Health care needs to become priority for Jokowi

When Indonesian President-elect Joko Widodo takes power in October, he will be confronted by a laundry list of pressing issues, ranging from budget-sapping energy subsidies and urgently needed infrastructure projects to figuring out why heavy spending on education does not seem to be paying off.

Then, there is health. After making steady progress through the 1990s in lowering the country's infant mortality rate, Indonesia has stagnated and will probably fail to meet next year's Millennium Development Goal (MDG) of 28 deaths per 1,000 live births.

According to the United Nations Children's Fund (Unicef), a child below the age of five dies somewhere in Indonesia every three minutes. That is about 150,000 a year, with many of those deaths due to a lack of simple sanitation and hygiene.

Every hour, a mother dies because of complications related to pregnancy or during child birth.

More bad news, this time on the HIV front. Bucking a worldwide downward trend in deaths related to acquired immune deficiency syndrome (Aids), a new United Nations report says Indonesia is one of six countries being left behind, with a massive 427 per cent increase in cases between 2005 and 2013.

Tuberculosis (TB) is another priority. With 91,000 deaths among the 528,000 cases of the disease recorded each year, Indonesia has the third highest TB rate in the world, behind China and India.

That is a troubling 6.3 per cent of total recorded diseases, compared with 3.2 per cent across the rest of the South-east Asian region.

Poor health-care system

HEALTHY economic growth is supposed to bring equivalent dividends in the quality of health care. Yet despite this year's promising roll-out of Universal Health Care (UHC) for 86.4 million of the nation's poor, the 1 per cent of GDP invested in health remains one of the lowest in the world.

That leaves it on a par with neighbouring countries like Laos, Cambodia and the Philippines, but behind Malaysia and Brunei on 2 per cent, and Vietnam and Thailand, both on 3 per cent.

Neo-natal deaths - when a baby dies within 28 days of birth - point to flaws in the efficient and effective delivery of quality round-the-clock mid-wifery and referral services, which in turn are often related to larger health system issues.

Infant deaths may have been reduced from 97 to 31 (per 1,000 live births) since 1990, but the rate has plateaued now that the large-scale introduction of immunisation, vitamin A distribution and what health professionals call other so-called "low-hanging" fruit has run its course.

Of course, there are much bigger geographic and demographic challenges for a sprawling archipelago of 250 million people, but, all the same, compare that 31 figure to the Philippines (30), Vietnam (23), Thailand (13) and Malaysia (nine).

But even today, in a country where a surprising number of urban dwellers prefer going to a traditional healer rather than a real doctor, Indonesia has the third highest number of non-immunised children. As a result, it still experiences outbreaks of vaccine-preventable diseases like measles and diphtheria.

While President Susilo Bambang Yudhoyono's government may have increased access to health services over the past decade, better-quality advice is needed when it comes to such things as swaddling and longer-term breast-feeding.

Malnutrition and poor water and sanitation are major contributors to child mortality. It is sobering to read that Indonesia has the fifth highest number of stunted children in the world and the second highest number of people - 52 million - practising open defecation.

Frustratingly, increasing coverage on interventions is not translating into reduced mortality. The same lack of progress applies in a different way to education, despite the fact that public spending absorbs 3 per cent of GDP.

Outer Islands

WHILE rates of mortality soar in less populated parts of Indonesia, it is the high population pockets that contribute to the greatest numbers in terms of morbidity and deaths. Health experts say both require radically different approaches.

Isolated groups of small islands and parts of Papua require more "waiting homes" so expectant mothers have somewhere to go to await birth. It has taken time to explain to husbands why this is necessary, particularly in Papua where under-five mortality rates stand at 90 per 1,000 live births.

In many parts of less-developed eastern Indonesia which, along with Kalimantan, accounts for 15 per cent of the total population, a 24/7 service just is not there. There may be health clinics dating back to president Suharto's days, but they often do not have proper facilities or even basic medicines.

The reason seems obvious. Decentralisation may have been politically crucial when it was launched in 2001, but it has also blurred the lines of authority and impacted negatively on accountability. The lack of a regular mechanism to track progress masks serious regional inequalities. What is needed is a systems approach to health service delivery, such as the better distribution of skilled health-care providers and the identification of bottlenecks.

The challenge of HIV

INDONESIA'S HIV epidemic is a related threat. About 10 people die of Aids-related illnesses every day. Six years ago, an estimated 200,000 children and young people under 25 were living with HIV. Today, they are now believed to be responsible for a fifth of new cases, or at least seven a day.

Along with the Central African Republic, the Democratic Republic of the Congo, Nigeria, Russia and South Sudan, Indonesia faces the triple threat of a high HIV burden, low treatment coverage and little if any decline in new HIV infections. Experts attribute the increase to the high number of people from traditionally low-risk population groups contracting HIV and to the government's failure to ensure access to anti-retroviral therapy for those already living with the disease.

About 3 per cent of those infected with HIV also have active tuberculosis. This prevents people from earning wages and leads many already-poor families ever deeper into poverty because of the high cost of sustained treatment.

Mostly, the disease preys on those living in rural areas, those with weak immune systems and those seeking health services from centres that do not treat the disease in the directly-observed, low-cost way recommended by the World Health Organisation.

Mr Joko has some major challenges ahead. But given the huge toll that preventable and curable disease is taking on the nation's children, it is hoped health will become as much a priority as education.

thane.cawdor@gmail.com