A young girl helps her mother at a medicine stall in a market in Bowae, Flores. Inappropriate self-treatment has led to very high levels of antibiotic resistance in Indonesia - Elizabeth Pisani
A community meeting in the Papuan highland district of Paniai, mid 2012. People have come to talk to the district head (the bupati) and the head of the health department about service provision. Except the bupati is not there; he’s gone walkabout in Jakarta and is being represented by the (Javanese) second assistant district secretary. And the head of health isn’t there either; he has something better to do, and has sent the (Torajan) secretary for health.
The crowd rounds on the secretaries: ‘What’s the point of regional autonomy if all the service providers are from outside, and all the money goes to buying flash cars for functionaries from other islands?’, asks one gentleman. ‘We want to be seen by [health staff from] our own people!’ There was a lot more in the same vein: people are clearly cross that decentralisation (and in this case, Papuan regional autonomy) is not delivering what it promised: health services that are better suited to local needs.
The secretary for health heard them out. Then, quietly: ‘There are five Papuans in Paniai trained as midwives. Five. And not one of them wants to work with patients.’ He went on to explain, with an unprecedented frankness clearly born of frustration, that because these five are the only locals with any health qualifications, every single one of them has lobbied to run a puskesmas, or primary health clinic.
He reminded the crowd, too, that the department has given 30 motorbikes to puskesmas throughout the district to use in outreach and service delivery. ‘After just a couple of months, you don’t see them anymore, lost, maybe, broken maybe, who can say?’ Seven out of seven speedboats given to puskesmas to serve the populations around Paniai’s lakes had also evaporated or rusted into disuse, he said.
The logic of dysfunction
The case of Papua is extreme; trained health staff are in exceptionally short supply there and new districts (kabupaten) and municipalities (kotamadya) have been budding off with great virulence – there are now 38 kabupaten/kota across two provinces where there used to be just eight grouped in a single province. But it highlights what ails Indonesia’s health system as a whole. The motorbikes and speedboats, for example: they may just have been stolen, but it is just as likely that that have failed because of poor maintenance, or simply run out of petrol. The situation is a lot worse with medical equipment, which generally requires trained staff and reagents or other supplies to keep it running, besides needing to be professionally maintained.
I have several times seen expensive equipment still sitting in its wrapping because no-one knew how to use it. In an office in the Ministry of Health in Jakarta, I once found two computers unused because they had three-pin square plugs on them instead of the Indonesian standard two-pin round. Rather than spend a few pennies on adaptors, the division had requested funding for two new computers from a foreign donor. Absurd though this seems, it’s quite rational. The incentives in the health system are stacked heavily in favour of capital spending: it allows politicians and their flunkies to show off concrete investments and to take kickbacks; recurrent spending, including maintenance, is harder to turn to the advantage of functionaries.
This logic was present even in a more centralised system; it has been aggravated by decentralisation because directly-elected local government heads are especially keen to be photographed with high-profile, capital-intensive services: the new hospital building, the MRI scanner, whether or not they are needed. In many cases, they are not. Districts with small populations don’t need equipment to diagnose rare conditions – they’d be better off sending people to a reference hospital elsewhere. That’s fine if there’s a provincial hospital handy. But Indonesia is hamstrung by its administrative structure as well as its geography.
On the island of Lirang, in Southwest Maluku, I watched a frail old woman being hauled up from a fishing boat to the deck of a cargo boat (there is no functioning port). She needed to go to hospital, but of course there is no hospital in Lirang, nor should there be: only 8,000 people live in Lirang and the four other islands in the sub-district of Wetar combined. In pain but remarkably resigned, this woman sat next to me on the deck of the boat for three days and three nights before arriving at Saumlaki. That gave us lots of time to chat. Why, I asked, did she not go in the other direction to Kupang, a much bigger city with better facilities only a day and a half from Lirang? Because, she replied, Kupang is in NTT (East Nusa Tenggara), a different province.
As a resident of Maluku, this woman could not use her health insurance in NTT. Saumlaki would be difficult enough, because it is no longer in the same district as Lirang. Health services in Saumlaki, Southeast Maluku, are no longer funded to care for patients from the newly excised Southwest Maluku. ‘But if you know people from the old days, you can usually fix it with a bit of this,’ the lady rubbed forefinger and thumb together. The administratively correct alternative would be for this sick 70-something year-old to travel another three days to the provincial capital of Ambon.
Missing in action
Petty political jealousies and funding arrangements often undermine cooperation between new districts and those from which they have been split, the mother district or kabupaten induk. Hospitals and doctors are concentrated in larger towns and cities. When a town gets promoted to become a municipality, or kotamadya, the rump district is left with few facilities. Often they build health facilities – that photo-op for the district head again – but then have trouble staffing them. To give just one example from a recent World Bank expenditure analysis in South Sulawesi, there are an average of 2.2 health facilities per 10,000 people in the municipalities in that province, with 41 qualified medics for the same number of people in those municipalities. The rural kabupaten have rather more facilities: 3.2 per 10,000 people, but those 10,000 are served by just 13 trained health staff.
A neglected community health centre (puskesmas) in Lombok. Incentives for capital spending mean a new puskesmans has been built 10 kilometres away. This facility now languishes in the care of a single midwife - Elizabeth Pisani
Indonesia’s ratio of health providers to population is among the lowest for a country of its income level. So I was surprised, in well-funded Aceh, to run in to an Acehnese graduate from a nursing college in Jakarta who had been working on an ad-hoc basis in a private clinic for the last two years. ‘I can’t afford to get a job in the puskesmas,’ he said. The going rate to get a prized job as a civil servant nurse in East Aceh is 60 million rupiah, paid under the table to some individual in a local government that will then provide a salary of around three million a month.
Health staff often repay the debts they incur getting a job by operating private practices after hours. On the Maluku island of Banda Naira, I stopped for a coffee in a road-side kiosk directly opposite the local puskesmas. The owner was cradling his sick child. Why didn’t he take the kid across the road? I asked. The puskesmas appeared to be open, and even staffed. ‘I’m waiting until evening, when you get the strong medicines. In the daytime you just get the over-the-counter stuff (obat warung).’
People appear to believe that the often free healthcare provided by a growing number of provincial and district governments is not worth having; they would rather pay to see the same doctor at home after hours. Two thirds of doctors at puskesmas run private clinics, and the proportion is highest in rural areas. They don’t seem to be short-changing the people who they see at the puskesmas in terms of diagnosis, at least (how they distribute the drugs the government supplies is less well studied, though there are some eye-popping examples of abuse in the drug supply system: see for example Michael Buehler’s article on HIV drugs in Inside Indonesia). Evidence from the Indonesian Family Life Survey suggests that health staff in public facilities are as good or better at following diagnostic procedures as those in the private sector. When they turn up for work, that is.
Staff absenteeism is a huge problem in the public sector. In a 2006 study published in The Journal of Economic Perspectives, researchers did spot checks on puskesmas in 10 provinces and found that 40 per cent of staff were not at work; doctors were more likely to be missing than nurses or midwives. The government has tried to address this problem by obliging recent graduates from medical school to do at least six months on a relatively well-paid temporary contract in a remote area, but this scheme creates other headaches associated with uncertainty and high turnover. Allowing doctors on state salaries to run parallel private practices is one way of trying to keep them in remote islands and rural areas. And if it doesn’t increase absenteeism too significantly, a shift to private practitioners by wealthier patients might free up more resources in the public system for poorer families.
Another step Indonesia is taking to address low staffing ratios in the health system is to increase medical education. A growing number of nursing and midwife schools are now pumping out more than 10,000 new midwives and 34,000 nurses each year, even though it’s really not clear what they are being taught. There are efforts underway to get some kind of an accreditation system in place, but there are currently no agreed standards for medical education and no real quality control. In medical schools, the huge number of applicants has created wonderful money-making opportunities. It is an open secret that securing a place at medical school will cost a minimum of 10 million rupiah for students with good grades, ranging up to 250 million for those who don’t have even the basic qualifications. Exam results are for sale too.
Not surprisingly, then, health staff have not increased in quality as much as they have in quantity. According to a 2006 World Bank study on the provision of health services in Indonesia, while the number of doctors jumped by 26 per cent and the number of midwives by 12 per cent in the 10 years to 2006, their score for diagnostic performance barely budged in that time. It remains worryingly low; when last measured, only two thirds of health workers in the public sector were correctly diagnosing common illnesses in kids. In adults, they followed correct procedures little better than half the time. But there’s no clear system for holding providers to agreed quality standards even in the public sector; the private sector is almost totally unregulated.
Whose job is it anyway?
In theory, the Ministry of Health in Jakarta calls the shots on standards, not just in medical education but in service provision too. It creates national guidelines for all manner of things, from lab procedures to treatment of individual diseases. But the system which used to funnel these guidelines from the centre through the provinces to the service providers in the public sector has broken down. So has the system which used to funnel data on disease distribution from the districts to the centre. That’s critical, because viruses and cancers do not recognise district boundaries.
In health intelligence as in military intelligence, someone with a national overview has to be planning to prevent threats and distribute troops rationally across the whole country. Now the epidemiological Big Picture has been lost because districts no longer routinely report data to the provinces, as they are meant to. ‘Part of my function is supposed to be to map health needs against the population, then take that to the bupatis and the district planning boards and argue for the rational distribution of funds,’ the head of one provincial health department told me. ‘But the money goes straight from Jakarta to the districts, who can do whatever they want with it. All we can do is sit at the side of the road and watch.’
The role of the standards setters and quality assurers is restricted in another important way. The single most important health facility, the district hospital, does not answer to the district health department. The head of the hospital is a political appointee, answering directly to his or her patron, the bupati. This is sometimes a strength: visionary hospital heads can choose to cooperate with puskesmas and other actors to lift the performance of the whole district health system. But not all hospital heads are visionary, or even qualified; the health department has no leverage over them at all.
The Ministry of Health in Jakarta continues to hold a few trump cards. It does a lot of the hiring and deployment of doctors who have civil servant status. And it still controls the too-many programs which focus on single diseases or issues: HIV, TB and malaria are current favourites. Many of these programs reflect the institutional priorities of various donors and the current fashion in ‘global health’ more than they reflect Indonesia’s needs. But they are well-funded, and provide the centre with an important source of both income and patronage. These vertical programs greatly distort priorities at both the national and the local level.
The most egregious example is probably the area in which I worked for many years, HIV. In 2010, Indonesia spent US$ 69.2 million preventing HIV infections and AIDS deaths. Sixty per cent of that was taken out of the wallets of taxpayers in other countries. A chunk of it went to establishing and supporting district and provincial AIDS Control Commissions even in places with no real epidemic, lots more went to programs aimed at keeping ‘innocent’ women and children (already at close to zero risk for HIV in most of Indonesia) at no risk. Only five per cent of it was spent on preventing infections among those who really are at risk – drug injectors, gay men, sex workers of all genders and their clients. But only 8,000 Indonesians have died of AIDS ever, and fewer than 200,000 are believed to be living with HIV nationwide right now. That compares with around 32,000 deaths and 320,000 life-altering injuries in road accidents in the last year alone. The dedicated budget for prevention of death and injury on the roads: zero.
The solutions are political
This imbalance highlights another shortcoming of the Indonesian health system (one that it shares with many other countries): the incentives are stacked very heavily in favour of curative care and away from the basic public health work that would make curative care less necessary.
A vendor uses anatomical models to explain the benefits of herbal medicines in a market in Bowae, Flores - Elizabeth Pisani
This may change in years to come, because the state is increasingly picking up the cost of people’s illnesses. One of the great achievements of recent years is the expansion of health insurance, especially for poorer Indonesians. According to another recent World Bank study, the national scheme, Jamkesmas, increased health insurance coverage for the poorest 30 per cent of Indonesians from 17 to 43 per cent in the five years to 2009. If consumers can negotiate their way through a confusing thicket of schemes, there are also many provincial and district-funded schemes, as well as free care for priority conditions such as TB and pregnancy. This has increased service use in some areas (‘Now people come to hospital every time they have a headache,’ complained a doctor in Aceh, one of the first provinces to provide a generous package of free healthcare), though not in others: pregnant women covered by Jamkesmas were no more likely to have medically skilled help at their birth than women with no insurance at all.
It’s not yet clear whether greater consumption of health services is translating into better health. Infant mortality fell to 34 dead kids per 1,000 live births in 2007 from 46 a decade earlier, according to Demographic and Health Survey data. For adults, though, things are less rosy. Adult survival, measured as the likelihood of a 15 year-old surviving until they are 60, appears to have fallen in Indonesia in recent years, possibly because of changes in lifestyle and diet. More healthcare won’t change that, unless it is also good quality healthcare that addresses the needs of the local population rather than the whims of a planner in Jakarta, Geneva or Washington.
Publicly funded health programs are likely to expand further: a promise of free healthcare always goes down well with the electorate (see article by Edward Aspinall and Eve Warburton in this edition). Such promises also increase expectations; one of the reasons that health providers get away with such poor performance is that consumers, traumatised by years of repeat visits to health centres that are locked or crowded with people waiting hours for high-handed service, have such low expectations.
Indeed even with the new health insurance schemes, two thirds of Indonesians questioned in the 2009 Susenas survey didn’t bother to use any health service at all last time they were sick. They either did nothing, or took one of the potions on offer at the local market. At one market I visited recently in rural Flores, the selection ranged from antibiotics past their sell-by date to slices of ants’ nest, by way of the bitter herb sambiloto and a concoction of roots and lava known as raja gunung, the king of the mountain. Irrational drugs policies fostered by a cosy alliance of pharmaceutical firms and senior health ministry officials mean that these remedies may be as effective as those on offer in the health system. Indonesia’s national HIV program went on treating sex workers with drugs we knew didn’t work for four years before the national guidelines were changed and service providers were allowed to switch to more effective medicines, now provided by a favoured local producer.
As people’s expectations rise, they might begin to hold their politicians to higher standards. And that in turn might reduce the distortions, inefficiencies, rent-seeking and outright corruption in government offices, private hospitals, pharmaceutical company warehouses and medical schools alike. It is curing these political ills, rather than more training programs for midwives, that is the key to improving healthcare in Indonesia.
Elizabeth Pisani (pisaniATternyata.org), the author of The Wisdom of Whores, is taking a break from her day job as an epidemiologist to work on a book about Indonesia, to be published by Granta and WW Norton in early 2014. Contacts and commentary at http://portraitindonesia.com.