Indonesia

Striking a balance between access, innovation and affordability in cancer care

Case study:

Indonesia

Striking a balance between access, innovation and affordability in cancer care

With immuno-therapies transforming the field of cancer care, governments around the world are seeking ways to improve public access to that care. One of the most intriguing innovations in recent years has been in Indonesia, where a new national health insurance programme – JKN-KIS – was introduced in 2014.

The programme has had a significant impact on the Indonesian healthcare landscape. According to analysis by The Lancet, it has succeeded in improving health equity and service access, and the number of beneficiaries has risen from 133 million in 2014 to 224 million in 2019.

Number of beneficiaries:

However, the service has also struggled with budget deficits. With prevalence up 30% between 2013 and 2018 (RISKESDAS 2018), cancer treatment is now the second-biggest area of JKN spending; unfortunately, this has led policymakers to limit funding for some cancer treatments. Consequently, private health insurance has a critical role in expanding access, especially where innovative new treatments are concerned.

The challenge

President of the Indonesian Society of Oncology and Chairman of the Indonesia Cancer Foundation, Professor Aru Sudoyo, is emphatic about the impact of the national health insurance programme. “The JKN is one of the best things that has ever happened [in Indonesian healthcare],” he says. “As a young doctor, patients diagnosed with cancer would come to me and say, ‘I don't have the money, and I cannot impoverish my family with the cost of the treatment.’ That is not happening now.” The program has also helped address the challenge of building healthcare infrastructure to serve Indonesia’s population of over 270 million people spread across 5,000 inhabited islands.

Now, says Professor Sudoyo, the challenge for oncology is clear: “It is a matter of improving access to the drugs.” Budgetary pressures have led to restrictions on usage, even for approved treatments. “Our budget dictates that a drug can be used for cancers A, B and C, but not cancers C, D and E – even though, in the international guidelines, it is approved for the treatment of all these types of cancer,” he explains.

The role of private insurance

One effect of these restrictions on the public sector has been increased interest in private health insurance. “Private insurance has been giving more and more patients access to treatment in the last few years,” says Professor Sudoyo. “People are starting to realise that, if they get sick, they will be in trouble, because the government insurance has these limitations.”

The success of private insurance, says Professor Sudoyo, has hinged on a new level of collaboration with pharmaceutical companies, which has helped reduce costs. Further collaboration between insurers and pharmaceutical companies will be essential to reducing costs and boosting funding, says Professor Sudoyo: “I see no other way forward,” he asserts.

Professor Sudoyo also says that insurers are helping to improve general understanding of cancer and awareness of treatment options, including in remote regions where traditional attitudes and treatments remain common. They are also contributing positively to the critical task of educating doctors about new treatments. “Tackling cancer and building awareness go hand in hand – and this is where private insurance comes in,” he says.

Driving treatment uptake

Despite the progress made in Indonesia, critical barriers remain, says Professor Sudoyo. One relates to legislation on co-funding the cost of cancer care: “If you are being treated under the umbrella of the national health insurance programme, then you cannot add to your treatment, using your own money or your insurance.”

“If you are being treated under the umbrella of the national health insurance programme, then you cannot add to your treatment, using your own money or your insurance.”

Professor Aru Sudoyo,

President of the Indonesian Society of Oncology and Chairman of the Indonesia Cancer Foundation

Professor Sudoyo is optimistic that this rule will be modified, however: “I see change on the horizon. I think co-sharing will become part of the system.” When this happens, he anticipates that “it will be a major leap towards improving the access of people to cancer treatment”.

Greater flexibility in funding must go hand in hand with a redoubling of efforts to build awareness and promote early detection. The rising prevalence of cancer means policymakers and providers need to take all available steps to increase access to treatment. “We have to mobilise all the forces available to us – including private insurance, pharmaceutical companies and NGOs,” says Professor Sudoyo. “My patients have already seen some of the benefits of these, so I’m optimistic about the future.”