Progress and Setback
Women and children
The epidemiological transition
Government Policy and Finance
Progress and Setback
Indonesia is the fourth most populated country in the world, with 300
ethnic groups speaking 350 languages spread over the country's 6,000 inhabited
For 30 years from 1967, Indonesia made remarkable progress. A period
of economic growth raised per capita income from US$50 in 1968 to US$
1,124 in 1996, despite an increase in population from 147 million in 1980
to 179 million in 1990, with a forecast of 210 million in the year 2000.
Between 1980-1990 the annual population growth rate was 1.9%, with a Crude
Birth Rate of 22.5 per 1000 and a Crude Death Rate of 7.4 per 1000 in
1998. The population pyramid grew towards an older population, with a
life expectancy at birth of 64 years for males and 67 years for females
(1996). As a consequence of better socio-economic development and improved
preventive and curative services, the infant mortality rate declined from
142 per 1000 in 1968 to 50 per 1000 in 1998. The proportion of the population
living in poverty dropped from 60% in 1970 to an estimated 11 -13% in
1996. Most of the poor lived in rural areas, in some of the remote islands
or upland areas. By 1997 the literacy rate for those aged 10 years or
more was 89%.
These achievements received a severe set back in mid-1997 when the Indonesian
economy collapsed. The value of the currency plummeted, prices increased,
and unemployment rose dramatically. In addition, parts of the country
suffered from long droughts and extensive forest fires. This sudden crisis
resulted in political turmoil and, in 1998, a change of government. The
ensuing political instability has had a direct impact on economic recovery.
The proportion of population living in poverty increased from the estimated
11-13 % (1996) to 24.2%(1998).
Although the health status of Indonesians has not been affected drastically
in the short term, the economic crisis has certainly slowed development
of the health system. The Government of Indonesia is taking special steps
to protect the health of its population through the modification of its
Seventh Five-Year Plan (Repelita VII), but the pace of progress in solving
health problems has been slow. The health status of Indonesia still lags
behind neighbouring countries. Maternal mortality in particular is very
high at 334 per 100,000 live births (1997). Moreover, national figures
mask considerable regional disparities in health indicators. For example,
the infant mortality rate ranges from 27 per 1000 live births in Jakarta
to 90 in West Nusa Tenggara(1998).
Communicable diseases are a major cause of morbidity and mortality in
Indonesia. Technical strategies for communicable disease control have
already been accepted, adapted to country-specific needs and adopted.
However, implementation of these accepted strategies needs to be improved,
particularly given the shift to a decentralised health system. Major problems
Tuberculosis which is the second highest cause of death and the primary
killer among infectious diseases. An estimated 175,000 people die every
year from tuberculosis. The DOTS strategy has been expanded to 225 districts
(74.8%) out of a total at of 311 districts, covering 88 out of the 210
million people. Case finding is presently only 10% of the expected incident
Leprosy is on the verge of being eliminated. Current efforts focus on
Malaria is still a public health problem. Approximately 1.5 million
cases are detected annually. In 1997, the parasite incidence ranged from
0.12 per 1000 population in Java and Bali to around 40 per 1000 population,
under 10 years of age, in the outer islands. In 1998, there were malaria
outbreaks in the highlands of Irian Jaya and resurgence in Central Java.
Dengue fever/dengue haemorrhagic fever usually occurs in epidemic proportions
during the peak season, starting in November and peaking in May. In 1998,
30,000 cases were reported from cities and also from some rural areas.
STDs remain a serious problem, especially in high-risk groups, and promote
the spread of HIV/AIDS. Control is complicated by social and cultural
attitudes towards these diseases and possible interventions. As of January
1999, the cumulative number of reported AIDS cases was 227, of which 113
AIDS patients had died. The progression rate seems to increase slowly,
doubling in more than two years. However, this may be due to under-diagnosis
Women and children
The health of women and children continues to be a cause of concern.
With five million pregnancies every year in Indonesia, more than 20,000
women die annually during pregnancy and delivery. The high number of maternal
deaths is a particular problem in rural areas, given limited access to
delivery by skilled attendants and an inadequate referral system. Almost
50% of women give birth without skilled attendants and 70% have no postpartum
care during the six weeks following delivery. The management of obstetric
cases only reaches about 10% of the estimated total.
Many of the traditional childhood infectious diseases have been controlled
through immunisation. Polio is close to elimination and current efforts
focus on surveillance and final sub national Immunisation Days campaigns.
Routine EPI coverage has been maintained above 80% nationally with donor
assistance though rates are falling in pocket areas. However, with decentralisation
of the health system, renewed efforts will be needed to ensure that immunisation
coverage is sustained.
An important objective in Indonesia is to reduce the IMR to less than
50 and the under-five mortality rate to 66 per 1000 live births. One of
the strategies is the Integrated Management of Childhood Illness (IMCI)
within which special emphasis will be put on the quality of health services
and the prevention of illness and appropriate health care seeking behavior
at the family and community level.
Malnutrition, especially among mothers and children, will require additional
resources for improving breast- feeding practices, complementary feeding
The epidemiological transition
As the life expectancy of Indonesians improves, the concern is shifting
from communicable to degenerative diseases. This epidemiological transition
has presented the health care delivery system with a double burden. Chronic
conditions include cancer, circulatory diseases, metabolic disorders,
congenital disorders, tobacco dependence, mental health and neurological
disorders. Since these diseases are expensive and difficult to cure, it
is appropriate to focus on their prevention, and especially on promoting
healthy lifestyles with an emphasis on reducing tobacco dependence. However,
although Indonesia has placed high priority on health promotion and prevention
over the last two decades, the translation of these priorities into policies
and implementation has been fragmented and ineffective.
Indonesians are increasingly exposed to health risks from environmental
hazards. Cases of severe urban air pollution and massive air contamination
of ground and surface water resources by industries and households are
common. Many potentially harmful chemicals are readily available to the
public and are regularly used at places of work in agriculture, industry
and commerce. Food contamination of both microbiological and chemical
origin is a major issue. The haze from the forest fires in Indonesia has
had significant disruptive social and economic effects on people living
in affected areas. However, there is little serious commitment to tackle
these problems because of complexity of the issues, and a lack of clear
responsibilities both in the public and private sectors.
In addition Indonesia is currently facing a large number of complex emergencies
arising from multiple natural disasters and many areas of civil unrest.
Vast displacements of populations - amounting to about 1 million by the
end of 2000 -have taken place in West Timor, Malukus, and Aceh provinces.
Government Policy and Finance
Following the change of government, the President in March 1999 proclaimed
a new development policy which employs a health-oriented national development
approach -"Healthy Indonesia 2010". The new mission of the National
Health Development Programme is to lead and initiate health-oriented national
development; maintain and enhance the health of individuals, family and
community, along with their environments; maintain and enhance good quality,
equitable and affordable health services; and promote public self-reliance
in achieving good health.
The main focus of the new approach is:
- decentralisation as the key to health sector reform, in the context
of broader political decentralisation
- an emphasis on health prevention and health promotion, "the Healthy
Paradigm", rather than on curative services
- an effective human resources development programme, to support decentralisation
- access to quality basic health services through a community managed
care approach (JPKM).
A Framework for Health Priorities for Indonesia provides the guidelines
for all Ministry of Health and Social Welfare (MoHSW) programmes. Donor
assistance will focus on supporting these priority programmes.
The budget system in Indonesia is complicated, highly centralised, inflexible
and fragmented. Every administrative level has a local budget, including
a budget for health. However, at least 90% of government budget comes
directly or indirectly from the central government.
The available budget fails to meet the health needs. Based on the best
available data, it is estimated that the total health development budget
was 2.4% of the annual national development budget in fiscal year (FY)
1996/97 increasing to 3.0% in FY 1999/2000, or 0.4% of GDP in FY 1996/97
increasing to 1% in FY 1999/2000. Although the government is committed
to health as one of its top priorities, preliminary analysis of public
expenditures shows a decreasing health budget in real terms, especially
for FY 1998/99.
Funds flow into the sector from a variety of sources, the major ones
being allocation of government revenues - both central and local government;
payments by households (fees for services, drug purchases); employer contribution
to health; limited support from NGOs, and foreign loans and grants. In
the period 1985-1995, on average only 30% of health care expenditure came
from government sources, while 70% came from non-governmental sources,
including the organised private sector (employer and insurance) and out-of-pocket
health expenditure from households. The distinction between public and
private provision of health care is quite blurred in Indonesia, mostly
due to the fact that public health professionals also work as private
providers during non-working hours.
Over the next few years, Indonesia will face an important transitional
period. After more than 25 years of highly centralised government, Indonesia
is undergoing rapid democratisation and decentralisation of political
and bureaucratic power. While the course of these political developments
is not wholly predictable, it is likely that there will be periods of
political instability and resulting adjustments. Furthermore, trends toward
increasing democracy are likely to lead to changes in the function of
the government itself. Strong political movements towards good governance
and reform of the public sector will have major effects in the health
During this period of political change, Indonesia will still be recovering
from the economic problems it has faced since the last quarter of 1997.
If the political situation stabilises, economic changes are likely to
proceed more quickly. Conversely, continuing political uncertainties may
hinder recovery and pose the risk of even more severe economic problems.
Indonesia is likely to face severe monetary constraints over this period,
with little prospect of large increases in public sector expenditure.
The political and economic situation will have an overriding influence
on health in Indonesia over the next few years. Decentralisation in particular
will have a major impact. Successful programmes that are highly centralised
(such as immunisation and drug supplies for health centres) may suffer
severe initial setbacks in a decentralised system. Public health activities
may not receive adequate funding under a local budgeting system. There
are likely to be severe disruptions in the health workforce in the public
sector as personnel face sudden changes in their employment. Diseases
of the poor - infectious diseases exacerbated by malnutrition, especially
tuberculosis and malaria - will remain major issues in Indonesia. Efforts
in the last few years have not yielded the expected results. A major part
of the problem lies in broader issues of health system development. These
include the need for: efforts aimed at greater advocacy for health; effective
mechanisms for financing health care; efficient procurement and distribution
of essential commodities; the effective delivery of basic services through
a wide range of delivery organisations, both public and private; ensuring
access to the most vulnerable sections of the population; and rigorous
surveillance and monitoring of the results. Development of an integrated
approach to these health issues is especially important in the context
of the Government of Indonesia's current decentralisation initiative.
Priority issues over the next 5 years will be :
Decentralisation is a key challenge for the future development of the
health sector. In Indonesia, the current move involves all sectors and
requires the development of new roles for all levels of government. Precautions
are necessary to prevent any adverse effects of decentralisation. Good
governance should be the underlying principle.
Equity in healthcare services
The issue of equity is growing in importance. The government has a policy
to promote access to health care for the poor and vulnerable groups through
the 'Health Card' programme, but it is not working well, and will have
to be revisited. In theory Health Card holders are eligible for free care
at public facilities but many district governments, especially those in
poor districts, are reluctant to provide free services.
At the same time low utilisation of public health facilities is a matter
of concern, particularly given the massive investment that has gone into
building a vast network of facilities across the country. Some of the
reasons for this low utilisation include poor quality of services; limited
health insurance coverage; and the blurred distinction between private
and public health care. Most health personnel are also private providers
after office hours. This creates a conflict of interest which adversely
affects the performance of the public health facilities.
The geographical distribution of health and health-related professionals
is another key issue. Since 1992 central government has had a 'zero growth
policy' for civil servants. This restricts the availability of health
personnel, especially in remote areas. A MoHSW initiative to counter this
- the Contract Programme - has led to uncertainty and demotivation among
young doctors. Another major obstacle is the reluctance of health personnel
to work in rural areas and difficulties in posting female health workers
in the periphery. This will become a key issue in the decentralised health
system if health personnel are directly recruited and paid by district
Launched in 1988, the concept of autonomous hospitals ("swadana")
allows hospital managers to retain hospital revenues as an additional
means to meet operational costs. Although there is some evidence that
this initiative has improved the quality of services, it has not achieved
the objective of lowering public subsidies to these hospitals. Also, since
fees have usually increased, the ability of the poor to access these services
is likely to have been curtailed even further. Such autonomous hospitals
need to improve efficiency in the use of funds and facilities. There is
also need to take appropriate steps to sustain the private heath sector,
in the wake of the economic crisis.
Public/Private Health Services
Services are mainly provided by highly subsidised public facilities.
There are about 7600 health centres and 340 hospitals across the country,
giving an average of 30,000 population per health centre and one district
hospital in every district. In
addition, there are referral hospitals that provide a variety of specialty
services in every province. Most public providers also double as private
providers after official hours. As a result of the economic growth, there
is also a vast growth of private hospitals and clinics across the country
especially in big cities. There are 351 private hospitals, most of them
owned by social and religious affiliated institutions. Prior to the economic
crisis, there was a growing tendency to build 'for profit' hospitals.
Despite this development, access to health care is still a major problem
because of low coverage of health insurance - only 15% of the population,
especially for hospitalisation.
One area where the impact of the 1997 crisis was felt early on is drug
supply. Currency devaluation caused prices to rise, which resulted in
problems of availability and, even more, of affordability of drugs. Decentralised
procurement of drugs, and the tendency of health providers to use drugs
irrationally, will continue to be important concerns.