#HealthPerspective : The Condition of Implementing Universal Health Coverage and Future Challenges of Realizing Digital Health in Indonesia

Universal health coverage (UHC) has been identified as a priority especially in Indonesia, the World Health Organization, and the United Nations General Assembly. Since it was explicitly incorporated into the sustainable development goals (SDGs) as target 3.8, it still needs a lot of effort on promoting UHC. The principle of “no one must be left behind,” particularly in genuine support for primary health care (PHC); reliable domestic financing, which requires enlightened leadership and deliberate dialogue between finance and health sectors; harnessing and regulating medical and technological innovation; and mutual learning and harmonised aid among donor countries.

In Indonesia, PHC is provided by general physicians in government-owned healthcare centers and private healthcare facilities. There are more than 9754 district-level health centers nationwide, with various auxiliary health centers located in some sub-districts. Secondary and tertiary healthcare is provided by public and private hospitals in every city. Before the implementation of the national health insurance system, Jaminan Kesehatan Nasional (JKN), most health service costs were out-of-pocket. There were only health centers and a small number of select private PHC physicians had contracts with PT. Askes, an organization that provided health insurance for civil servants. Then, following the reform on January 1, 2014, the government began encouraging Indonesians to register as JKN members. This led to the establishment of more PHC facilities in contract with Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS for Health), a health insurance organization that replaced PT. Askes following the implementation of JKN. As a result, the payment system has changed from out-of-pocket to social insurance-based payments.

Under JKN, patients are encouraged to follow the strictly tiered referral system made possible by new regulations for payment eligibility by the BPJS for Health, except in the case of emergencies. Physicians must treat patients in accordance with Indonesian competency standards and clinical practice guidelines for physicians in PHC facilities. When necessary, PHC physicians can refer patients to C or D hospitals (secondary care providers); when higher specialization is needed, secondary care providers can refer patients to A or B hospitals (tertiary care providers). Despite these new regulations, there are many direct referrals from PHC physicians to A hospitals and many cases are treated in hospitals despite falling under the scope of PHC physician care. 

JKN has introduced several new programs providing guidelines for PHC physicians in patient care and treatment, such as the Management of Chronic Diseases Program for type 2 diabetes and hypertension, as well as the counter-referral, home visits, and health screening programs. Additionally, Indonesian PHC physicians typically work with colleagues and healthcare professional networks (e.g., networks of other physicians, dentists, nurses, midwives, pharmacists, and administrative staff). When PHC facilities can’t provide basic services such as immunization and family planning, PHC physicians can refer patients to other PHC facilities using these networks.

Strong primary healthcare systems are effective in reducing inequities of access by providing local services and facilitating continuous, comprehensive, and coordinated care. Strengthening primary healthcare systems to reduce inequities requires action on many fronts. Firstly, domestic financing and development aid should emphasise investments in essential services that can be provided at the community level and by basic health workers. Making essential medicines universally affordable and available is critical. Secondly, population of older people and the growing burden of non-communicable diseases are new challenges to national health systems. Two thirds of the world’s older people live in low and middle income regions. The preoccupation with infectious diseases and reproductive health has shaped the primary care systems in many countries. Older people, however, are more likely to have non-communicable diseases that require sustainable health care.

The next phase of UHC would require investments in reducing primary risk factors of adverse health outcomes to prevent or delay high-burden diseases such as cardiovascular disease, diabetes, and hypertension. This UHC phase would comprise URC (Universal Risk Coverage), as well as the national insurance would cover costs to reduce proximal risks at the individual and family levels. Besides that, investments in proper maternal care to enhance fetal growth and development would reduce the burden of neonatal and infant mortality and long-term risk for noncommunicable diseases. Improving on maternal care, including management of hypertension in pregnanc, diabetes and protein–calorie deficits would be important. However, transition to maternal multiple micronutrient supplementation would be an improvement over the iron folate supplement to improve infant birthweight and survival, especially for women who are anaemic and for infant girls, to enhance child cognition.

Another key aspect needed for successful implementation of UHC as well as URC would be a fully functional frontline digital health-information system and integrated health data, as planned in the future health strategy of the Ministry of Health of Indonesia by 2019. From previous experiences, frontline health centers, including doctors, midwives, vaccinators, nutrition workers and community health volunteers need to fill out paper registers with individual patient or client data. These data are not actively used to track services or target preventive care, whereas it is useful for patient-level analyses by routine reporting of aggregate monthly case data to the nationwide.

Technological innovations in healthcare (pharmaceuticals, diagnostics, devices, etc) for information and communication technologies could substantially change the way health services. Governments need an action by creating a regulatory environment that supports research and development, encourages equitable access to technologies and medicines, and protects the public against unintended harms.

These are possibly impact of growing digitalization on the health sector:

• Rapid falls in the cost of smartphones and access to the internet and in the development of low cost diagnostic technologies
• Development of smartphone applications that link information on symptoms and diagnostic indicators to advice on treatment
• Emergence of business models that enable information platforms to link to suppliers of goods, such as drugs, at scale
• Create platforms that maintain secure personal health records and enable people to link to different types of healthcare provider

Government of Indonesia’s action is needed to ensure the digital health and other information based technologies contribute to UHC, rather than to meeting the needs of a privileged minority, expanding markets for suppliers of drugs or diagnostic devices, or generating data for commercial use. Governments can work with development agencies to accelerate progress by shifting investment from pilots to routine efforts and by testing new forms of collaboration between public and private sectors.

However, Digital  health  professionals  also needs to actively  learn  from  each  other  through  peer-to-peer  knowledge  exchange  and  technical  assistance.  This  networking  allows  physicians  to  deliver  common  issues  around  digital  health  governance,  architecture,  the  use  of  standards  and  cost-effective  implementation  support.  There  are two major platforms for cross-country learning, sharing and collaboration across the region.

Author:

Frizka Aprilia, S. Ked

Junior Doctor

References:

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