NHI debate: PPP model that works for 250m Indonesians – template for SA?

Judging by the vociferous comments on social media after my interview with Dr Nicholas Crisp, middle-class South Africans are almost universally camped against the concept of national health insurance. But most South Africans DO agree the status quo is disastrous. While corruption, cadre deployment and incompetence are blamed, deep structural issues inherited from pre-1994 were never addressed. South Africa’s solution surely lies outside those provided in often-referenced First World countries like the UK and France. Among the global success stories is Indonesia, a developing country with an efficient universal healthcare system serving a widely dispersed population four times SA’s. The President of Indonesia’s national health insurance body is Dr Ali Ghufron Mukti. He is a university professor and serves as the director general of Indonesia’s Ministry of Research Technology and Higher Education. We met during his visit to SA last week. – Alec Hogg

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Relevant timestamps from the interview

00:00 – Introductions
00:45 – Dr Ali Mukti on his visit South Africa
01:16 – Dr Mukti on the geography and politics of Indonesia
02:21 – On the background of Indonesia’s national healthcare system
03:51 – On the debates surrounding National Health Insurance
04:42 – On the standard of healthcare in Indonesia
06:27 – On whether doctors emigrated from Indonesia upon the inception of NHI
07:00 – On the processes and successes of NHI in Indonesia
08:13 – On private sector involvement
09:54 – On what healthcare NHI in Indonesia offers and provides the “normal” person
11:09 – On taxation and funding of NHI in Indonesia
12:04 – On the benefits of universal healthcare
12:57 – On the percentage of Indonesia’s GDP that goes toward NHI
13:44 – On the differences between the UK’s NHS and Indonesia’s NHI
14:50 – On talks with the South African Health Department
16:12 – On where Indonesia has gotten NHI right
18:40 – On the operational costs of NHI in Indonesia
20:12 – On combatting corruption
20:48 – Concludes

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Edited transcript of the interview

Alec Hogg: We’ve been engaged in a compelling debate on BizNews regarding proposed National Health Insurance for South Africa. Some argue that the country can’t afford it, foreseeing potential corruption and a descent into chaos if it’s enacted. The NHI Bill has passed one level of parliament but still has to proceed through the Council of Provinces. It’s good to have with us today in our Cape Town studio, Dr Ali Ghufron Mukti, president of the National Health Insurance System in Indonesia. Welcome, Mr. Mukti. Could you tell us what brings you to our country?

Dr Ali Mukti: Thank you, Alec. I am here attending the International Health Economic Association conference.

Alec Hogg: Indonesia is a country that many South Africans may not fully understand. It is the fourth most populous country on Earth, correct?

Dr Ali Mukti: Yes, there are a lot of people. We consist of 17,000 islands and Bali is one of them, famously known for being a tourist destination. Because we have so many islands, it’s not as simple as in South Africa. Also, the pace of development varies. For example, Jakarta and the province of Papua are quite different. But we are trying to harmonise.

Alec Hogg: 275 million people, 600 languages, 17,000 islands – the logistics of providing health to all Indonesians seems incredibly challenging. Can you tell us when the decision was made to introduce universal health care in Indonesia?

Dr Ali Mukti: T he decision was taken in 2014. It wasn’t that long ago. At that time, it was very difficult because we had to consider various groups of people, the rich and the poor, and different organisations like the Entrepreneur Association, the Workers Associations and many more. They debated, it was very tense with different dynamics, but we now have maybe the world’s largest and fastest single integrated national health insurance schemes. All people can access it easily with their national identity number and go to any health facility they choose.

Alec Hogg: I hear your presentation at the International Health Economics Conference was well-received. But with all the debates you mentioned, does it remind you of what’s happening in South Africa now with all the strong emotions?

Dr Ali Mukti: Yes, I think so. It wasn’t easy at the time in Indonesia, and I was assigned as the chairman of the Committee for Preparation of National Health Insurance. But we were successful, and now we are pleased to see that the principles of solidarity in this national health insurance are well implemented and appreciated by all Indonesian citizens.

Read more: Discovery Health CEO challenges NHI, begs closed door ANC to open its eyes and ears

Alec Hogg: What’s the experience of the people – are there long queues before they can access hospitals?

Dr Ali Mukti: That’s an excellent question. We have always been in deficit since we established the system, but the pandemic has somewhat been a blessing in disguise. People now avoid hospitals unless they really need to go, which has reduced utilisation and claims, and for the first time in 2021, our finances were positive. As a result, we now pay hospitals in advance, increased tariffs, and medical personnel are happier and more satisfied.

Alec Hogg: Did you lose doctors due to the change to national health?

Dr Ali Mukti: No, they remained committed to staying and serving in the country. They had to struggle with less than ideal payment conditions initially, but now they’re happier. The people too, they’re happier with the National Health Insurance because it allows them to consult even when they’re healthy. We’re also emphasising prevention, and screening. Everyone over the age of 15 has to fill in questionnaires assessing their risk, and we encourage those at high risk to undergo further medical examination.

Alec Hogg: What about habits like smoking?

Dr Ali Mukti: Yes, we have many smokers in Indonesia, and we’re increasing the tax on tobacco, some of which goes to the national health insurance.

Alec Hogg: Does the private sector still participate?

Dr Ali Mukti: Absolutely, in fact, 65% of the hospitals collaborating with us are private, and they’re content with the partnership.

Alec Hogg: Medical aid schemes, private medical aid schemes, do you have them in Indonesia? If so, did they reduce in size after national health was introduced?

Dr Ali Mukti: Not really. They didn’t reduce significantly. In Indonesia, we also have commercial, profit-oriented health insurance. It’s not very common because people are generally satisfied with national health insurance. However, for the very wealthy who may not be satisfied with it, there’s an option to purchase additional health insurance or commercial health insurance. This gives them certain privileges, such as choosing their own doctors or hospitals. But for most people who have national insurance, these choices are determined by the system.

Alec Hogg: What do you get as an Indonesian citizen from your national health insurance? Could you just give us an example of what the average person can do?

Dr Ali Mukti: Normal people, especially the poor, benefit greatly. Before national health insurance, there was a saying in Jakarta – “the poor are forbidden to fall sick” because they couldn’t afford to pay for healthcare. But now, there’s no financial barrier for the poor or the general population. As for the wealthy, they’ve always had money to pay for healthcare. However, it’s now mandatory for all citizens to have national health insurance. This encourages a sense of solidarity, where the rich can help the poor, the healthy can help the sick, and the young can support the elderly.

Read more: SLR on NHI – Foreign influencers and private companies: A concerning trend in South Africa

Alec Hogg: Who funds this?

Dr Ali Mukti: The government, through taxes, pays for those who cannot afford it. Those who are employed contribute as well; the employee pays 1% and the employer pays 4% of their salary.

Alec Hogg: What other benefits have there been of providing universal health care?

Dr Ali Mukti: Well, it’s not only an implementation of the solidarity principle outlined in our Constitution, but it also helps people stay healthier. A healthier population is more productive and can contribute more to the economy. This leads to a more prosperous and stronger country overall.

Alec Hogg: What percentage of GDP does Indonesia spend on health, and how does it compare to other parts of the world?

Dr Ali Mukti: We spend around 3% of our GDP on health. That might not seem like much, especially when compared to the U.S., which spends about 18% of its GDP on health. But when comparing life expectancy, it’s not far off. Indonesia’s life expectancy is around 72 years, while in the U.S., it’s around 76 or 79 years.

Alec Hogg: How does your universal health care compare to Britain’s?

Dr Ali Mukti: There are some differences. Many doctors in Britain aren’t satisfied and have gone on strike due to low salaries and other issues. In contrast, doctors in Indonesia are generally content. Britain’s system is tax-based and depends on parliament, politicians, and other variables, whereas in Indonesia, we’re directly responsible to the president, and the funds belong to the members. We’re responsible to them, not to any minister. That’s a key difference.

Alec Hogg: Have you had a chance to meet with the South African Department of Health while you’ve been here?

Dr Ali Mukti: Yes, I met with the Minister of Health in South Africa a couple of days ago. We had a very productive two-hour discussion. They expressed interest in seeing firsthand how Indonesia runs its program. Compared to the UK, where the waiting time for elective surgery is around 18 weeks, in Indonesia, the wait time is less than a month.

Read more: Dr Nicholas Crisp – Case for NHI (and why vested interests are pursuing Operation Fear)

Alec Hogg: That’s quite remarkable considering Indonesia’s population is 275 million and the country isn’t as wealthy as the UK, yet it only spends 3% of its GDP on health.

Dr Ali Mukti: Yes, that’s correct.

Alec Hogg: What is Indonesia doing right and perhaps the UK isn’t that South Africa can learn from, ?

Dr Ali Mukti: I’m not saying the UK is doing anything wrong. I’m just stating the facts. In the UK, the waiting time is approximately 18 weeks, and many medical staff are unsatisfied. In contrast, the waiting time in Indonesia is less than a month, and our medical staff are generally content.

Alec Hogg: Where do you see your approach succeeding? When you converse with the Minister of Health, what are the critical suggestions you make for the implementation of national health in south Africa?

Dr. Ali Mukti: Firstly, we need to implement the principles of solidarity, meaning we help each other. Secondly, in Indonesia, we are fortunate to have a single integrated health scheme. Although hospitals and health facilities across the country can collaborate, they rely on public feedback and assistance. We listen to the needs of the people and adjust accordingly. For example, people want faster, better quality services, and that’s where we direct our focus. Currently, we are undergoing a transformation. Firstly, a structural transformation, forming a special organisation dedicated to improving the quality of care. Secondly, a cultural transformation, changing the ethos of the organisation. Our threefold tagline promotes the non-discrimination of health services.

Alec Hogg: How much does this cost? Often, cost is a significant concern. I interviewed Dr. Nicholas Crisp, who’s leading NHI efforts in South Africa, and he said that the administration of medical aids amounts to 15% of total costs. What is your expenditure like?

Dr. Ali Mukti: Are you referring to operational costs? Because we are overseen by the Minister of Finance, efficiency is crucial. Every year they decrease the operational cost. Initially, it was 5%, but it’s been reduced yearly. Now it stands at around 2.89%, or less than 3% of total costs. We are extremely efficient.

Alec Hogg: That’s impressive. Your operational cost percentage is 2.89%, and the rest of the tax raised for your universal healthcare?

Dr. Ali Mukti: It is allocated for the people. We maintain efficiency, for instance, our staff’s salary and headcount are limited. If you compare with France, they have around 85 000 staff members while Indonesia only has 8 500, serving 258 million people compared to France’s 70 million.

Alec Hogg: Another significant issue here in South Africa is corruption. Do you grapple with that as well?

Dr. Ali Mukti: Yes, corruption is unfortunately a global challenge. However, we are taking measures to mitigate it. We are developing an anti-fraud system in collaboration with the European Union’s anti-fraud and anti-corruption system. Our goal is to use machine learning and digital ecosystems to automatically detect fraudulent activities.