THE PRESENT STATUS OF HEALTHCARE SERVICES IN INDONESIA

SECTION 01
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SECTION 01 THE PRESENT STATUS OF THE HEALTHCARE SERVICES IN INDONESIA

SECTION 01

CHAPTER 1

THE PRESENT STATUS OF HEALTHCARE SERVICES IN INDONESIA

By Prof. Dr. Azrul Azwar MPH Chairperson, the Indonesian Association of Family Physicians
Outline National health development program Brief description of the country National health status Public health services Medical care services Financing of health services

NATIONAL HEALTH DEVELOPMENT PROGRAM

The general objective of the National Health Development Program in Indonesia as stipulated in the National Health System is to provide a healthy life for all Indonesians. The specific objectives of the National Health Development Program in Indonesia are: To To To To To enable people to maintain their own health and live a healthy and productive life promote an environment conducive to the health of the people promote good nutrition among the people decrease morbidity and mortality promote a healthy and prosperous family life

To achieve these objectives, various healthcare efforts have been implemented, including among others, the strengthening of the healthcare delivery system as part of an overall health development program. This is being carried out both by government and the private sector. This paper aims to assess the present status of the healthcare services in Indonesia.

BRIEF DESCRIPTION OF THE COUNTRY

Indonesia is the worlds largest archipelago, extending between two continents, Asia to the North and Australia to the South. It lies between two oceans, the Indian to the West and the Pacific to the East. The distance from the west to the east point of Indonesia is 3,200 miles, and the distance from the North to the South is 1,100 miles. The total area of Indonesia is 5,193,260 square miles, covering both land and sea territories. The total land area is an approximately 1,904,650 square miles, comprising 13,677 islands of which only 7.25% (992 islands) are inhabited. Almost 85% of the total land area is included in the five main islands, Kalimantan (the biggest), Sumatera, Papua, Sulawesi and Java. Because Indonesia lies along the equator, the climate is tropical, with high humidity, slight changes in temperature and heavy rainfall. Except at higher elevations, the temperature

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generally ranges from 20 to 30 Centigrade. Humidity ranges from 60% to 90%. Table 1 summarizes the physical features of Indonesia. Table 1. Physical Conditions of Indonesia
PHYSICAL CONDITION Total area (sq ml) Land area (sq ml) Number of islands Number of islands inhabited Temperature (celsius) Humidity (%) FIGURES 5,193,260 1,904,650 13,677 992 20-30 60-90

Indonesia gained its independence on August 17, 1945, after more than three and a half centuries of occupation by the Dutch and a further three and a half years by the Japanese. Indonesia is a republic, with a President as head of state, chosen by the Peoples Consultative Assembly every five years. The capital city is Jakarta, situated on the island of Java. Administratively, Indonesia is divided into 32 provinces, each with a legislative council and headed by a Governor. The provinces are divided into Districts and Municipalities, each with a legislature and headed by a Bupati for the regencies and a Walikota for the municipalities. At present, there are 243 districts in Indonesia, while the total number of municipalities is 61. East district and municipality is divided into sub-districts, headed by a Camat, and is further divided by villages. Each village is headed by a Lurah and divided into hamlets which, in turn, are further divided by neighborhoods. The villages (except in the big cities), hamlet and neighborhood groupings are headed by elected persons who serve in a voluntary capacity. At present, the total number of sub-districts in Indonesia is 3,839 and the total number of villages amount to 65,554. Provinces, districts and municipalities are autonomous regions with administrative responsibilities. They have to finance public services, including the health sector, in their respective area of responsibility. The information about the administrative divisions of Indonesia, mentioned above, is summarized in Table 2. Table 2. Administrative Divisions of Indonesia
ADMINISTRATIVE DIVISIONS Number Number Number Number Number of of of of of Provinces Districts Municipalities Sub-districts Villages NUMBERS 32 243 61 3,839 65,554

The total population of Indonesia in 2000 was 203,456,005, making it the fourth most populous country in the world. The rate of population increase is 1.34%. The population distribution is uneven, with about 59.3% of the population live on Java Island, although Java occupies only 7% of the total land area. About 69.1% of the people live in rural areas, where health facilities and most other public infrastructure are unsatisfactory.
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Indonesians are basically of Malay heritage and are divided into approximately 300 ethnic groups, about 360 languages and dialects. Islam is predominant religion and the national language is Bahasa Indonesia. Indonesia has passed law providing compulsory education for children. Primary school enrollment rate is 97%. It is estimated that around 15.9% of the population is illiterate. The main occupation of majority of the people is in agriculture. The primary sources of governments income are from export revenues of oil, LNG (liquefied natural gas) and lumber. The annual growth rate is running at an average rate of 4%, and the GNP per capita in 2000 is US$680. Information about the social and economic condition of Indonesia can be seen in Table 3. Table 3. Socio-Economic Condition, the Year 2000 Figures
SOCIAL & ECONOMIC CONDITION Total population (millions) Rate of population increase (%) No. of people living in rural areas (%) Ethnic groups Moslem(%) Literacy rate(%) Primary school enrolment rate(%) Annual economic increase rate (%) GNP per capita (US$) FIGURES IN 2000 203.5 1.35 57.7 300 90 84.1 97 4 680

NATIONAL HEALTH STATUS

Due perhaps to the fact that Indonesia is still a developing country, the present condition of Indonesian healthcare remains unsatisfactory although there have been major improvements compared to two decades ago. Various health indicators for Indonesia can be seen in Table 4. Table 4: Health Status Indicators for Indonesia
INDICATOR/VARIABLE Infant mortality rate per 1000 live births Under five mortality rate per 1000 Maternal mortality rate per 100.000 live births Crude death rate per 1000 Life expectancy male female Low birth weight (%) Protein Calorie Deficiency per 100 Underfives Clean water supply per 100 population Latrines per 100 population Percentage EPI coverage YEAR 1993 1993 1993 1994 1993 1993 1993 1993 1986 1986 1993 FIGURES 58.0 81.0 425 6.0 60.8 64.6 15.0 40.0 30.0 37.9 93.6

The primary cause of death in Indonesia since 1995 is cardiovascular diseases that now overtake predominant infectious diseases, reflecting the double burden faced today.
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The pattern of death in Indonesia is still strongly related to general poverty, low income per capita, high rates of illiteracy and various socio-cultural factors. According to Household Health Surveys, the 10 leading diseases in the country are: acute respiratory tract infection, diseases of skin, diseases of teeth, mouth and gastro-intestinal tract, other infectious diseases, bronchitis-asthma and other disease of respiratory tract, malaria, nerve disorders, cardiovascular disorders, diarrhoea and tuberculosis.

PUBLIC HEALTH SERVICES

The responsiblility for dealing with public health problem in Indonesia lies with the government. Following the basic principle of sound public health, public health services provision in Indonesia strongly encourages community participation through primary health care services. The main health body entrusted with carrying out public health services in Indonesia is the Community Health Center (Puskesmas), situated at sub-district level serving a population of about 30,000-40,000. There are over 7,000 such centers in the country by the year 2000. The Puskesmas render 6 basic services (health promotion, MCH/FP, CDC, Nutrition, Environmental sanitation, Curative care) and various developmental services according to local areas need. In most instances, a doctor, with a staffing between 8-32, consisting of nurses, midwives and other auxiliary personnel, heads each Puskesmas. In densely populated areas, there are Sub-Community Health Centers (Puskesmas Pembantu) at the village level, generally headed by a senior nurse or midwife, and operated under the supervision of, and linked to, the Community Health Center. At present, the total number of Puskesmas Pembantu in Indonesia is 19,977 To serve people who live in very remote areas, there are Mobile Community Health Center (Puskesmas Keliling), operated by and based at the local Puskesmas. The staff of Puskesmas Keliling consist of one doctor, assisted by two or three personnel, including nurses/midwives and a driver. At present, there are about 6,024 Puskesmas Keliling serving villages within the sub-district. To support the activities of the Puskesmas, the community health effort is organized in the form of the Integrated Services Post (Posyandu), located at the hamlet level. The responsible community institution to Posyandu is the village community resilience committee. The activities of each Posyandu, assisted and supervised by local Puskesmas staff, consist of five basic types of health services. These are: (i) MCH Services, (ii) Nutrition Services, (iii) Family Planning Services, (iv) Diarrhoeal Disease Control and (v) Immunization Services. At present, there are about 251,459 Posyandu registered in Indonesia. The position of the healthcare delivery system responsible for combating public health problems in Indonesia is summarized in Table 5. Table 5. Public Health Delivery System in Indonesia
PUBLIC HEALTH DELIVERY SERVICES POINT Community Health Center Sub-Community Health Center Mobile Community Health Center Integrated Services Post FIGURES 7,100 19,997 6,024 251,459
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To guarantee successful operation of the Puskesmas, a referral system has been introduced. Any public health problem that cannot be overcome by the Puskesmas will be referred to higher health institutions/offices at the district, provincial or even the national level. In accordance with the principle of devolved autonomy, there are District Health Offices at the district level and the Provincial Health Office at the provincial level. The Ministry of Interior and the Ministry of Health at the national level coordinate the health offices that are directly under the coordination of the local government. The general rule is that the main function of the Ministry of Health is to provide conceptual guidance, technical guidance and material, as well as financial contribution and assistance to the local government district and provincial health offices. In brief, the organizational structure of the health offices in Indonesia is shown in below Table 6. Table 6. Organizational Structure of the Health Offices in Indonesia.
Central Province District Sub District Village Mobile Community Health Centre Ministry of Health Provincial Health Office District Health Office Community Health Centre Sub Community Health Centre Integrated Services Post Community Ministry of Interior Provincial Government District Government Camat Lurah

Hamlet Neighborhood

Head of Hamlet Head of Neighbourhood

MEDICAL CARE SERVICES

The healthcare delivery system that is responsible for medical problems in Indonesia, in general can be divided into three categories: (i) primary medical care facilities, (ii) secondary medical care, and (iii) tertiary medical care facilities. In contrast to public health concerns which are under the government, the responsibility of the government is to encourage medical care services in Indonesia to have a considerable private sector involvement. Management of medical care services in Indonesia is therefore a shared responsibility between the public and private sectors. The primary level personal/medical care facility managed by the government is the Puskesmas assisted by the Puskesmas Pembantu and Puskesmas Keliling. Besides the
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provision of medical personal care, the Puskesmas also makes provision for public healthcare services in the community medical care facilities. The primary medical care facilities managed by the private sector vary. There are private midwives practitioners and private medical practitioners found in almost every part of the country. The number of private midwives practitioners in Indonesia is estimated to be approximately 34,000. Around 20% of the private medical practitioners are specialists, while the rest are general practitioners. Since most of the midwives and doctors are government employees, their private practice is usually conducted in the afternoon after the closing of government offices. In some places, although it is illegal, paramedics also have their own private practices. Most private medical practitioners in Indonesia operate their practices as a sole practice, although in the big cities there is now an increasing trend for group practices that become more popular. Other types of primary medical care facilities managed by the private sector in Indonesia are the MCH clinic and the polyclinic. These types of medical facilities are usually managed by midwives or nurses, although the responsible person for these facilities is still the doctor. Unfortunately, the actual number of private MCH clinics and private polyclinics in Indonesia is not available. Table 7. Situation of Private Medical Care Facilities in Indonesia (1993)
TYPE OF FACILITIES Private Private Private Private midwife practitioners (estimated) medical practitioners (estimated) MCH clinics polyclinics NUMBERS 45,000 34,000 NA NA

The secondary and tertiary medical care facilities in Indonesia are located at hospitals. There are around 1,200 hospitals registered in the country, of which 404 hospitals are government or local government hospitals. The total number of beds available in all hospital is 111,460, which means that for every 100,000 people there are around 59.8 hospital beds available. In brief, the number of hospitals in Indonesia is shown in Table 8. Table 8. Number of Hospitals in Indonesia by the Year 2000
TYPE OF HOSPITALS Government Army State-Owned Private Total NUMBER OF HOSPITALS 404 111 83 589 1,187 NUMBER OF BEDS 58,912 11,427 7,874 34,247 113,460

Government hospitals are divided into five categories, namely the A, B, C, D and E type. Type D (with 25-100 beds) and type C (with 100-400 beds) government hospitals are considered to be secondary level medical care facilities in Indonesia. These hospitals are situated in the district capitals, of which there are 305 in the country. Type D hospitals are in transitional period and ought to be promoted to a type C hospital. Type C hospital are expected to be able to provide at least six major specialty services, namely internal medicine, pediatrics, obstetric and gynecology, surgery, radiology and clinical pathology.
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Type B (with 200-500 beds) and the type A (with 100-400 beds) government hospitals are considered as secondary level medical facilities in Indonesia. Type B hospitals are located in the provincial capitals and are expected to be capable of providing a broad spectrum of specialist services, while type A hospitals are expected to provide a broad spectrum of sub-specialist services. At present, the total number of type B government hospitals is 23 and the total number type A government hospitals is 4. Type E hospitals are specialized hospitals, numbering 72 throughout the country. The specialized hospitals operated by government are predominantly for specific diseases commonly found in the community, such as leprosy, TBC and mental illness. The number of government hospitals in Indonesia is shown in the following table: Table 9. Number of Government Hospitals in Indonesia (1992)
TYPE OF HOSPITALS Type Type Type Type Type Total A B C D E NUMBER OF HOSPITALS 4 23 121 184 72 404 NUMBER OF BEDS 3,510 12,050 20,058 11,654 11, 651 58,912

Most of the private hospitals in Indonesia, belong to missionaries and charity foundations and are usually general and specialized hospitals, managed on voluntary basis. In the recent years, the government has introduced a new policy that allows private hospitals to be managed on a profit-making basis, the majority of which are found in the big cities.

FINANCING OF HEALTHCARE SERVICES

Health Services in Indonesia are operated under a fee for service system. The number of people covered by health insurance schemes is still limited mainly to civil servants and some private employees. In brief, the number of people covered by health insurance schemes in Indonesia can been seen in the following table. Table 10. Number of People Covered by Health Insurance Schemes
TYPE OF HEALTH INSURANCE SCHEMES Government civil servant Private employee social security scheme Public health funded scheme Private health insurance scheme Total NUMBER OF PEOPLE COVERED 15 million 2.5 million 14 million 1 million 31 million

Annual health expenditure in Indonesia is still very low. It is estimated to be around 2.5% of GNP or about US$18 per capita, a level far under the WHO recommended expenditure level of at least 5% GNP. A big portion of total health expenditure in Indonesia comes from the people, whereas the contribution of government is only around 30%. The small contribution of government are utilized for all-line subsidy that creates unfair health financing for the poor. Most of private spending on health care is out-of-pocket, because
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only around 20% are protected by various types of prepaid care.

CONCLUSION
Indonesia still faces various health problems. To overcome these challenges, Indonesia has implemented, since 1969, a series of Five Year National Development Programs, including the National Health Development program. Significant progress has been achieved in health care sector, both in public health services as well as in medical services. The management of the healthcare delivery system in Indonesia is carried out both by government and the private sector, including some forms of public-private mix. The low level of health spending, the misdirection of government subsidies, and the big portion of population with out-of-pocket spending indicating low proportion of people protected by prepaid care, are challenges in that needs to be reformed gradually towards more fairness in health financing.

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