Interview: Romeo Lledo

How would you assess the recent noteworthy improvements in the health sector ?

ROMEO LLEDO: The highlight of 2015 in the health sector was the consolidation of the universal health care programme, Jaminan Kesehatan Nasional, under the name Healthcare and Social Security Agency (Badan Penyelenggara Jaminan Sosial Kesehatan, BPJS). This new scheme was successful in attracting 130m members by the end of 2014. In 2015 the government required all employed Indonesians to be BPJS members as part of its efforts to raise funds for the programme. The health insurance programme aims to cover all Indonesians – the fourth-largest population in the world with around 250m people – by the end of 2019. With the BPJS , primary care is provided by general practitioners in the government’s health centres, known as Puskesmas. These centres are becoming acceptable among the majority of Indonesians, and the general practitioners are improving their clinical skills due to their exposure to the different cases they encounter in their practices. In the private hospital segment, we can see other players becoming aggressive in their expansion plans. Hospital groups are going public, or inviting investors to raise funds, to increase their bed capacity and investments in medical equipment to enhance health care services.

What amount of the national budget should be allocated to health services?

LLEDO: For the 2016 national budget, the 5% appropriation for health care represents 1% of Indonesia’s GDP. Total health care expenditure (THE) is 3.5% of GDP. General government health expenditure (GGHE) was estimated at 40% in 2012, or 1.4% of GDP. Based upon these figures, and using the 2012 40% GGHE to the estimated THE, the 5% appropriation from the national budget would not be enough, even assuming that GGHE will remain at 2012 levels. At least 7% of the national budget is needed. By comparison, in 2013 Singapore spent 4.5% of GDP and 1.6% GGHE, Malaysia 4.03% to GDP and 2.17% GGHE and Thailand 4.6% to GDP and GGHE 3.63%. Now, to make the budget expenditure more efficient, it is important for the government to be able to coordinate with hospitals. The trend is for the government to lower costs, but hospitals still need to be profitable, and small hospitals can be led into bankruptcy. We cannot afford to have certain hospitals losing money and closing their doors, as it is very important to reduce the gap between supply and demand. If we have a big budget allocation and it does not address the outcomes, we will face problems in guaranteeing good coverage for the Indonesian population.

What are the main challenges to achieving Indonesia’s goal of universal health coverage by 2019?

LLEDO: The main challenges can be separated into two types, first by looking at middle-class and high-income Indonesians, and then at the poor and nearly poor Indonesians. The former need to be convinced to enrol in the programme. Currently, Indonesians in these segments are not attracted to the benefits and infrastructure of the BPJS as they want to choose their own doctors, and want the privacy of having their own rooms, which the BPJS does not offer. For the latter, the issue is more about how to reach these people and make the necessary facilities accessible to them. This is possible, provided the government launches the needed infrastructure and support facilities to address the aforementioned challenges.

How can the government respond to the human resources needs of the health sector?

LLEDO: Currently, medical schools in Indonesia only produce about 2000 general practitioners and 800 specialist doctors annually. To help close the gap the government could consider ideas such as facilitating “joint collaborations” with professionals from abroad.