HEALTH AND HEALTH CARE IN INDONESIA

HEALTH IN INDONESIA

Life expectancy at birth: total population: 72.17 years, country comparison to the world: 137; male: 69.59 years; female: 74.88 years (2014 est.). "Life expectancy" is an abstract and complicated concept based on a complex formula that attempts to predict the lifespan of children born today by subjecting a hypothetical child born today to the current risk of dying in each bracket he or she matures through until, in effect, the accumulated risk of death is 100 percent.

Maternal mortality rate: 220 deaths/100,000 live births (2010), country comparison to the world: 52. Infant mortality rate: total: 25.16 deaths/1,000 live births, country comparison to the world: 71l male: 29.45 deaths/1,000 live births; female: 20.66 deaths/1,000 live births (2014 est.). Obesity - adult prevalence rate: 4.8 percent (2008), country comparison to the world: 160 Children under the age of 5 years underweight: 18.6 percent (2010), country comparison to the world: 36. [Source: CIA World Factbook]

In the early 1990s, 39 percent of the children in Indonesia were regarded as malnourished according to the World Bank. The infant mortality rate doubled after the Asian economic crisis in 1997. The lifetime risk of a mother’s death related to childbirth: 1 in 41 (compared to 1 in 10 in Nepal and 1 in 230 in Sri Lanka).

Since the 1980s, health in Indonesia has shown overall improvement. Life expectancy was estimated at 70.8 years in 2009, a substantial increase since 1980, when it stood at 52.9 years. However, the distribution of improvements, like the distribution of resources for health maintenance and improvement, has been unequal. In 2003 life expectancy was 72 years in Jakarta and Yogyakarta but only 63 years in Nusa Tenggara Barat Province. Whereas infant mortality nationwide decreased from an average of 105.0 deaths per 1,000 live births in 1980 to 75.2 in 1990, to 36.0 in 2000, and to an estimated 29.9 in 2009, local rates varied dramatically. The poor, rural, and less-educated classes generally suffered much higher mortality rates than their educated urban counterparts. [Library of Congress]

Health Care in Indonesia

Health expenditures: 2.7 percent of GDP (2011), country comparison to the world: 181, and lowest among members of Association of Southeast Asian Nations, which includes Laos and Cambodia. Physicians density in Indonesia: 0.2 physicians, 0.8 nurses or midwives for every 1,000 inhabitants (2012). Hospital bed density: 0.6 beds/1,000 population (2010). There is about a 75:25 percent ratio of public to private health-care expenditures. [Source: CIA World Factbook]

In Indonesia both traditional and modern health practices are employed. The government runs a three-tiered system of community health centers with puskesmas (community health centers) at the top. Usually staffed by a physician, these centers provide maternal and child health care, general outpatient curative and preventive health care, pre- and postnatal care, immunization, and communicable disease–control programs. Specialized clinic services are periodically available at some of the larger clinics. [Source: Library of Congress *]

Second-level community health centers include subpuskesmas (community health subcenters) consisting of small clinics and maternal and child health centers staffed with one to three nurses and visited weekly or monthly by a physician. Toward the middle of the first decade of the twenty-first century, the World Health Organization (WHO) reported that there were 3.6 health centers per 100,000 population. The third level of community health services consists of village-level posyandu (integrated service posts). These posts are not permanently staffed facilities but rather monthly clinics on rented premises, in which a visiting team from the regional health center supports local health volunteers. *

History of Health Care in Indonesia

Modern public health care was begun by the Dutch to safeguard plantation workers. It expanded to hospitals and midwifery centers in towns and some rural health facilities. The modern health-care system continues the Dutch colonial pattern of low levels of investment in health care. The Dutch did relatively little in the field of public health prior to 1910, with the exception of giving smallpox vaccinations. In the 1930s, however, the government devoted increased attention to health education and disease prevention, particularly in rural areas. An elaborate public-health infrastructure had developed by 1939, including a particularly sophisticated model program in Purwokerto in central Java. But this public-health system collapsed after the Japanese invasion in 1942. During World War II, the mortality rate rose dramatically, and the general health situation of the country deteriorated.

During the New Order public health and family planning became a priority for rural areas and about seven thousand community health centers and 20,500 sub-health centers were built by 1995. In the postwar period, a network of maternal and child health centers was established, but resources were extremely limited, with just one physician for every 100,000 people. The first dramatic improvements resulted from the establishment of the network of community health centers in 1969. Although at first the general population strongly resisted using these facilities, by the time of the 1980 census, 40 percent of people reporting illness in the prior week had sought treatment at one. By 2005 the community health centers catered largely to the rural and urban poor, and most urban residents who could afford to do so sought health care from private physicians and clinics.

The government’s five-year economic development plan, community health services are organized in a three-tier system with puskesmas (community health centers) at the top, was established in 1969 as part of the first Repelita. Since the early 1990s, the Department of Health planned to have three to four subcenters per health center, depending on the region, and this plan has been largely realized in the twenty-first century. [Source: Library of Congress *]

In the late 1990s there were with 0.66 hospital beds per 1,000 population, the lowest rate among members of the Association of Southeast Asian Nations (ASEAN). 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. *

The use of modern forms of health care has increased. For example, in 2003 the United Nations Children’s Fund (UNICEF) reported that 68 percent of births in Indonesia were attended by a trained midwife or other health specialist, compared to 58 percent in the late 1990s. Recent studies show a correlation between the rise of education levels and the increased use of hospitals, physicians, and other health resources. The government introduced a national health insurance program in 2014.

The Asian financial crisis affected government expenditure on health, causing it to fall from US$ 6 (1997) to US$ 1–3 (1997–1998) per person per year (Departemen Keuangan, 1997, 1998, 1999). However, government expenditures on health recovered and even surpassed precrisis figures at US$ 8 per capita per year by 2007 (Departemen Keuangan, 2007). In 2007, the health budget reached Rp. 18.5 trillion (~US$ 19 billion; Departemen Kesehatan, 2008), of which 8.3 percent was allocated to the Directorate General of Disease Control and Environmental Health and 1.2 percent was allocated to the National Institute of Health Research and Development (NIHRD). In other words, Indonesia spent US$ 1.8 billion on disease control and research. The health budget in 2007 had increased threefold from that of 1999. [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

Problems with Health Care in Indonesia

Heath care is woefully inadequate in Indonesia. Even the most basic treatments are prohibitively expensive for ordinary people. Corruption is widespread in the health care. Doctors demand bribes for treatments and people have to pay for “free” medical care. Many elite Muslim families go to Christian hospitals because they offer better health care.

Although everyone is entitled to free healthcare, many get fed up with the bureaucracy of obtaining the services. A man who earns $120 a month a lies on railroad track as medical treatment told the Los Angeles Times, "You have to pay to go to the doctor, but here it's free," he said. "You can come whenever you want, morning or afternoon, and you can stay all day." [Source: Kate Lamb, Los Angeles Times, September 9, 2011 |^|]

In Jakarta medical faculties exist in a number of provincial universities. Training is often hampered by poor facilities, and medical research is limited as teaching physicians also maintain private practices to serve urban needs and supplement meager salaries. Physicians and government health facilities are heavily concentrated in large cities, and private hospitals are also located there, some founded by Christian missions or Muslim foundations. Many village areas in Java, and especially those in the outer islands, have little primary care beyond inoculations, maternal and baby visits, and family planning, though these have had important impacts on health conditions. [Source: everyculture.com ]

One of the most notable features of Indonesia’s health-care system, in comparison with those of other Southeast Asian nations, is the low level of government support. For example, in 2006 the Philippines expended 3.3 percent of its gross domestic product (GDP) on health care, Malaysia 4.3 percent, Singapore 3.4 percent, and Timor-Leste 16.4 percent. That same year, only 2.2 percent of the GDP of Indonesia was devoted to health care, far less than the 5 percent recommended by the WHO. Of these percentages, however, as of 2006, the Indonesian government provided 50.4 percent of the total national expenditure on health care. This compares favorably with Malaysia’s 45.2 percent, Philippines’ 39.6 percent, and Singapore’s 33.6 percent but not with Timor-Leste’s 88.8 percent. [Source: Library of Congress]

Cambodia has a GDP which is three times lower than that of Indonesia, and a greater proportion of its population live in poverty (68 percent vs. 54 percent). Thailand and Malaysia are developing countries with a higher GDP and a poverty rate which is two to four times lower than that of Indonesia. Singapore, meanwhile, is an example of the developed countries of Southeast Asia, with a GDP that is 17 times higher than Indonesia’s and with reportedly no proportion of the population living below the poverty line. In terms of healthcare delivery services, the availability ratio of hospital beds in Indonesia is six times higher than the ratio in Cambodia. This ratio is three to five times lower than the ratio in Thailand, Malaysia and Singapore. The ratio of physicians to population in Indonesia is lower (two to 15 times lower) than the ratio in other countries. Similarly, the ratio of nurses and midwives to population in Indonesia is about two to five times lower than the ratio in neighbouring countries. This situation is exacerbated by the sheer size of Indonesia’s population; a population 3–45 times the size of the populations in neighbouring countries. [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

Hospitals and Clinics in Indonesia

Healthcare services are made up of primary health centres, public hospitals, private and semi-private pharmaceutical industries and private sector healthcare facilities and personnel. Primary health centres are mainly located in sub-districts and provide maternal and infant care, family planning and in-patient and out-patient services to the community, as well as communicable disease control services. In 2007, there were 8234 primary health centres, with a centre serving, on average, about 27,400 people (Departemen Kesehatan, 2008). The number of primary health centres increases at a rate of about 2.7 percent per year. The service coverage by province ranged from 8000 to 52,000 people per health centre. Seven provinces failed to meet the standard target of a maximum of 30,000 people per health centre. These were Riau, Banten, West Java, Central Java, East Java, Bali and West Nusa Tenggara. The area coverage per centre was 192 square kilometers on average; however, in sparsely populated Papua, Central Kalimantan and East Kalimantan area, coverage was greater than 1000 square kilometers. [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

The number of hospitals was 1319 in 2007, which provided a total of 142,707 hospital beds (Departemen Kesehatan, 2008). Ownership of these hospitals was 49 percent private and 51 percent public and government operated. The overall ratio of population to each hospital bed was 1581:1. The Indonesian Ministry of Health (MoH) declared the ideal ratio to be 1000 people per bed. The annual increase in hospital beds is typically 1.1 percent. The total number of people seeking hospital treatment was about 30 million in 2005, with ~7.8 percent of them being referred from lower levels of healthcare delivery, including primary health centres (Badan Pusat Statistik, 2007b).

In order to increase the coverage of community services, Indonesia implemented community-based health effort programs, such as health posts, with integrated village maternity huts and village drug posts. By 2006, there were 269,202 health posts, called Pos Pelayanan Terpadu or Posyandu, which provided maternity and child health services, family planning, nutritional development, immunization and diarrhoea control (Departemen Kesehatan, 2008). There are four of these Posyandu in each village. In total, there were 25,754 maternity huts, known as Pondok Bersalin Desa or Polindes, which provide midwives with delivery units, as well as providing improved maternity and child health services and family planning services. In addition, there are 9598 village drug posts, known as Pos Obat Desa, which assist in the distribution of some essential drugs directly to the community.

Doctors and Health Care Workers in Indonesia

According to the Indonesian MoH in 2007 there was about half a million health personnel employed in Indonesia (Departemen Kesehatan, 2008). Nurses and midwives made up 54 percent and 14 percent, respectively, of that number. Typically, for every 100,000 people, there were 138 nurses and 35 midwives. Eight percent of these half a million health personnel were licensed physicians, yielding a service ratio of about 19 physicians per 100,000 people. Health personnel specializing in public health made up two percent of this half a million, with a service ratio of approximately four per 100,000 people. The distribution of health personnel was 257,555 (45 percent) at hospitals and 184,445 (32 percent) at healthcare centres (Departemen Kesehatan, 2008). [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

The distribution of Indonesian health-care workers is also highly uneven. To alleviate the problem of physician maldistribution, the government requires two to five years of public service by all graduates of medical schools, whether public or private. In order to be admitted for specialist training, physicians first have to complete this service, which is normally fulfilled by staffing puskesmas. Only two years of public service are required for those physicians working in remote areas such as the provinces of Nusa Tenggara Timur, Sulawesi Tenggara, Kalimantan Timur, Maluku, Papua, and Papua Barat, whereas three to five years of service are required for a posting in Java, Bali, or Sumatra. Despite such requirements, it is difficult to attract medical-school graduates to these remote, understaffed regions, particularly without additional cash incentives. [Source: Library of Congress]

Drugs and Public Sanitation in Indonesia

Indonesia achieved self-sufficiency in basic pharmaceutical production by the early 1990s, but as the twenty-first century began, Indonesians still had one of the lowest per capita expenditures for modern drugs among the members of the Association of Southeast Asian Nations (ASEAN). According to one estimate in 2000, Indonesia’s annual consumption of medicine was US$4 per capita, compared to US$6 in the Philippines and US$11 in Thailand and Malaysia. Many Indonesians continue to rely at least partially on traditional herbal medicines, in part because modern pharmaceuticals are expensive. When modern medicines are used, ongoing problems include overprescription of antibiotics, overuse of injections, poor patient compliance, use of unlabeled drugs, and inattention to drug interactions. By 2005 Indonesia had about 200 pharmaceutical companies and nearly 1,000 pharmaceutical wholesalers. Most were located on Java. [Source: Library of Congress *]

The activities of the pharmaceutical industry ensure the availability, accessibility and distribution of drugs to the community. By 2005, according to the Drug and Food Control Agency, there were 465 standard pharmaceutical companies and 1634 small, traditional drug companies in the production sector (Departemen Kesehatan, 2008). The traditional ‘drug’ companies typically produce herbal elixirs ranging from vitamin supplements and skin ointments, to solutions purported to boost the intellect, energy or sexual stamina. The distribution of pharmaceutical products is managed by 2493 wholesalers, 10,275 dispensaries, and 7056 drugstores (Departemen Kesehatan, 2008). Although many statutes restrict the distribution of prescription drugs, it is generally the case that many anti-infective therapies, including antimalarials, which are officially prescription only drugs, can be purchased over the counter. [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

In 2008 about 89 percent of the urban population in Indonesia had access to clean water, and about 60 percent had access to piped water, mostly from a shared faucet. The number of urban dwellers with a household connection rose between 1990 and 2008, from 28 percent to 37 percent. In rural areas, the proportions were smaller: approximately 71 percent had access to an improved water source, and about 8 percent had a household connection in 2008. Many mid-dle-and lower-class Indonesians continue to rely on the country’s frequently polluted streams, canals, and water catchment areas. In many coastal cities, the freshwater table is being threatened by the drilling of private wells, which become contaminated by leaking septic tanks. This situation has given rise to the popularity of commercially purified water sold in sealed plastic containers. According to the WHO, 82 percent of urban residents and 54 percent of rural residents had access to modern sanitation facilities in 2007, but only 67 percent and 36 percent, respectively, used these improved facilities in 2008. Even in urban areas, the WHO estimated that 16 percent of residents were without proper sanitation. Many commercial and residential areas are served by a waterborne sewerage system of open drainage canals discharging raw wastes directly into rivers or the sea. In the slum areas of Jakarta, residents are subjected to frequent flooding and the outbreak of waterborne diseases resulting from clogged sewers. *

Indonesian Government Health Agencies

Most government-affiliated infections research and surveillance systems in Indonesia are managed by three separate government agencies: (1) the NIHRD, (2) the Directorate General of Disease Control and Health Environment and (3) the Directorate General of Medical Care. All of these are under MoH authority. The Ministry of Research and Technology also sponsors infections research, primarily through the research conducted at the Eijkman Institute for Molecular Biology. Moreover, many academic institutions operating under the authority of the Ministry of Education have long histories of vibrant and productive research on infections, especially in schools of medicine and of public health. [Source: Iqbal R.F. Elyazar, Simon I. Hay, and J. Kevin Baird, PMC Apr 13, 2011]

The NIHRD commenced operations in 1975. Its main functions were (1) to develop policies, programs and implementation strategies for health systems, health policy, biomedicine, pharmaceutics, ecology, health status, nutrition and food, (2) to evaluate and screen health technologies and (3) to disseminate research results. Most malaria research conducted at the NIHRD is carried out by three main branches: (a) the Research Centre of Biomedicine and Pharmacy, (b) the Research Centre of Ecology and Health Status and (c) the Research and Development Centre of Vectors and Diseases. In 2006, these three NIHRD centres had 88, 50 and 15 researchers, respectively. That year, NIHRD received Rp. 174 billion (~US$ 2 million) and spent 25 percent on research and development, 72 percent on human resources and facilities development and 3 percent on research results dissemination (Departemen Kesehatan, 2006d).

The NIHRD organizes health surveys. The Basic Health Research, called Riskesdas or Riset Kesehatan Dasar project, initiated in 2007, is an example of this. A total of 258,366 households and 987,205 individual household members were sampled, with sampling reaching every province. The survey collected information about household and individual demographics, mortality, access to health facilities, sanitation, food and drug consumption, history of diseases, perceived responsiveness of health facilities, health behaviour, disabilities, mental health, immunization, growth monitoring and infant health. Riskesdas also collected 36,357 blood samples in order to measure biomedical variables. In the specific instance of malaria, respondents were asked about any history of confirmed malaria, symptoms of malaria and malaria medication usage (National Institute of Health Research and Development, 2008).

As part of the National Health Survey System, the Central Bureau of Statistics (with NIHRD) has conducted a Household Health Survey (SKRT; Survey Kesehatan Rumah Tangga) every five years since 1975. In this survey 10,000 households are selected by stratified multistage random sampling. The survey collects information on household and individual characteristics, environment, morbidity, mortality, pregnancy and delivery (Soemantri et al., 2005). In addition, the National Family Planning Bureau also conducts Indonesian Demography and Health Surveys (SDKI, Survey Demografi dan Kesehatan Indonesia) every 3 years (this began in 1981). The surveys are designed to collect data on fertility, family planning, and maternal and child health. A total of 35,000 households are sampled across all provinces. In order to participate, respondents must be married and aged 15–49 years (females) or 15–54 years (males) (Soemantri et al., 2005).

The Directorate General of Disease Control consists of five directorates: (a) the Directorate of Epidemiology Surveillance (144 personnel), (b) the Directorate of Communicable Diseases (98 personnel), (c) the Directorate of Vector-borne Diseases (104 personnel), (d) the Directorate of Non-Communicable Diseases (80 personnel) and (e) the Directorate of Health Environment (99 personnel). The Directorate of Vector-Borne Diseases is responsible for malaria and vector control activities (Departemen Kesehatan, 2006c).

Simples Cataract Surgery Restores Sight to Indonesian Blind

Reporting from Padang Sidempuan, Sumatra, Binsar Bakkara, “They came from the remotest parts of Indonesia, taking crowded overnight ferries and riding for hours in cars or buses – all in the hope that a simple, and free, surgical procedure would restore their eyesight. Many patients were elderly and needed help to reach two hospitals in Sumatra where mass eye camps were held earlier this month by Nepalese surgeon Dr. Sanduk Ruit. During eight days, more than 1,400 cataracts were removed. [Source:Binsar Bakkara, November 22, 2012 <+>]

“The patients camped out, sleeping side-by-side on military cots, eating donated food while fire trucks supplied water for showers and toilets. Many who had given up hope of seeing again left smiling after their bandages were removed. "I've been blind for three years, and it's really bad," said Arlita Tobing, 65, whose sight was restored after the surgery. "I worked on someone's farm, but I couldn't work anymore." <+>

“Indonesia has one of the highest rates of blindness in the world, making it a target country for Ruit who travels throughout the developing world holding free mass eye camps while training doctors to perform the simple, stitch-free procedure he pioneered. He often visits hard-to-reach remote areas where health care is scarce and patients are poor. He believes that by teaching doctors how to perform his method of cataract removal, the rate of blindness can be reduced worldwide.” <+>

“Cataracts are the leading cause of blindness globally, affecting about 20 million people who mostly live in poor countries, according to the World Health Organization. "We get only one life, and that life is very short. I am blessed by God to have this opportunity," said Ruit, who runs the Tilganga Eye Center in Katmandu, Nepal. "The most important of that is training, taking the idea to other people." During the recent camps, Ruit trained six doctors from Indonesia, Thailand and Singapore.” <+>

End-of-Life Issues as Debated as Suharto Hovers near Death

As Suharto hoovered near death a quiet debate was sparked on end-of-life issues such as when to use ventilators and other machines to keep a patient alive. Robin McDowell of Associated Press wrote: “When Suharto began struggling to breathe, his doctors asked Health Minister Siti Fadilah Supari if he should be placed on a ventilator, to which she responded "no," let him die naturally -- advice the family ignored. A few days later Suharto was starting to breathe on his own, prompting doctors to decrease dependence on the machine, said Dr. Mardjo Soebiandono. [Source: Robin McDowell, Associated Press, January 17, 2008]

“When it comes to end-of-life issues in Indonesia, a country that provides no legal guidelines for doctors, religion plays a role. Islam says all possible steps should be taken to save a dying patient, unless the risks outweigh the benefits, said Dr. Rusdy Malueka, an Islamic ethics specialist. Malueka was among more than 100 hospital directors, doctors and researchers taking part in an end-of-life workshop in the city of Yogyakarta. The meeting, a collaboration between Harvard Medical School and the University of Gadjah Mada, was organized before Suharto fell ill.

"There really is no systematic policy at hospitals on how to deal with end-of-life patients," said Retna Siwi Padmawati, a bio-ethics researcher, describing the burden doctors may face in trying to convince families that some cases are futile. Some physicians base their decisions on international guidelines, she said, adding others look for advice wherever they can find it, "from the Internet, for instance." For many families without money or health insurance, end-of-life issues are often determined by cost. When they can no longer afford expensive treatment, they ask doctors to pull the plug. The last time the issue captured Indonesia's attention was in 2004, when a man filed a motion with a court asking to authorize lethal injection for his wife, who had been in a "persistent vegetative state" for three months after a Caesarean section. She regained consciousness before a ruling was issued.

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Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, Lonely Planet Guides, Library of Congress, Compton’s Encyclopedia, The Guardian, National Geographic, Smithsonian magazine, The New Yorker, Time, Newsweek, Reuters, AP, AFP, Wall Street Journal, The Atlantic Monthly, The Economist, Global Viewpoint (Christian Science Monitor), Foreign Policy, Wikipedia, BBC, CNN, and various books, websites and other publications.

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© 2008 Jeffrey Hays

Last updated June 2015

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