Friday, July 29, 2016

Indonesia - Health systems, diseases and political hugs

Would you like to get a hug from Barack Obama? Well, here’s one way to do it: contract Ebola, but make sure you recover from it.

That was how Nina Pham got her much publicized bear hug in October 2014 from the US president, in no other place than the Oval Office itself.

So who’s Nina Pham? She’s a Texas nurse, the first person to contract the disease on US soil after treating a Liberian patient. The hug she got from Obama was not any ordinary hug — it was a politically symbolic hug, as Ebola was a metaphor for a threat that comes from outside of American shores.

The hug was meant to give a message of protection and security, in addition, in the case of the Obama-Pham hug, a congratulatory: “Yaaay, we beat this alien threat!” After all, cross-country infectious diseases are as much a security threat as, say, a missile attack.

I bet Obama wished he could have hugged his mother, Ann Stanley Dunham, upon recovery from uterine cancer.

Unfortunately, in 1995 she succumbed to the illness after having first been diagnosed with appendicitis at a hospital in Jakarta. After her appendectomy, she told me she still was not feeling well and returned to her native Hawaii to get a second opinion. The second opinion she got stopped her in her tracks: she never returned to Indonesia and died in Hawaii about a year after she received her cancer diagnosis.

One of Obama’s personal motivations in pushing for Obamacare was his mother. In a speech in 2009 to the American Medical Association, he spoke about how “she fought cancer in her final days, spending time worrying whether her insurer would claim her illness was a pre-existing condition”.

What he was also probably thinking but did not say, was how on earth could she have been diagnosed only with appendicitis in Indonesia when the reality was that she had fourth stage uterine cancer?

Which brings me to the quality of healthcare in my country. Giving the right diagnosis is obviously critical to fixing someone’s health. Unfortunately mistaken diagnosis as well as malpractice in Indonesia is not uncommon. Another lamentable fact is that doctors often overprescribe medication because they are bribed by pharmaceutical companies.

In a Democratic Party debate in January, Hillary Clinton said that the Affordable Care Act “is one of the greatest accomplishments of President Obama, of the Democratic Party, and of our country”. So let’s forget Obama’s drone war for now shall we, and focus on the accomplishment of his presidency, which we can be inspired by.

Indonesia’s record of health care is not exactly what one could call stellar. It’s been dotted with crises, the most recent one being the fake vaccine scandal. It is obviously caused much concern among parents, and even panic to the point that a doctor was attacked in Jakarta.

What is significant is that it points to deep-seated problems in the country’s health system. Indonesia may be the biggest Southeast Asian country, and even dubbed as “the superpower” of ASEAN, but its health system is one of the worst in the region.

Government expenditure on health is currently a low five percent. Healthcare infrastructure is sparse: less than 2,500 hospitals with just over 300,000 beds. This means 0.9 beds for every 100,000 people. About 900 of these hospitals are state-owned and over 1,500 private, however most are in urban areas.

At least there are over 9,700 community health centers (Puskesmas) that provide comprehensive healthcare, and where both modern and traditional health practices are used.

According to the Patients per Doctor Map of the World, the ratio of doctors to patients in Indonesia is 1:7,700 — below Yemen (1:3,000), Myanmar (1:2,800) and Pakistan (1:1,400). The WHO standard is 1:1000. Then of course there is the distribution whereby more doctors are in urban areas, and much more sparse in the regions.

Government officials often mention Indonesia’s demographic bonus, due to the fact that 29 percent of the population is aged under 15. This means that in 2020 to 2025, the majority of the population will be of productive working age. But is that enough?

A friend of mine recently commented that he thought the demographic bonus was public relations’ spin for a nation with an inadequate health-care system, high levels of pollution, lack of education regarding proper health and nutrition and workplace and roadway safety, widespread corruption and an alarming rate of smokers, all of which contribute to the “drop-off” rate of Indonesia’s aging population.

Exactly. Healthcare does not exist in a vacuum. There are so many factors that contribute to it: poverty (28 million below the poverty line), inadequate education and unsafe drinking water, which is a major cause of diarrhea, contributing to the death of 31 percent of children between one month to one year old and 25 percent of children between one and four years. It is also been suggested that one third of children under five have stunted growth due to malnutrition. So much for demographic bonus, huh?

Incidences of both degenerative as well as infectious diseases like HIV/AIDS, dengue fever, dengue haemoragghic fever (DHF), malaria, avian flu and other animal to human diseases are still high and continue to pose a significant threat to human health in Indonesia.

Furthermore, government policies are also inconsistent. Take tobacco for example. The bill on tobacco control is still seen as being on the side of the tobacco industry and 400,000 die each year from smoking-related diseases (see “The new Marlboro country and a generation lost in smoke(s)?” in The Jakarta Post, April 27).

The government says it intends to increase its health expenditure to 12 percent, reaching US$46 billion per year by 2019. It is also true that since 2010, about 56 percent of Indonesians have had some sort of health coverage, and in 2014 the Jaminan Kesehatan Masyarakat (JKN) was launched to implement universal health care.

But unless it does not improve the overall conditions that my friend mentioned, it will be money and effort poorly spent.

Now that Obama is nearing the end of his eight-year presidency, perhaps we could ask him to come to the land where he spent four years of his childhood, to help with Indonesia’s health system.

In fact, maybe he could be an informal vice-president to his pal and lookalike (!) Joko “Jokowi” Widodo to help run the country — minus drones of course! We would welcome him with all the hugs that he wants and they would not be politically symbolic!

Julia Suryakusuma

You can find older posts regarding ASEAN politics and economics news at SBC blog, and older posts regarding health and healthcare at IIMS blog. I thank you.

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