Cancer treatment is relatively expensive, and even considered to impoverish the patient. For this reason, the state must enlarge its role, through the National Health Insurance (JKN) scheme.
The chairman of the Indonesian Health Economics Association, Hasbullah Thabrany, said that the government should not suppress cancer financing, because it is considered to be sucking up the JKN budget. Instead, because this disease costs a lot, the government should come up with a better risk-sharing scheme.
“These chronic diseases, cancer and others, are diseases that can impoverish a person or household, and therefore must be shared. That is the basic concept of JKN,” said Hasbullah in a discussion regarding the revision of the JKN, Thursday (28/10) evening.
Hasbullah added that fundamentally there must be an understanding that diseases with high medical costs must be shared. In insurance, this concept is referred to as risk sharing. Since cancer financing is expensive on an individual level, the costs must be shared in order to be cheap.
High Cancer Financing
On average, the cost of cancer treatment is around IDR 50 million per year. The cost may be higher up front, when it comes to surgery and so on. But over time, the cost will drop to an average of IDR 50 million. In Indonesia, there is one cancer patient in every ten thousand citizens. That’s why, said Hasbullah, JKN must be able to create a cancer financing scheme of IDR 50 million per year that is borne by ten thousand people. Mathematically, only IDR 5,000 per year is required for payment from each JKN participant. Because it is paid every month, the fee is no more than IDR 500 per month.
“Don’t be afraid of not being able to. Don’t be afraid of the state going bankrupt. No, the country will not go bankrupt. Because it’s brought together. We don’t ask the state to pay for it all, while we don’t pay dues. We pay dues, and we also pay taxes, which are much higher than that,” said Hasbullah in a discussion organized by the Indonesian Cancer Information and Support Center (CISC).
The small role of the government in public health financing can be seen from the large cost of health spending through the state budget. A number of neighboring countries, such as Malaysia, Thailand, Vietnam, the Philippines and China are in high positions in the Universal Health Coverage (UHC) Index.
“Because of our weakness, the ranking is still low, there are many cancer patients who have not received adequate services. Some health workers and hospitals have to bear the burden, because they are not funded, with adequate UHC funds,” added Hasbullah who is also the Chief of Party, USAID-Kemkes Health Financing Activity.
Those countries spend at least 3 percent of Product Domestic Bruto (GDP) for the health sector. Since 20 years ago, Indonesia has always been in a low position. Timor Leste, which used to be low, is now even continuing to increase the percentage of their GDP for the health sector, to almost 3 percent.
According to the Ministry of Health, in 2019 the number of cancer cases handled in Indonesia reached 2.7 million cases. The cost of care issued by BPJS Health reached Rp4.1 trillion. In 2020, the number of cases fell to 2.5 million cases at a cost of Rp. 3.5 trillion. This decline is thought to be due to people reducing the frequency of accessing health services due to the pandemic conditions.
Cancer Deaths Rise
The Chairperson of CISC, Ariyanthi Baramuli Putri, said that since its establishment in 2003, the organization has regularly held monthly meetings. The meeting became a forum for mutual psychosocial support and empowerment of members, namely cancer patients. They also provide shelter for underprivileged patients as well as policy advocacy.
One of their current policy advocacy is related to the government’s plan to evaluate JKN. It is hoped that this revision will be an opportunity to improve health services for cancer patients.
“Through BPJS Kesehatan, many patients have been helped. The biggest challenge is the rate of increase in new cases and deaths from cancer,” said Ariyanthi.
Data shows the death rate from cancer in Indonesia in 2018 was 207,210 cases. Meanwhile, in 2020 it increased to 234,511 cases. The data shows an increase in the number of deaths by 27,300 cases in 2 years. That’s why, Aryanthi said, they have high hopes at this time, when the government reviews the JKN program regarding guaranteed rates and services.
“We want to voice the hope of cancer patients, so that the JKN revision, which is currently being carried out by the government, ensures that cancer services are guaranteed and improved in quality and coverage according to medical cancer service standards,” he said.
In addition, CISC also hopes that the policy-making process for patients can involve the patients themselves.
There are Service Standards
Head of the Indonesian Association of Internal Medicine Hematology Oncology (Perhompedin) Jakarta, Ronald A Hukom, reminded that there are service standards that must be provided for cancer patients. At least, the consensus of the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) can be a benchmark.
“This is the consensus, since July 2006. There are requirements that should always be met in achieving what is called a quality cancer service,” said Ronald.
These requirements include access to information, where the patient must understand what the doctor will do, the benefits and risks. In addition, there are guarantees of confidentiality, privacy, access to medical records, prevention services to the absence of discrimination.
Ronald reminded that in 2007 there was a decree from the Minister of Health regarding the focus of cancer control, namely prevention.
“But in reality, as we have seen so far, this prevention has not yielded satisfactory results. Patients come to many referral hospitals already in stage three or four. There are numbers that say 60 percent, some say more than 70 percent,” said Ronald.
Ronald also presented data related to cancer cases in Indonesia in this discussion. In 2018, Indonesia recorded 348,809 cases, and increased to 396,914 cases in 2020. Of that number, the highest was breast cancer, which recorded 58,000 cases in 2018 and 65,000 cases in 2020. Cervical cancer is in second place with 32 thousand cases ( 2018) and 36 thousand cases (2020). Compiled by lung cancer whose case range is the same as colon cancer, namely 30 thousand cases (2018) and 34 thousand cases (2020).
Strive for Early Detection
In a presentation delivered in early October on its official website, BPJS Health acknowledged that catastrophic diseases were at the top of the list, in financing the health services of the JKN-KIS Program. According to the Managing Director of BPJS Kesehatan, Ali Ghufron Mukti, they spent around Rp. 20 trillion for catastrophic diseases, with Rp. 3.5 trillion or 18 percent for cancer.
“The most cancer patients guaranteed by the JKN-KIS program are 41-60 years old, 69 percent of the sufferers are women,” said Ali Gufron.
This condition, termed Ali Gufron, is like two sides of a coin. On the one hand, there is a growing number of people who can access health services for cancer treatment. But on the other hand, the burden of health care costs continues to grow.
“This is a big task for all of us, how to control the number of catastrophic sufferers, including cancer,” added Ali Ghufron.
To serve JKN-KIS patients in cancer cases, BPJS Kesehatan cooperates with 714 hospitals with chemotherapy facilities, 507 hospitals with oncology boards, and 35 hospitals with radiotherapy facilities throughout Indonesia.
In addition, promotive and preventive efforts in First Level Health Facilities (FKTP) are also enhanced.
“Early detection is very important. We also guarantee a Pap smear or IVA service as an early detection of cervical cancer, this service can be obtained at FKTP in accordance with applicable procedures and regulations. In addition, we also provide consulting services online that can be used by JKN-KIS participants through the Mobile JKN application,” said Ali Ghufron.
A number of challenges remain to be overcome in health care for cancer patients. According to BPJS Kesehatan, the challenges include the distribution of health facilities and the unequal availability of medical personnel. The National Guidelines for Medical Services (PNPK) for cancer diagnosis and chemotherapy services are also still limited. [ns/ab]