Bruce Gale – An elderly man was left literally rolling in pain outside the emergency room of the Cipto Mangunkusumo General Hospital (RSCM) in Central Jakarta in mid-May after being denied treatment.

As bystanders looked on, 78-year-old Sa'at clutched his abdomen and groaned in pain. A large sign hung outside the government-run hospital, one of the biggest in the country, saying the emergency room could no longer accept patients because its beds were full.

Media reports say that about 75 per cent of the patients that arrive at RSCM every day are from poor families. Hospitals are often reluctant to accept poor patients because the government is lax on reimbursements.

Public health care expert Kartono Muhamad blames the system: "When the hospital is earning profit, the government puts its hand out for its share. But when it comes time for the government to pay, it stalls."

"Orang miskin dilarang sakit" (the poor are not allowed to get sick) is a phase with which millions of Indonesians are familiar. Then there is SADIKIN – a pithy Indonesian-style acronym warning lower-middle-class citizens about the cost of private medical treatment. It stands for "sakit sedikit miskin" (if you get sick, you will become poor).

So what is wrong with Indonesia's health insurance system, and what can be done to improve it?

Indonesia maintains a confusing patchwork of health insurance systems that vary in effectiveness and leave millions without any form of social security.

The four state-owned companies involved are Askes (for government employees), Asabri (for the military), Jamsostek (for workers in large factories) and Taspen (an old-age savings pension scheme used by state-owned companies).

For the desperately poor there is the Surat Keterangan tidak Mampu (SKTM) card, which is supposed to ensure that those who hold them get free treatment at hospitals and clinics throughout the country. These cards are issued by local kecamatan (subdistricts) and the resulting medical claims are met by a combination of local taxes and central government revenues.

The result is that an estimated 56 per cent of Indonesia's 238 million population – including private sector employees – have some form of health insurance. The remaining 44 per cent of the population have no medical insurance at all.

Apart from government hospitals, there are numerous charities in the country that provide medical services focusing on the needs of lower income groups. These include Muslim organisations such as Nahdlatul Ulama and Muhammadiyah, as well as Christian groups such as the Catholic Church and the Salvation Army. Government policy is to reimburse these hospitals as well if the poor present their SKTM cards.

But the system is far from perfect. According to Firman Lubis at the University of Indonesia's faculty of medicine, it is not only the poor who have such cards. Influence or bribery can also ensure possession, while genuine cases go without. Those with no fixed address find it particularly difficult to obtain the card.

The SKTM system is also becoming increasingly ineffective as millions across the archipelago move to urban areas looking for work. Because medical expenses are funded partly by the subdistrict that issues the SKTM cards, local officials are reluctant to provide such documentation to new arrivals who do not posses locally issued identity cards. Needless to say, Indonesia's bureaucracy is such that obtaining such identity cards is also difficult. And when a poor citizen finally does get his SKTM card, there is no guarantee that medical treatment will be supplied.

The 2004 Social Security Law attempted to change all this by setting up a single national health insurance system under which medical insurance cards could be used across the country. But the law's implementation has been delayed for years due to prolonged debates on how the social security system should be organized. For example, the 2004 law stipulates that the four existing state-owned companies should become the backbone of the system. Many legislators, however, insisted that the system would be more efficiently run by a single non-profit entity.

In a compromise announced late last year, the government and Parliament agreed that multiple non-profit bodies would run the social benefit programme. But the two sides have yet to agree on how the multiple insurers system would be implemented, including the level of contributions by the government, citizens and employers.

Last year, Indonesia opened up its health-care sector to foreign investment. The government is also encouraging investors to reserve 25 to 50 per cent of beds and services for Class 3 wards, which will be paid for by the government.

But a more systematic and comprehensive approach to the nation's health-care system awaits the outcome of ongoing debates within the Jakarta elite. Meanwhile, poor Indonesians like Sa'at will just have to wait.