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A healthcare revolution in the regions

Regional governments around Indonesia are devising new and ambitious free healthcare schemes for their electorates, but to what end?

Edward Aspinall and Eve Warburton

warburton1‘Improve the free medical service for a glorious South Sumatra’: having lost in Jakarta, Alex Noerdin is running for re-election this year in his home province, relying heavily on his healthcare program - Edward Aspinall

Over the past decade, Indonesia has witnessed an explosion of local health insurance programs, or Jamkesda (Jaminan Kesehatan Daerah). The nature and scope of these schemes vary greatly from region to region, but most involve a district or provincial government subsidising basic medical services for residents. Sometimes the services are provided free to all residents, more commonly just for the poorest. While accurate data is hard to obtain, the World Bank recently estimated a rise from some 60 district insurance schemes in 2008 to over 300 in 2010. This means that a majority of Indonesia’s districts have such local schemes in operation, and the number keeps growing. What accounts for this sudden spike over such short period?

The surge in local healthcare programs is directly related to democratisation and local electoral politics. Populist campaigns have become a prominent feature of Indonesia’s regional elections, as candidates promise free social services, like healthcare or education, in a bid to appeal to voters. The new political salience of healthcare at the local level (and at the national level too) amounts to a near revolution in the way politicians engage with their electorates.

Since the fall of the Suharto regime in 1998, people in Indonesia have become used to accounts of oligarchic politicians who manipulate legal processes and use the power of money to gain power at the local level. The spread of local healthcare schemes shows there is more to the story. Politicians are realising that their electorates want better social welfare and public services, and many are trying to respond. However, the impact so far on healthcare standards and indicators has, sadly, been far from revolutionary.

A history of healthcare

Local governments first began delivering health insurance back in 2003 when Megawati Soekarnoputri’s government introduced the Health Service Insurance for Poor Families program, or JPK-Gakin. The idea was for district administrations to implement their own community health insurance schemes in line with local needs. However, few programs ever really got off the ground before Susilo Bambang Yudhoyono’s new government introduced a bill that laid the foundation for a nation-wide program and made JPK-Gakin redundant, Law no. 40/2004 on a National Social Security System (SJSN). At the same time, Yudhoyono’s government introduced a program to provide free, but rather basic, healthcare to the poor - Askeskin (heath insurance for the poor), which was replaced in 2008 by Jamkesmas (community health insurance).

Some regional administrations put up a fight. In 2005, East Java’s government spearheaded a challenge at the Constitutional Court claiming that SJSN gave the central government a monopoly on social service provision and contravened the constitution and Law no. 32/2004 on Regional Governance. The court agreed that SJSN did not prevent local governments from developing their own social security programs, including for healthcare. Since then, the number of local health insurance programs has multiplied year on year.

One of the pioneering schemes was Jaminan Kesehatan Jembrana (JKJ) introduced in 2003 by Gede Winasa, the head of Jembrana district in Bali. Under this scheme, all members of JKJ, whether poor or non-poor, get free primary care from public and private providers. Residents identified as poor get secondary and tertiary care as well. Funding comes primarily from the district budget, with some central and provincial government subsidies. Winasa had previous experience in the health sector, both as a dentist and as a health bureaucrat, and he was widely praised for his vision and effective leadership by the media. It seems that many politicians around the country looked at the good publicity he received, and his popularity with voters, and free healthcare schemes began to spread like wildfire.

Most Jamkesda programs offer basic care at community health centres (puskesmas), and usually just for the poor who aren’t covered by other programs, like the national scheme Jamkesmas. But in resource-rich regions like Aceh, healthcare programs are far more generous. In 2009 Aceh’s then Governor, Irwandi Yusuf, introduced the Jaminan Kesehatan Aceh program. Like the scheme in Jembrana, JKA offers universal coverage for all residents of Aceh, and it caused a dramatic spike in the uptake of health services with the result that some local hospitals have struggled to cope ever since.

JKA also covers virtually all ailments and patients with complicated conditions can be flown to hospitals in Jakarta to receive treatment. Costs are so far about Rp. 400 billion (US$41 million) per year. Officials on the border of Aceh report that people are crossing over from North Sumatra to obtain Aceh identity cards that will allow them to access free healthcare. The funding for JKA comes from ‘special autonomy funds’ paid by the central government as a result of the 2005 peace deal that ended the separatist insurgency in Aceh.

Even in the poorer regions of Indonesia, local administrations feel compelled to offer some kind of free or heavily subsidised health service. In Kupang, the capital city of one of Indonesia’s poorest provinces, East Nusa Tenggara, the government introduced an insurance program that offered free basic care at public hospitals to residents not covered by alternative schemes, like Jamkesmas. Meanwhile in Central Lombok, rather than providing basic healthcare coverage, the district head promised an even narrower program that offered free maternal heath services to pregnant women.

Driven by politics

Local free healthcare schemes mostly have their origins in elections. Over the last five years or so, candidates competing for local office right across the country have made promises of free healthcare and other services in a bid to mobilise support. The model is so widespread that most local politicians see it as a basic ingredient of a winning campaign nowadays. Some of the politicians offering these schemes, like Gede Winasa, have reputations as reformers, but many of them are machine politicians and oligarchs of the traditional sort.

warburton2Local politicians have to be seen to care about healthcare: the former head of Bireuen district in Aceh, Nurdin Abdul Rahman, talking to journalists at the district’s main public hospital, Edward Aspinall

Alex Noerdin, the Golkar-affiliated governor of South Sumatra, for example, has made healthcare a central component of all his recent political bids. As the head of the resource rich district of Musi Banyuwasin in South Sumatra, Noerdin fulfilled his campaign promise to provide free healthcare to all residents in 2006. Noerdin then capitalised on this success and made free healthcare a cornerstone of his bid for South Sumatra Governor in 2008. Once elected, Noerdin introduced Jamsoskes Semesta, an insurance program that provides all South Sumatran residents access to free health services at government hospitals and community health centres.

In 2012, Noerdin ran in Jakarta’s gubernatorial election and adopted the same approach. According to the media, his campaign team was even given material incentives (cash, trips to Mecca, motorbikes) to sign up Jakarta residents to an insurance plan offering free healthcare. Membership would kick in following Noerdin’s victory. This time it wasn’t enough, and Noerdin didn’t win the governorship. But the successful candidate, Joko Widodo (‘Jokowi’), made his own healthcare promise – the ‘Healthy Jakarta Card’ offers Jakarta residents free care at puskesmas and class III hospitals all over the city. Jokowi promised a significant improvement on the Jamkesda program introduced by the previous governor, Fauzi Bowo, earlier in 2012. Fauzi’s scheme only offered free care to poor residents at a limited number of hospitals. Jokowi’s new program is open to all Jakartans and is expected to cover around 4.7 million residents by the end of 2013.

The Jakarta election is a good example of the dynamic now in play through regional Indonesia. Many local elections have become virtual bidding wars, in which rival politicians offer ever more generous health insurance schemes (alongside other campaign promises and inducements) to entice voters. Alex Noerdin, after losing in Jakarta has returned to South Sumatra where in 2013 he will stand for re-election as governor, again relying in large part on his record or healthcare policy reform. Rather than running to other issues, his rivals point out the deficiencies in Alex’s scheme, and are promising even more generous coverage.

False promises?

Yet for all the various healthcare initiatives that have emerged at district and provincial levels, the overall picture is one of deteriorating health indicators and services across the country. A 2008 World Health Organization report found that decentralisation has led to the erosion of a once unified health system, seriously undermining the quality of disease surveillance and public health programs. Diseases like polio and leprosy, once under control, are reemerging and the districts are not able to address these or other complex diseases like avian influenza (see Scott Naysmith’s article in this edition).

Health experts are sceptical of local programs that are introduced by district officials with little knowledge or experience in the health sector. The fact that many schemes are designed primarily to attract votes often means that they do not meet the community’s complex health needs. And some regions are struggling to cope with the costs. In East Java, where the government once agitated for regional administrations’ right to implement local programs, healthcare services are overwhelmed and underfunded. In 2010, the program was badly in debt, with a budget allocation of just Rp50 billion (a little over $US 5 million) and costs totalling Rp112 billion. This kind of blow-out is not uncommon. Often it happens because poor health infrastructure cannot deal with the sudden spike in demand that comes once services are offered for free. Sometimes the problem comes when officials incorrectly (and often corruptly) identify residents as ‘poor’ and thus eligible for free services, leading to overburdening of the system.

In fact, health insurance may soon no longer be the vote getter that regional politicians have come to rely on. In 2012 the national parliament passed the bill on Social Security Administering Bodies (BPJS), bringing important parts of SJSN into effect. The new bill basically recentralises social security administration and makes one non-profit body responsible for implementing a nation-wide health insurance program for all Indonesians, including the poor and those working in the informal sector. In theory, all the local programs will now be folded into this nationwide scheme. The tentative beginnings of universal social protection, even of an Indonesian welfare state, are now visible.

To be sure, Indonesia’s system of public health is beset by deep problems, many of them made worse by the policy incoherence that has come with political democratisation and decentralisation (see Elizabeth Pisani’s article in this edition for a catalogue of some of the worst problems). In the regions, ordinary people still bemoan the quality of the healthcare they can get in the public system, and people who can afford it will go to private providers or even overseas. But in many places, too, it’s now easy to find people who speak with amazement and delight at the fact that they or family members have been treated for serious complaints without paying a thing. Politics is leading the way in opening up a system of comprehensive and free healthcare coverage. It might just end up leading to the delivery of better quality and more effective healthcare services too.

Edward Aspinall (edward.aspinall@anu.edu.au) researches Indonesian politics at Australian National University and is an editor of Inside Indonesia. Eve Warburton (evewarburton@gmail.com) is a research assistant at the Department of Political and Social Change, Australian National University, and administrator of the Sydney Southeast Asia Centre, University of Sydney.


Inside Indonesia 111: Jan-Mar 2013