In late 2011, epidemiologist, writer and adventurer Elizabeth Pisani granted herself a sabbatical from the day job and set off to rediscover Indonesia, a country she has wandered, loved and been baffled by for decades. She was on the road and the high seas for a year, covering dozens of islands in 27 provinces. This site records photos and musings from that journey and beyond. See more about the project
In need of public care? Malinda Dee, pre-leaks. (Photo from Luwuraya.net)
So 2014 will be an exciting year for Indonesia. Mostly, of course, because of the elections. But also because, if things go well, a national health insurance scheme will be expanded to cover all Indonesians. It’s an incredibly ambitious plan. But in a wonderful report on BBC radio by Claire Bolderson, Health Minister Nasfsiah Mboi is optimistic. Asked if the government can achieve a target that appears to elude even the mighty United States, she replies “Inshallah, by 2014, we’ll be there”. You can listen to Claire’s report here (mp3), and I recommend that you do; my favourite scene is the nurse gilling fish on a ward in Makassar but there are some tragic tales of really good intentions frustrated, as well as of unnecessary death.
In theory, poorer Indonesians already get free healthcare through the Jamkesmas scheme. But in practice, Jamkesmas leads sick people into a rabbit warren of incomprehensible bureaucracy, and often offers third rate services. And it doesn’t only go to the poor. A useful World Bank report on the scheme (pdf) notes that “Not all of the poor are reached by the program, and there is considerable leakage to the non-poor.”
Speaking of leakage, who remembers Malinda Dee, the glamour puss owner of two Ferraris, a Mercedes and a Hummer? She argued that Jamkesmas should foot the bill to fix a botched breast enlargement. At the time her silicon sacks burst, the former “relationship manager” at Citibank was being held on charges of stealing 4.4 million dollars from her clients. Since she was a ward of the state, Malinda said, the Indonesian people should pay for her operation.
Few of the users of Jamkesmas are quite so undeserving. But Indonesia has one of the lowest ratios of doctors and of hospital beds to population of any country at its income level. If all poor people really were able to afford care from next year and immediately started to demand it, the system would be overloaded very quickly. That’s already happening in some parts of the country. In Papua, Indonesia’s easternmost province, indigenous Papuans are spurning (free) local clinics and travelling miles to hospitals because they think they will get better care. The rush to hospitals was so overwhelming that what they actually get is very long queues. When the nation’s capital Jakarta made health care free for all earlier this year, it turned in to exactly that: a free-for-all. People who had never had access to any higher level health care at all suddenly abandoned primary clincis and stampeded the hospitals, sometimes just because they could. Predictably, the result was chaos.
But I do find myself slightly agreeing with the sainted Jakarta Governor Jokowi when he said that with something as necessary as health insurance, it was better to get started and then iron out the wrinkles later than to drag one’s feet for ever. I don’t doubt that many Indonesians will be disappointed and frustrated by the roll-out of universal health insurance from next year. But I salute the government for even putting it on the national agenda, less than 70 years after independence. It took the United States more than 225 years to do the same; and they’re still working on the wrinkles, too.
The picture above was taken in Lombok, in what I thought was an abandoned health centre. There was a little lab, a couple of consulting rooms, a dispensary, all mouldering with neglect. But on a door to a room in the back yard I saw a sign “The midwife is IN”. I knocked on the door, and to my amazement there she was. Could this derelict place be a living Puskesmas, a village health centre? I asked where the rest of the staff were. “Oh they’ve built a new puskesmas down the road, so it’s just me here now,” came the reply.
It’s no bad thing that people get upgraded health facilities. But just down the road? When there are so many remote areas with no facilities at all? This wreck of a building illustrates the distorted incentives in Indonesia’s health sector. It’s more profitable, both politically and financially, to build new stuff in already well-served areas than it is either to maintain existing facilities or to expand to places that qualified staff don’t want to stay in. In this piece in the new edition of Inside Indonesia, I conclude that only healthier politics can cure Indonesia’s sick health system. The whole issue is dedicated to the politics of health: there are pieces on the tobacco lobby, the neglect of mental health, abortion and much else. Check it out.
Wednesday was a sad day for Indonesia. and for me. It marked the death of Endang Sedyaningsih, who encompassed what is best in the women in this great country: courage, determination, integrity, compassion and humility. It is a rare combination at the best of times; in the Indonesian cabinet, where Endang held the position of Minister of Health, these qualities are nothing short of exceptional.
In my last post, I was pretty rude about Indonesian doctors. Endang counts among the “several smart friends who were once great doctors”. Unlike many ministers in Indonesia, she knew her territory inside out. For three years, she worked as head of a rural health centre in Nusa Tengarra Timur, the poorest province in Indonesia. She gave up doctoring in favour of public health and research, a choice that I predictably enough applaud, not least because a lot of her research was among sex workers and other marginalised groups. Indeed her thesis at Harvard centred on the lives of the women who sold sex in Kramat Tunggak, Jakarta’s largest red light district. She argued for improving health services for the women that worked there. Jakarta Governor Sutiyoso, seeking to burnish his credentials with Moslem voters, responded by bulldozing the area and building a gopping mosque and Islamic centre in its place. When Kramat Tunggat was closed in 1999, HIV prevalence among brothel and street-based sex workers in north Jakarta was 0.4 percent. Since the rise of the mosque and the dispersion of the sex trade, it has risen to 10.5 percent.
Endang was fearless both physically (not many of my colleagues were prepared, as she was, to brave the Jakarta traffic on the back of my motorbike…) and politically. During the reign of her controversial predecessor, Siti Fadilah Supari, Endang had to put up with a lot of flack because the national health research institute she headed cooperated closely with foreign researchers in trying to develop vaccines against bird flu, which has a higher case fatality rate in Indonesia than in any other country. For Siti, this cooperation amounted to collaboration with the enemy. Her book “It’s Time for the World to Change! God’s Hand Behind the Bird Flu Virus” is actually more about the hand of the CIA behind the virus – a mish-mash of conspiracy theories which were such an embarrassment to the Indonesian government that the book was eventually pulled from bookshops.
Leading the research programme for the Ministry of Health, Endang kept her head down and got on with her work. In her eyes, finding a vaccine that could protect millions of her fellow countrymen from a strain of flu that killed eight out of 10 of those infected was more important than whipping up populist anti-Americanism to score cheap political wins. When she was appointed health minister in Indonesian president Susilo Bambang Yuduhyono’s second cabinet, the press showered her with nonsense about being a CIA plant. Again, she kept her head down and got on with her work, trying especially to improve services in the far-flung corners of the nation so often overlooked by those trapped in the political spider’s web of Jakarta.
Endang was an Indonesian nationalist in the truest sense of the word: not a knee-jerk Xenophobe, but someone who consolidated learning, skills and relationships acquired around the world and used them in the service of the men, women and transgenders of the Indonesia she loved so much. I am angry that she was taken from us by lung cancer at the age of only 57, but am proud to have called her a friend.
“Why don’t you go to Penang/Singapore?” is the first thing most Indonesians say when they hear I don’t have kids. Obviously childlessness must be fixed, and obviously it is far too important to be left to the Indonesian health system. I usually give people short shrift when they trash the health system here. I have several smart friends who were once great doctors. Ok, they’ve mostly shifted into management jobs now, but Indonesia’s med schools are full of bright young things to take their place.
Or are they? A recent report from the World Bank wrings its hands over the quality of medical education in Indonesia. It finds that accreditation standards for health schools are wonky in the first place, are not properly applied, and are in any case not published. Not too surprising really. Another recent report from the World Bank notes politely how absolutely crap Indonesia’s education system is. In internationally standardised tests of 15 year-olds, over half of Indonesians scored less than one out of six on maths tests, and not a single Indonesian student reached the score of five or six that, according to the OECD which runs the tests, indicates decent critical thinking skills. When basic education is so poor, it would be miraculous for medical education to be much better. But the World Bank health worker report doesn’t even mention the thing that worries me most: training for doctors and jobs as nurses are for sale.
Even the best state universities, the ones that in the past gave scholarships to my smart friends, are raking in money selling places in med school. The starting price to get in, for students with exceptional grades, is 10 million rupiah, over US$ 1,000. The lower your grades, the more you have to pay to get in. Medical school is so fashionable these days that I’ve heard of people paying up to 250 million rupiah just to get in. That’s not for tuition, of course, that’s purely for the privilege of being able to say “My eldest is studying to be a doctor”. If they are either stupid or lazy or both, they will have to pay another great whack each year to pass their exams. When they graduate they’ll have had a very expensive education. But would you want them taking care of your tumour?
The sale of jobs starts at a much lower level. Nurses and even midwives now have to put out to get hired even in small town health centres. The going price in Aceh, where I’ve spent the last few weeks, is 60 million rupiah for an entry level job (assuming that you have already earned, or indeed bought, the appropriate qualifications). Sixty million rupiah, US$ 6,600 dollars, to get a job that will earn less than US$ 300 a month. Is it any surprise that most health centre staff, doctors, nurses and midwives included, go to work in the morning and run a private practice in the afternoons or evenings?
I often ask people why they pay to see the doctor in the evening when they could see exactly the same doctor for free in the morning. The universal response is that doctors keep the “strong” medicine for their private patients. At the health centre you get obat warung – “kiosk drugs”, cheap, over-the-counter stuff. Given the deterioration of standards required of people studying medicine in the first place, I would have thought the drugs they give you would be the least of your concerns.
Some years ago, when I was working on HIV prevention in Indonesia, we diligently treated sex workers for common infections such as gonorrhea and chlamydia, using national treatment guidelines. They were not cured. After much head-scratching, we sent some samples off for resistance testing. The results were pretty shocking. We found that 100% of our gonorrhea samples were resistant to tetracycline (marketed here as “SuperTetra!”), and 40% to Ciprofloxacin, the second commonly-subscribed antibiotic. (It took a shameful four years to change the national guidelines to include drugs that actually worked, and during that time we continued to use ones we knew didn’t work. But hell, it’s only hookers, right?…)
In an effort to find out why so many bugs in Indonesia are resistant to tera, cipro, amoxy and the rest, I went out to ask the nation’s pharmacists, Here’s one, helping with prescriptions in a market in Boawae, Flores.