High Cost of Health

The Jakarta Post ,  Jakarta   |  Sat, 05/24/2008 6:54 AM  |  Center Piece

Although Indonesia ranks fairly well in international health surveys, the reality on the ground – expensive medical fees, poor infrastructure and the persistence of communicable diseases – is very different. Maggie Tiojakin reports.

In 2007, the World Health Organization published a report that clumped Indonesia in a pool of ‘relatively healthy’ countries — alongside India, Maldives and Ukraine – based on its mortality rate.

A Human Development Index report released by the United Nations Development Program the same year placed Indonesia 107th, a tiny step up from its previous position of 108th. The report, measuring a nation’s standard of living, classified those below 100 as falling into the ‘medium’ range.

The problem, of course, with ranking as ‘relatively healthy’ and ‘medium’ is that we are not quite right yet, and still not moving forward quickly enough.

“Public health is, and always has been, a sensitive issue,” says Stefanus, a 34-year-old general physician who has been involved in various community projects across the archipelago with non-profit organizations.

He equates public health with the delicate game of Jenga, where players take turns removing blocks from a tower and placing them back on top.

“If you structure one piece in a faulty way, it falls apart,” says Stefanus, when interviewed via online instant messaging service. “So, in order for public health to improve, our economy, education, culture — among ten million other things —have to work.”

Tall order, yes, but not impossible. Vietnam went from being a war-ridden country with arguably one of the worst healthcare systems in the world, to an emerging Asian economic tiger with a reputation as one of the fastest growing markets in the global healthcare industry.

How?

In 2001, Vietnam’s Health Ministry announced the Strategy for Protection and Care of the People’s Health, a new system to improve public healthcare by 2010. No less than US$1.5 billion was invested, half of which went to the purchase of new medical equipment. Two years later, the Vietnamese government spent $420 million on pharmaceutical imports, making it one of the largest importers of foreign drugs. Today, more than 200 pharmaceutical companies worldwide are registered in Vietnam (Pacific Bridge Medical, 2007).

Indonesia announced more or less the same program in 1999, aiming to achieve a ‘Healthy Indonesia’ by 2010. In 2003, the Health Ministry introduced 50 indicators of a healthier population that were meant to battle communicable diseases by promoting preventive care, building accessible health posts, providing extra training programs for health professionals and educating the public about healthy lifestyles.

Two years short of the finish line, we have yet to eradicate diseases like polio, diarrhea, malaria and tuberculosis. With more than 300 confirmed polio cases (WHO Global Health Report, 2005), Indonesia comes third after Yemen (478) and Nigeria (801) on the list of countries with the highest polio risk factor. 

“Our population grows 1.5 percent every year,” says Herman Trikarama, the local communications director for an international NGO based in Jakarta. “The number of people we have to reach out to affects our ability to do it. It’s easier to contain communicable diseases and promote healthier lifestyles in countries with smaller populations, because they don’t have to deal with the kind of disparity we deal with here in this country.”

By disparity, he means the gap between the rich and the poor, urban versus suburban communities, as well as the disproportionate decentralization of healthcare access throughout the various provinces.

Murni is a 33-year-old woman who makes her living as a waitress at a small restaurant in Jakarta. A single mother of two little girls, she says she only takes her daughters to see a doctor if they are literally at death’s door.

“Once, Rina [her 12-year-old daughter] caught hepatitis. She was bed-ridden for days before I could take her to the nearby clinic,” recalls Murni. “The doctor’s fee and prescription drugs cost Rp 400,000. For me, that’s a month’s work. So I had to borrow money from friends and neighbors. It was a nightmare.”

But it’s not much easier for the haves.

“Healthcare is generally quite expensive for everyone, regardless of their economic status,” says Stefanus. “The more money you have, the better care you expect. I don’t know how to say this … whether you’re rich or poor, you always end up paying more than you can normally afford.”

Expensive and unreliable healthcare is why private insurance companies have been booming these past few years. With insurance policies valued from 60 to 500 million rupiah, covering expenses from dental cleanings to overnight hospital stays and major surgery, thousands and perhaps millions of people are insuring themselves to anticipate the brutal aftershock of having to pay for hospital bills that figuratively may cost an arm and a leg.

“The price for health in this country is ridiculously high and people are aware of it. Most of my clients are in their 40s and 50s,” says Donald, a sales manager at a private company that sells life and health insurance. “They know how incredibly risky it is to live their lives without any kind of health plan, at least from a financial point of view.”

What about the government healthcare plan?

“Look at the condition of public hospitals,” Donald replies, adding that more than half of his clients would sooner seek medical care abroad. “I’m not saying the government is neglecting the people, but I don’t think they pay enough attention to us, either.”

A lawyer who also boasts a medical degree, Herman chooses to look at the immediate facts in his approach toward public health issues.

“The government has set out a goal which, I think, is commendable. But between a wobbly economy and everything else that we’re trying to improve, I honestly believe we have to be a bit more realistic.”

And the reality is that money is tight, health is expensive. Of the 192 countries listed in the WHO report, Indonesia has one of the lowest health expenditures (3.1 percent of total GDP), on par with Myanmar (2.8 percent), Kuwait (3.5 percent) and Bhutan (3.1 percent).

The logic is simple: no money, no progress.

Lack of medical training for professionals is a prevailing cause of the country’s stagnant development in the public health sector, while lack of information and knowledge leads people to ignore the perils of their unhealthy lifestyles, as they eventually resort to cheaper solutions like self-medication with dodgy, uncertified drugs or traditional healers, some of whom are charlatans  

“Clearly, we can’t let our society sink into despair,” says Herman. “However, it’s going to take time. The government has to gain the people’s trust and respect, that’s a first. Second, we — the people — have to take our own preventive measures. Smoking, for example. The smoking ban in cafés and restaurants lasted for, what, a month?”

A new campaign launched by the World Health Organization, supported by all 175 members, aims to create global public health security through a unified healthcare system. It envisions a healthier world where the risk of an outbreak is minimized so everyone, everywhere is safe.

As for Indonesia, the struggle continues. Each day remains a challenge.

“Ultimately, we can’t rely on statistics to find the solution for something this big, this delicate,” Herman says. “Money is a problem, yes, but it’s not the problem. By 2010, we may or may not have achieved our goals. Still, it’s nice to know that we have a goal.”

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