Amid mounting reports of difficulties in accessing the country's nascent "universal" health-care system, the Social Security Administrator for Health, or BPJS Kesehatan, the public was appalled to learn of the death of 4-month-old Tiara Debora in West Jakarta earlier this month, apparently due to the hospital withholding crucial emergency treatment because the patient's parents failed to pay a deposit.
The scandal has reinvigorated public debate on the issue of humane health care for ordinary Indonesians. More importantly, it has brought the problems currently afflicting the health-care industry to the fore.
The hospital in question, Mitra Keluarga Kalideres, is part of the most extensive private hospital chain in Indonesia, but not affiliated with BPJS. So when the physically distressed Debora was admitted by her parents, the hospital management asked for deposit of Rp 11 million ($830) before their baby would be admitted into the pediatric intensive care unit, a normative practice at Indonesian private hospitals. Alas, the parents only could come up with Rp 5 million and Debora was duly refused service. While waiting to be transferred to another hospital affiliated with BPJS, Debora died.
Debates have raged among Indonesia netizens whether the blame lies with the hospital or the parents. Most have argued that the hospital, out of humanity, should not have denied Debora emergency services even though it was unaffiliated with BPJS. Others have pointed out that her parents were either ignorant of BPJS procedures or deliberately disregarded them because they should have taken their baby to another hospital affiliated with the government-operated health-care system in the first place.
It has always been understood by the Indonesian public that hospitals unaffiliated with BPJS will refuse services to individuals using BPJS. It is also common knowledge that even affiliated hospitals tend to give BPJS patients second-class treatment due to allegations that government compensation under the system is unreasonably paltry.
Based on these commonly held assumptions, Mitra Keluarga Kalideres was initially seen to have broken no protocol. Taking into account the reports of delayed payments by the government to affiliated hospitals, it was almost understandable why an unaffiliated facility would want to stay clear of the BPJS maze of uncertainties.
But judging from the reactions by the majority of Indonesian netizens, the hospital's fault was not one of procedure but morality. The public finds it unacceptable that an entity within the health-care industry should be so solely driven by profit, forsaking the inherent element of service to humanity. The public condemnation of Mitra Keluarga was so adverse that the hospital chain's shares took a beating following the scandal.
Wading into the debate and anxious not to share the blame, government agencies responsible for health care were keen to chastise the hospital management, which subsequently apologized to Debora's parents and the public. BPJS Kesehatan public relations officer Irfan Humaidi, for instance, insisted that under a 2014 ministerial directive, all hospitals, either affiliated or unaffiliated, are obligated to provide emergency services to BPJS patients. Humaidi also said unaffiliated hospitals are able to claim the costs of emergency treatments from his agency.
While there is no doubt the directive he referred to does exist, this must have come as news to most people in the country. Ordinary BPJS participants have always been told to report to the appointed local health clinic (Puskesmas) first and use the services of affiliated hospitals during an emergency. The sudden invocation of a hitherto obscure (and unimplemented) directive, if anything else, hints at the slipshod nature of BPJS operation by government agencies.
Since its inception in 2014 under the presidency of Susilo Bambang Yudhoyono, BPJS, without overlooking the services it has performed for ordinary Indonesians, has been less than ideal in providing reliable health care for its clients. There were signs when it was inaugurated that it was far from ready to take on the enormous task of dispensing health care to Indonesia's more than 250 million people.
In his speech during the BPJS's inauguration, then outgoing President Yudhoyono said he was proud to be able to leave a legacy of "universal health care" to the nation, even though BPJS had hardly roped in enough hospitals to do what it was required to do. In leapfrogging the new agency into action just before his departure from office, the president may have done it irreparable harm and started a culture of haphazard improvisations.
Three years into its operation, BPJS has clearly failed to command the services of all hospitals in the country, including the largest private operator, Mitra Keluarga. Its meekness before health-care industry behemoths is in marked contrast to its strong-arm tactics in dealing with fee-paying BPJS participants.
From the initial advisory encouragement for ordinary Indonesians to participate in the program through the payment of a low monthly fee, BPJS has now enacted a rule that a personal application for membership is only accepted when all the individuals listed on the client's Family Card (KK) are also registered on the system. Participants in its sister program, the Employees Social Security System (BPJS Ketenagakerjaan), have their wages automatically deducted to pay fees for members of their nuclear families.
A government regulation mandates all hospitals to have been affiliated with BPJS by 2019. While this may sound encouraging in terms of what BPJS should be: a truly "universal" health-care system for all Indonesians, the projection may run into difficulties as the agency continues to produce budget deficits from year to year. In 2015, it posted a deficit of Rp 6 trillion, followed by Rp 9 trillion the following year. It remains unclear whether the deficits were largely borne out of mismanagement by the agency, or abuse by its affiliates.
Tiara Debora's untimely death and the scandal it unleashed expose the limitations and indeed inadequacies of Indonesia's trial government-administered "universal" health-care system. The incident has also informed the government of public expectations of what the system should be: a user-friendly, nonprofit-oriented health-care regiment accessible to all Indonesians, regardless of economic status. The ball is now clearly in the government's court.
Johannes Nugroho is a writer from Surabaya. He can be contacted at firstname.lastname@example.org and on Twitter: @Johannes_nos