Adisti Sukma Sawitri, The Jakarta Post, Jakarta
Sitting near a payment booth at Tarakan Hospital in Central Jakarta, Buce Iman Santoso clutched onto a letter belonging to his ill mother-in-law, Aminah.
The relief letter (SKTM) issued by the Health Agency had just been rejected by the hospital.
Hospital staff members asked Buce to return with more documents if Aminah was to be eligible for medical assistance at a reduced rate.
"How else can I prove that we are poor? I wouldn't ask for our bill to be discounted if we could afford to pay it," he said.
Buce said he submitted a relief letter and other documents stating his family was poor soon after Aminah was admitted to hospital a week earlier.
Hospital staff member Zuraidah said many people had abused the system in the past, and therefore the hospital had to carefully consider each claim.
"In accordance with procedures, patients must submit authentic documents twice - on the day they are admitted to hospital and on the day their payment is due," she said.
The administration launched two special health care plans five years ago. The Poor Family Cards (Gakin) scheme targeted almost 150,000 poor families registered with the Jakarta Statistics Board, while the relief letter scheme was introduced for unregistered low-income earners.
Unregistered people are those who have not been issued with an ID or family card by the Jakarta administration.
Unlike the Gakin system, which covers all of a patient's medical invoice, relief letters only allow for part of a patient's bill to be waived.
To obtain a relief letter, applicants must request notification letters from their neighborhood unit chief and subdistrict officials as well as a verification letter from the nearest community health center to confirm the family's financial status.
Despite this strict and lengthy process, officials often issue letters to people not eligible for medical benefits in return for bribe money.
Brokers offering to simplify the process are also profiting at the expense of low-income families.
Brokers usually offer their services near the payment booths of large hospitals.
Patients often pay brokers between Rp 500,000 (approximately US$54) and Rp 7 million to obtain a relief letter, the Heath Agency's deputy head, Salimar Salim, said.
She said the misuse of the scheme was evident from patient records and health expense claims made at various hospitals around the city.
She said as of September, the agency had to pay Rp 81 billion in hospital claims for 75,391 patients under the letter scheme, while it only had to pay Rp 55 billion for 99,672 Gakin patients.
Most claims made were for major surgery or the treatment of serious illnesses.
"After interviewing several patients, we realized many people were not poor, but just ran out of money due to the expensive treatment they were receiving," Salimar said.
"Sucipto", who works at a city-owned hospital, told The Jakarta Post he applied for a relief letter so surgery he underwent at Gatot Subroto Army Hospital in Central Jakarta would be discounted, despite the fact he had special insurance for civil servants from state-owned insurance company PT Askes.
He was unable to make a claim with the insurance company for his surgery as his policy did not cover treatment for injuries caused in accidents.
"The surgery cost Rp 27 million. I am not poor, but I am also not the kind of person who has that much money," he said.
As he had friends in relevant offices, he was able to get a relief letter within a week.
Sucipto said he knew his actions were wrong and he increased his insurance premium recently so he would be covered in the future.
He said it would be impossible to stop middle-income earners benefiting from the scheme, as many institutions only covered some of the health expenses of their employees.
The administration has discussed providing free health care to all residents in the next few years to avoid the misuse of heath care schemes for the poor.
Public policy expert Untung Afandi from the University of Indonesia said the administration should educate people in the middle and upper classes to acquire health insurance.
"The administration has to take care of a lot of other public services, including transportation and education. It would be very expensive to provide health insurance for everyone," he said.