For Indonesia’s disabled poor, the aspirations of a salaried job, attendance at a university, of having a home or a car or savings are far off. We would like to open the dark veil over health care for them. Our research shows that in many cities those who receive care number in the hundreds while those who are afflicted number in the tens of thousands.
Not only has the government not been friendly towards the disabled, the health insurance it offers them has not touched a population that according to the latest census data numbered approximately 10 million individuals in 2010.
Data on the Disabled Deficient
One of the major causes of the government’s failure is the limited data available to reflect the real situation. Data collected in 2010 by the Badan Pusat Statistik, Central Statistics Agency (BPS), suggesting Indonesia’s disabled population was about 10 million sufferers, are now seven years out of date and didn’t record information on the types of disabilities they suffer.
In 2014 the statistics agency, supported by the UN Population Fund, the World Health Organization and UNICEF did develop instruments recommended by the Washington Group, which added data collection information such as causes, the accessibility tools used, accessibility to education, public facilities, and others. However, there has been no census to determine how to use these instruments.
In addition, the agency’s data are not only different from the survey conducted by the WHO, but also different from the existing data in the Ministry of Social Affairs and the Ministry of Health.
The latest figure of the number of people with disabilities is gathered by Survei Angkatan Kerja Nasional, National Workforce Survey (Sakernas) in February 2017, recording the total working age of persons with disabilities is at almost 22 million. From this figure, 96.31 percents is actively working while 3.69 percent or 414,222 disabled are unemployed.
This gap, of course poses a negative impact on the implementation of government-led programs to provide service for the afflicted. As a result, access to health facilities remain weak because many of these disabled are not registered in the system.
National Health Insurance Discriminates
The government has a spaghetti bowl of agencies to provide health care, with inadequate coordination between them. Efforts to provide health care is under the auspices of Jaminan Kesehatan Nasional, the National Health Insurance program (JKN), although in reality it is implemented by Badan Penyelenggara Jaminan Sosial, the Social Security Agency (BPJS), whose performance is then overseen by the Dewan Jaminan Sosial Nasional, or National Social Security Council, which in turn requires individuals to pay monthly dues. For civil servants, these dues are directly deducted from their salaries, while ordinary participants pay the dues independently.
To ensure the national health insurance program can reach people with different economic backgrounds, the government has removed the registration requirements for Penerima Bantuan Iuran, Health Insurance Contribution Recipients (PBI). Unfortunately, the programs intended to provide access to health protection for all Indonesian citizens have not been able to reach the people who have disabilities.
Based on government legislation, only poor people who have been listed in the poverty data belonging to the BPS can be registered. Although the disabled who have been issued a certificate of poverty by the government can enjoy health insurance, hundreds of thousands of others do not have the certificate and remain outside the benefit system.
Although the disabled or families with disabled members have salaries corresponding to regional minimum wage requirements that disqualify them from being categorized as poor, health care costs they incur are very large which eventually make them fall into the poverty category.
People with disabilities still require other expenses, such as the purchase or maintenance of assistive devices, therapy, consumption of certain drugs, and so on. In BPJS Employment rules, while there is a clause in which the criteria for permanent disability entitles the party to receive JKN-BPJS freely, the definition of permanent disability is only for workers who have suffered on-the-job injuries rendering them permanently unable to work. Workers who have other disabilities are unable to register.
Relying On Local Government Policy.
President Jokowi Widodo said that as of 1 November 2016, the number of BPJS participants reached 170 million, equivalent to 66.7 percent of the population. Although the number of those registered by the agency has increased from year to year, very few of that number are individuals with disabilities. Hundreds of thousands have not been covered.
In the town of Sragen, for example, with some 7,400 disabled poor, the Health Department has begun to allocate free BPJS card dues for only 200 individuals, while thousands face an uncertain fate. In West Java, with 2 million disabled, of which 1.8 million are employed, only 300 workers with disabilities are registered as participants. With a target of 1,000 workers registered in 2017, we can see that a huge amount of homework remains to be completed by the local government.
Conditions are not much different in Yogyakarta, where 28,750 citizens with disabilities are without health insurance. The local government in 2015 took the initiative to independently create a Jaminan Kesehatan Khusus, Special Health Insurance program (Jamkesus) for tens of thousands of individuals with disabilities. This policy is considered as a strategic move to increase local participation of health services for the disabled. The government’s commitment can be seen from the provision of Jamkesus services which were held publicly 16 times in 2016 and 5 times until September 2017 in five districts in the province. For easy access, Jamkesus also provides a shuttle service for the disabled with mobility issues.
Local governments’ attention to the people with disabilities should be increased to offset the central government’s policy, which remains uneven. Synergy and coordination between the central government, local governments, and other related institutions should be a major concern to achieve compliance with health care access for the disabled. An initiative by Jamkesus in Yogyakarta is a lesson for other governments to continue to innovate and improve.
Muhammad Zulfikar Rakhmat is a doctoral candidate at the University of Manchester. Dikanaya Tarahita is an Indonesian freelance writer. They are regular contributors to Asia Sentinel.