Indonesia is struggling to fill a massive hole in the finances of its compulsory national health insurance system.

BPJS Kesehatan, the government agency that oversees the program, has suffered deficits in five of the six years since the system was introduced to much fanfare in 2014. This year, the shortfall between spending and premium income is set to balloon to 28 trillion rupiah (nearly $2 billion), more than double the gap in 2018.

In an attempt to balance the books, BPJS late last month announced a planned rise in premiums, and removed 5.2 million people from a list of beneficiaries -- some, the agency said, were dead or had never used the scheme. The government last year diverted some income from the tobacco tax to the program.

The rise in premiums has not got down well with the public.

"Increased premiums should be followed by improved service. I noticed the hostility of the hospital crew and they made up reasons that some medicines were not covered by BPJS," said one disgruntled twitter user. Another complained that it would have been better to persuade beneficiaries to regularly pay the monthly premium.

The program was aimed at bringing millions who had no health care provision -- those not rich enough to afford private coverage but with sufficient income not to qualify for government help -- into state care. The universal insurance gives all citizens access to a wide range of services at public facilities as well as private institutions that opt to join the program, covering treatments from common flu to emergency operations.

Nearly 80% of the Indonesian population of 260 million are now covered, up from around half when the program was launched in 2014. The jump in enrollment is championed as a success, but even that is behind the government's target of 100% by this year.

P

resident Joko Widido now has to decide whether to push on with the premium increase.

"If the rise is forced now, Jokowi's voters, who are mostly from the lower income class, would felt betrayed right after they trusted him to lead the government again," said Hasanuddin Ali, CEO of Alvara Research Center. "For now, it's better to postpone the rise to BPJS Kesehatan premium because society is still too exhausted with political turmoil after election."

But it is a dilemma, Ali added, because the shortfall in premium payments burden's the government's budget.

While Indonesia's fiscal deficit remains well under control at around 2% of gross domestic product, extra spending to plug the gap risks partially hampering Widodo's plans to increase spending on human resource development.

Indonesia will announce its budget for 2020 on Friday. While country's law states the budget deficit cannot exceed 3% of GDP, the government may be open to allowing it to widen to meet its pledges for infrastructure and other spending.

President Joko Widido's government will announce its budget for 2020 on Friday.   © Reuters

The health insurance premium is automatically deducted from the wages of most public servants and office workers. However, with 79% of Indonesia's total nonagricultural employment classified as informal, collection has always been a challenge for the agency.

The channels for payment include banks, convenience stores and post offices, but the issue is their willingness to pay and ability to pay, said BPJS spokesperson Iqbal Anas Ma'ruf. "The willingness is something we can't control other than providing more channels to pay the premium."

A regulation issued in 2018 instructs public institutions -- for example, those related to driver's license or passport renewal -- to avoid providing services to those who have not paid the premium. But Ma'ruf said "each institution would have their own target to serve the public accordingly" and this often leads to them ignoring the regulation.

Agus Pambagio, a professor of public policy at University of Indonesia, said there is also a problem on the health care provider side.

"There is a lack of strict accreditation to the health service providers which resulted in illicit practices," he said, adding that some providers falsely claim to have treated a patient 30 times. "These providers are misusing the claims."

Even the deficit figures have come under scrutiny. BPJS's numbers often differ from those released by other parties or announced by ministers, which tend to be based on audits from the Financial and Development Supervisory Agency (BPKP).

The starkest difference was in 2016, when BPJS's official books showed a surprise 157 billion surplus, as opposed to a widely reported 9.7 trillion rupiah deficit.

"BPKP can audit BPJS Kesehatan at a random moment," said BPJS's Ma'ruf. "There can be premiums that haven't been collected and unpaid claims to the hospitals that are not recorded on their audit."