• INDONESIA: Healthcare system failing millions

  

  Photo: Contributor/IRIN

  Indonesia's decentralised healthcare system is in need of reform (file photo)

  JAKARTA, 6 August 2009 (IRIN) - Indonesia's health system is failing to provide even the most basic care to vast swathes of the population, say specialists.
   
   Many who cannot afford doctors' fees often receive no treatment at all, while the wealthy fly abroad for a check-up.
   
   The system is plagued by under-funding, decentralization, lack of qualified staff, rising medical costs and outdated medical equipment, say insiders.
   
   "The health system desperately needs improvement," said Kartono Mohammad, a senior doctor and former chairman of the Indonesian Medical Association (IDI), adding that it is hard to even speak of a healthcare system since there is no regulation or quality control.
   
   "There are no laws that protect the patient," he said.
   
   Misdiagnosis
• In June, the system's failures were the focus of nationwide debate when a patient was sued by a hospital after her complaints about poor treatment were published on the internet.
   
   In 2008, Prita Mulyasari checked into the Omni International Hospital in Tangerang, a satellite city of the capital Jakarta, where she was misdiagnosed with dengue fever and given injections that made her hands and neck swell and made breathing difficult. Later, it emerged that the mother-of-two had mumps.
   
   Omni sued Mulyasari for damaging its reputation, but after an outpouring of public support, including from parliament, the lawsuit was dropped.
   
   "Doctors are very protective of each other. It is a conspiracy of silence," says Mohammad. "Doctors here don't want to testify against their own colleagues."
   
   And though it is unclear how many patients are misdiagnosed each year, many disputes are believed to be settled under the table.
• Those who have a choice fly to Singapore, Australia, Malaysia and even the United States or Europe in search of better care.
   
   According to Fahmi Idris, chairman of the IDI, at least one million Indonesians are estimated to seek medical care oversees each year.
   
              

  Photo: Edy Purnomo/UNICEF Indonesia

  Unable to pay doctor fees, many Indonesians go without (file photo)

   Access and cost
   
   But for most of Indonesia's more than 250 million inhabitants, even the lowest quality healthcare is often inaccessible.
   
   Access to health facilities across Indonesia's 6,000 inhabited islands varies greatly.
   
   While cities usually offer a range of services for most medical problems, in remote areas such as the easternmost province of Papua it can take several days to reach a doctor.
   
   Some islands or remote mountain villages can be inaccessible for months at a time during the monsoon season.
   
   In addition, many low-income earners or the unemployed avoid going to a doctor, explained Ajriani Munthe Salak, from the Legal Aid Institute for Health (LBH). "They stay at home, hoping the illness will disappear. They are afraid of bills and the bureaucratic system."
   
   According to the World Bank, about 100 million Indonesians live on less than US$2 a day.
• Government efforts
   
   Critics say a new health insurance scheme for the poor, Jamkesmas, launched by the government in early 2008 is too complicated, requiring a patient to provide documentation on income, identity, hospital registration, family records and a doctor's referral notice.
   
   The Health Ministry has spent seven years drafting an ambitious new universal healthcare bill, but it has faced delays, budget problems and technical hurdles, such as a lack of a common definition for malpractice, said Mariani Akib Baramuli, a member of parliament.
   
              

  Photo: ReliefWeb

  The country's geography makes access difficult. Of Indonesia's 17,000 islands, just 6,000 are inhabited

   "The country still faces significant challenges in developing and implementing effective and sustainable health-financing reform," according to Joachim von Amsberg, World Bank country director for Indonesia.
   
   Lawmakers hope the bill will pass during the current term that expires in October, but there is a huge backlog of other work.
   
   Meanwhile, as politicians debate the bill, the problem of affordable care is becoming more entrenched.
   
   Indonesian hospitals are even known to keep patients "hostage" until family members can settle their bills.
   
   Since 1999, Salak's organisation has handled almost 500 cases, mostly in Jakarta.
   
   "But that is just the tip of the iceberg. There are probably millions of people who don't have real access to healthcare," she said.
   
   With the vast distances involved, it is impossible reach everyone, she said. "We get calls from Papua, but we don't have money to fly over there, it is just too costly," she added.

2 more annotations...

• Indonesia had a three-tiered system of community health centers in the late 1990s, with 0.66 hospital beds per 1,000 population, the lowest rate among members of the Association of Southeast Asian Nations (ASEAN).^[1] In the mid-1990s, according to the World Health Organization (WHO), there were 16 physicians per 100,000 population in Indonesia, 50 nurses per 100,000, and 26 midwives per 100,000.^[1] Both traditional and modern health practices are employed. Government health expenditures are about 3.7 percent of the gross domestic product (GDP).^[1] There is about a 75:25 percent ratio of public to private health-care expenditures.^[1]

   

  Unsafe drinking water is a major cause of diarrhea, which is a major killer of young children in Indonesia.^[1]

• Disease

   

   

   

   

  

   In 2005 there were 303 reported cases of polio in Indonesia.

   

   

   

  HIV/AIDS has posed a major public health threat since the early 1990s.^[1] In 2003 Indonesia ranked third among ASEAN nations in Southeast Asia, after Myanmar and Thailand, with a 0.1 percent adult prevalence rate, 130,000 HIV/AIDS cases, and 2,400 deaths.^[1] In Jakarta it is estimated that 17 percent of prostitutes have contracted HIV/AIDS; in some parts of Papua, it is thought that the rate of infection among village women who are not prostitutes may be as high as 26 percent.^[1]

   

  Three other health hazards facing Indonesia in 2004 were dengue fever, dengue haemorrhagic fever (DHF) and avian influenza.^[1] All 30 provincial-level units were affected by dengue fever and DHF, according to the WHO. The outbreak of highly pathogenic avian influenza (A/H5N1) in chickens and ducks in Indonesia was said to pose a significant threat to human health.^[1]

   

  By 2010, there are three malaria regions in Indonesia: Nusa Tenggara Barat with 20 cases per 1,000 citizens, Nusa Tenggara Timur with 20-50, and Maluku and Papua with more than 50 cases per thousand. The medium endemicity in Sumatra, Kalimantan and Sulawesi, whereas low endemicity is in Java and Bali which almost 100 percent of malaria cases have been confirmed clear.^[2] At 1990 malaria average incidence was 4.96 per 1,000 and declined to 1.96 per 1000 at 2010. The government is targeting to rid the country of malaria by 2030 and elimination means to achieve less than 1 incidence per 1,000 people.^[3]

• Air quality

   
   
  • 1997 Southeast Asian haze and 2006 Southeast Asian haze - In all countries affected by the smoke haze, an increase of acute health outcomes was observed. Health effects; included emergency room visits due to respiratory symptoms such as asthma, upper respiratory infection, decreased lung function as well as eye and skin irritation, were caused mainly by this particulate matter.

• Vaccination

   

  Indonesia has routine vaccination to children below age 5 years as World Health Organization (WHO) recommendations including vaccination of Hepatitis B which has high prevalency in Indonesia. Almost all of the vaccines provided by PT Bio Farma which one of the 29 companies with a prequalification certificate from the WHO among 200 vaccine company in the world. It also has been exported to 110 countries in the world.^[4] Indonesian vaccines are prefer among countries with high Moslem population due to they are halal vaccines.

   

  PT Bio Farma as a global vaccine producer will produce pentavalent vaccine (diphteria, pertussis, tetanus, hepatitis B and haemophilus influanzae type B or HiB). In 2012 the GAVI (Global Alliance for Vaccine and Immunization) will donate 80 percent of the needs of pentavalent vaccine and in the third year government should self fulfilment.^[5]

   

  June 2011: The third phase test of dengue vaccine involving 800 humans with ages of 2 and 14 years old have been held in 5 community health center around Jakarta and will be conducted also in Bandung, West Java and Denpasar, Bali with 800 and 400 participants, respectively. The first test was performed on a limited number of soldiers and the second phase was conducted on a small number of children and if within the next 5 years the vaccine is found to be safe for humans, government will apply the dengue vaccine to public.^[6]

• Maternal and Child Health Care

   

  In June 2011, the United Nations Population Fund released a report on The State of the World's Midwifery. It contained new data on the midwifery workforce and policies relating to newborn and maternal mortality for 58 countries. The 2010 maternal mortality rate per 100,000 births for Indonesia is 240. This is compared with 228.6 in 2008 and 252.9 in 1990. The under 5 mortality rate, per 1,000 births is 41 and the neonatal mortality as a percentage of under 5's mortality is 49. The aim of this report is to highlight ways in which the Millennium Development Goals can be achieved, particularly Goal 4 – Reduce child mortality and Goal 5 – improve maternal death. In Indonesia the number of midwives per 1,000 live births is unavailable and 1 in 190 shows us the lifetime risk of death for pregnant women. ^[7]

• 100 percent insured

   

  On 2010, an estimated 56 percent of Indonesian mainly state employees, low-income earners and those with private coverage have some from health insurance. It will boost to 100 percent with a system of universal social health insurance coverage in place by 2014. The aim is that everybody doesn't have to pay when they are hospitalized in basic/class-3 hospital beds.^[8]

4 more annotations...

• 5.1  Health policies and strategies

   

  The creation of “Healthy Indonesia 2010” forces  the Ministry of Health and Social Welfare to forge collaborative  relationships with others. As health is a shared responsibility, the  Ministry of Health and Social Welfare must involve all strata of the  community, all related government departments and agencies, and the private  sector.  In the effort to achieve  “Healthy Indonesia 2010,”the Ministry of Health and Social Welfare must  also be proactive and forward-thinking.

   

  The ‘Healthy Indonesia 2010’ goals are:

   

          To initiate and lead a health orientation of the national  development

   

         To maintain and enhance individual, family, and public health along  with improving the environment

   

         To maintain and enhance quality, accessible, and affordable health  services

   

         To promote public self-reliance in achieving government health

   

  While the Ministry of Health and Social Welfare  was redefining the new Vision and Mission, two new fundamental Acts were  enacted, namely Act No. 22/1999 on Local Governance and Act No. 25/1999 on  Financial Balance Between Central Government and Local Governments.  The two Acts are a reference for the  implementation of decentralization policy in Indonesia, which give provinces  and districts a large autonomy to manage their own home affairs except  defence, monetary and fiscal, foreign affairs, justice, and religion.

   

  Based on the new Vision and Mission of National  Health Development and in line with the decentralization policy, it is  agreed that there are four paramount issues to serve as the pillars in  formulating a Strategy for National Health Development. These are:

   

         Initiating health-oriented national development

   

         Professionalism

   

         Community Managed Healthcare Programme (JPKM)

• Decentralization

   

  The identification of these four elements as  pillars of the Strategy for National Health Development does not mean that  other programmes should not be supported.   All programmes and plans of potential assistance to the Ministry of  Health and Social Welfare in achieving the new Vision and Mission should be continued, even though  these four pillars have the highest priority.

   

  Related  Links

  Program  and Policies

  Community Health

   

  Millennium  Development Goals (MDGs)

   

  The progress made towards achievement of health  related MDGs is given at Annex-2.

   

   

   

  5.2  Organization of the health system

   

  Structure  of the Health System

   

  There are 33 provinces and each province is  sub-divided into districts and each district into sub-districts. As  decentralization had been already implemented, the 349 regencies and 91  municipalities are now the key of administrative  units.

• Each sub-district in Indonesia has at least one  health centre headed by a doctor, usually supported by two or three  sub-centres, the majority of which are headed by nurses. Health centres  mainly provide eight programs. Most of the health centres are equipped with  four-wheel drive vehicles or motorboats to serve as mobile health centres  and provide services to underserved populations in urban and remote rural  areas.

   

  At the village level, the integrated Family  Health Post provides preventive and promotive  services. These health posts are established and managed by the community  with the assistance of health canter staff. To improve maternal and child  health, midwives are being deployed to the villages.

   

  The Decentralization Policy has been implemented  in Indonesia, with the implementation of Act No. 22/1999 regarding Regional  Governance and Act No. 25/1999 regarding the financial equality between  Central and Regional government. With the implementation of the aforementioned  Acts, the government system in Indonesia has been changed from  Centralized to Decentralized type of government, which provide regional  autonomy.  In the Act No. 22/1999,  there have been three levels of regional autonomy, i.e., Province,  District, and City regional autonomy.
• Paragraph 4, sub-paragraph 2 stated that there  is no hierarchical links between these three regional autonomy regimes.  However, in the explanation of paragraph 4, it is stated that Governor (as  Head of Province Regional Autonomy and Head of Administrative area) will  have to perform links in guidance, monitoring and supervision to the  District and City areas.  This is in  relation to the delegation of responsibility to Province which has been  stated as having limited autonomy; but it has been also given broader  de-concentration as representative of Central government.  The rule of Guidance and Supervision has  been clearly stated in the Government Act No. 20/2001 regarding Guidance  and Supervision of Governance implementation applied to local government.

2 more annotations...

• I never thought I would let the grim stories I'd heard about Indonesia's health care system turn me into one of those expats who left the country at the slightest hint of a sore throat. I may have been skeptical of undergoing any major procedure in the country where I've been living since 1994, but I was pretty confident local doctors could handle a run-of-the-mill condition like vernal conjunctivitis. I was wrong. 

     In April 2009, my right eye started to itch and turned red. My vision turned blurry, and I couldn't figure out why I was losing sight in that eye, so I went to see a general practitioner, who suggested I see a specialist as it looked as though the problem might be in the cornea. I followed his advice, and after enduring a merry-go-round of eye doctors in Jakarta, my eye continued to get worse. Weeks later, I decided to leave the country to seek treatment, but by then it was too late. The condition had already damaged my cornea. Doctors in Singapore, where many Indonesians go in search of better care, suggested a number of treatments, including a corneal transplant if the others failed to restore my sight. I opted for another opinion back in the U.S. (See the most common hospital mishaps.)

• For me to say that Indonesia's health care system is inadequate is, well, far from adequate, so let me quote a former head of the Indonesian Doctors' Association. "We have no health system," Dr. Kartono Mohammad recently told a group of journalists. "There is no quality control." At a time when Indonesia is striving to reach the ranks of the BRIC countries, strong fundamentals and an economy set to grow around 5% this year have yet to boost the hopes of millions in need of basic, reliable health services. For 2010, the health ministry has been allocated $2.2 billion, which is a slight increase over last year but still half of what is generally spent by the defense department. Overall, spending on health comes in at less than 2% of the year's total fiscal expenditures estimated around $110 billion. "It's still not enough," admits Health Minister Endang Rahayu Sedyaningsih. "Of course it is not right yet, but a national health system is there." 

    That might come as a surprise to the hundreds of Indonesians that still die each year of tuberculosis, malaria, dengue fever and other treatable illnesses. As for myself, I wondered how something as treatable as vernal conjunctivitis, which generally afflicts allergy sufferers, could lead to blindness. I had to go back to the U.S. to find out what at least six doctors here couldn't decipher; a doctor in Michigan diagnosed my problem in five minutes. "You have a case of vernal conjunctivitis," the cornea specialist told me. "If your doctors over there had looked under your eyelid they would have caught it, or at least they should have." (See "The Year in Health 2009.")

• In fact, they did look. A fairly senior doctor hastily flipped my eyelid but failed to notice anything, despite the development of bumps similar to cobblestones that were scraping my cornea every time I blinked. A simple steroid would have reduced the swelling (as it did once I was prescribed one in the States) but I was told over and over that steroid drops would make it worse. Instead, in addition to dozens of antibiotic and antiviral drops, the doctors in Jakarta "cleaned" my eye by scraping off a layer, hoping a new layer would grow over the damaged center that was now exposed like a scraped kneecap. The pain that ensued once the anesthetic wore off was like having shards of glass driven into my eye, yet it could have been mitigated with a bandage lens — a protective contact lens with no power, which I also never received.  

    Naturally, I thought about suing the doctors, an avenue which Kartono and other health care experts have warned me rarely pays off. "It is a very gloomy picture," says Ajriani Munthe Salak, a researcher from the Legal Aid Foundation for Health. The chances of winning a malpractice suit in Indonesia are slim, she said, and the chances of damages being paid even slimmer. 

    I had already told myself that I was fortunate to have the means to seek treatment overseas, and that I would not pursue legal action if my vision was restored. After nine months, thousands of dollars and a procedure performed by an American doctor, about 50% of my vision has been restored. The imbalance between the right and left eye, which has normal vision, causes routine dizziness and discomfort, but I remain optimistic that I will get my right eye back.
• If I don't, though, I feel compelled to do something, not so much for myself as for the millions of Indonesians who are much less fortunate and have nowhere else to go. The more I ask about the doctors I saw in Jakarta, the more horror stories emerge. One person I contacted reached a settlement in a similar case, though it cost her an eye. Others feared the prospects of a legal battle similar to one endured by Prita Mulyasari, a working class Jakarta woman who dared to criticize a local hospital and spent months facing down its lawyers. She has become something of an icon for all that is wrong with Indonesia's health care system. I don't know what I'll do yet, but I commend Mulyasari for having the courage to challenge a system that has let so many people down.

2 more annotations...