President Jokowi has chosen Dr. Terawan Agus Putranto as the health minister for the second term of his administration. What is the direction of the Health Ministry’s health policy to answer challenges in the future?
Before getting there, it is better for us to review the achievements of the health sector over the past five years. The most monumental breakthrough of the first period of Jokowi’s administration was the application of national health insurance through the Social Security Management Agency (BPJS). This is arguably a revolutionary policy in the health sector. Nevertheless, this policy still bears serious problems. The main problem that has not been resolved until now is the overdraft of BPJS financing. Hundreds of partner hospitals have not been paid by BPJS, causing some to go bankrupt.
The commotion of the BPJS deficit has colored news throughout the year. Indonesia has the second highest prevelance in ASEAN (under Timor Leste) in terms of the number of stunted children due to lack of nutrition. This is certainly not something to be proud of.
Challenges in the future
Jokowi has emphasized the importance of human resource development in the second period of his administration. He is very interested in the use of digital technology. Jokowi points out the importance of making use of Industry 4.0 to advance governance and encourage millennials to drive community initiatives and boost the economy. Millennials are expected to be the locomotive that pulls the carriages behind it to pursue progress. If this scenario is successful, a demographic bonus in the form of an explosion in the productive age population will contribute greatly to growth and progress. But, if it fails, the demographic structure will become a national burden.
With this description, what is the direction of the Health Ministry’s policy in the future? The Health Ministry has actually prepared. The presentation “The Health Ministry’s Policy Facing the Industry 4.0 Era” delivered by the expert staff at the Health Ministry for Health Technology and Globalization, Slamet and Didik Budijanto, at the seminar “l” at Airlangga University, Tuesday (12/11/2019), mentioned the Health Minister Regulation No. 46/2017 about e-health implementation strategies.
Four main points: strengthening governance; increasing investment and choosing the right strategies to accelerate e-health implementation; expanding and improving health services based on ICT applications; and arranging standardization of health informatics up to overcoming the complexity of the health care system. So, the Health Ministry since 2017 has prepared itself to welcome the Industry 4.0 fever in the interests of developing health policies.
The e-health road map includes e-planning, e-reporting, e-registration, health service information system, health service facility information system, and artificial intelligence for health services. For example, a platform built to record all hospitals in Indonesia and their management (hospital profiles, human resources, number and occupancy rate of the rooms, diagnosis, medical records, pharmacies, drug stocks, personnel, payroll, financial accounting, etc.). There is also an online registration application, through which a patient’s device can arrange reservations for the visits by selecting the hospitals/clinics, the date and time of the visits.
Furthermore, the Health Ministry has welcomed telemedicine through Helath Ministerial Regulation No. 20/2019 on the Implementation of Inter-health Telemedicine Services. Temenin (Integrated Telemedicine Technology for Your Medical Services) uses electronic transmissions to send images of Obstetric Radiology/ECG/Ultrasound images to patients who request consultation or for diagnosis. There is also a Sisrute (Integrated Referral System), which links patient data among service facilities [fellow community health centers (puskesmas), between puskesmas and hospitals, or vice versa). However, in general the response of the health sector to Industry 4.0 trend is still slower than other sectors. Banking, for example, is much earlier to implement e-banking. Despite being slower compared to other sectors, the Health Ministry’s response to Industry 4.0 deserves support.
Then what about the role of the private sector? As has widely been known, the private sector has moved faster than the government. Digital application-based health services have been widely applied. At least there are several health applications that are already popular, such as HaloDoc, Alodokter, Dokter.id, klikdokter, tanyadok, doktersehat, Go Dok, Home Care 24, media people, rilif, patienia, ApotikAntar, and LabConX. They are on average platforms which provide a variety of information about health, with citizen consultation services to doctors, ordering and delivering of drugs, health education and others.
If the government and the private sector move together to welcome Industry 4.0, it is hoped that the national problems in the health sector will be better addressed. Referring to the presentation of the Health Ministry, there are several major challenges, such as the high maternal mortality rate (MMR), infant mortality rate (IMR), and stunting; health financing; access and quality of health services; access to clean water; burden of infectious and non-communicable diseases.
The 2015 data shows that the MMR of 305 per 100,000 births is still very high. Meanwhile, the MDGs target of 102 per 100,000 births, which was originally targeted to be achieved in 2015, failed to achieve it. For IMR, 2014 data shows 190 IMR per 100,000 births, far above Vietnam which has reached 49 IMR, Thailand (26), and Malaysia (29). We are less healthy than Vietnam, Thailand and Malaysia. With regard to the stunting cases, WHO 2017 data shows that the prevalence of stunting cases among toddlers under five years old in Indonesia is 36.4 percent, the highest in Asia and third in the world. The 2018 Basic Health Research data shows the rate of cancer fell to 30.8 percent. It did go down, but it was still far from the WHO standard of 20 percent.
Difficult access to clean water can be illustrated in the 2017 drinking water survey in Yogyakarta, with 89 percent of water in general and 67 percent of household drinking water being reported to be contaminated with fecal bacteria. In fact, Yogyakarta is quite a developed area. What about inland residents outside Java? The difficulty in the access to clean water is strengthened by the Unicef report which records that 26 million Indonesians do not yet have toilets to defecate.
Meanwhile, for national health insurance (JKN), it is indeed burdensome when it comes to funding. The government has decided to increase BPJS fees starting next year, which so far has been responded to by the community less positively. This is very difficult. At a time when the global economy is in decline, our economic growth is also falling, the government is struggling to increase state revenues, including by raising the cigarette excise tax. According to some health experts, besides reducing the rate of growth of novice smokers, the additional income from cigarette excise can cover the BPJS deficit.
In such a situation, how big is the role of e-health to answer the challenges and problems of the health sector? E-health is believed to provide great benefits to health services. Basically, e-health can simplify, cut time and costs on various types of health services. A simple example of the benefits is the national medical record database, which can be accessed by authorities such as doctors.
If a Surabaya resident is in Manado and suddenly falls unconscious, enters the local hospital, the doctor no longer needs to ask for a bundle of medical records from the hospital in Surabaya. Just open it in the national medical record database to help diagnose the patient. Or the patient registration system via a smartphone app will cut the queuing time. And a series of other benefits. However, don’t be amazed simply by remembering the Javanese saying ojo gumunan. It does not mean that e-health is without risk. We know, one of the biggest dangers in today’s digital age is data theft. Both are done sophisticatedly by hackering/crackering or by simple manual methods, such as when a shopping center salesperson/restaurant waiter steals credit card data from the customers they use to pay, and then sells them to illegal buyers.
Database of medical records, for example, will be the target of many parties who will try to get them either legally or illegally. In countries where law enforcement is very advanced, such as in the US and European countries, data theft scandals are very widespread. Spyware software that is infiltrated into citizens’ e-mail systems to spy on and steal data is no longer a strange item. Let alone in our country where the law is still stumbling, the danger of theft of medical data is not something difficult to happen. Designers, developers and e-health users must anticipate this risk from the start. Hopefully with e-health, our health services will be more advanced and affordable, and also safe.
Djoko Santoso, Professor of Medicine at Airlangga University, Surabaya; Founder of rumahginjal.id
- revolusi industri 4.0
- national health insurance
- social security management agency