Challenges of health in the late 2014 and beyond Victoria Fanggidae  ;   Research and program manager of Perkumpulan Prakarsa (Center for Welfare Studies) in Jakarta

JAKARTA POST, 15 September 2014

                                                                                                                       

                                                      

In the later part of this year the health issue to focus on will be on how to achieve the remaining toughest targets of the Millennium Development Goals (MDGs). The international community will gather again to endorse the Sustainability Development Goals to replace the current MDGs in September 2015. To date, Indonesia’s progress towards fulfilling the MDGs has succeeded fairly well in education and gender related goals, but has been less satisfying for health related goals and targets. A September report on MDG progress from the Asian Development Bank and United Nations (UN) agencies indicated that Indonesia was on track for increasing skilled birth attendance and antenatal care visits (goal 5) and reducing tuberculosis incidents (goal 6). Nonetheless, Indonesia showed no progress on goal 6, reducing the prevalence of the human immunodeficiency virus (HIV), and only slow progress in achieving a decline in underweight children (goal 1), infant mortality and death rates of children under 5 years old (goal 4), maternal mortality (goal 5) and increasing access to safe drinking water and basic sanitation (goal 7). Among ASEAN countries, only Myanmar showed poorer overall progress than Indonesia in terms of health-related indicators (Table 1). If the MDG achievement record was a school report, we would have red marks. Hence, the first wake-up call should be to remind us how Indonesia lags behind the target to reduce HIV/AIDS prevalence among its population. Shocking statistics recently released by the UNAIDS highlights how HIV/AIDS is a true iceberg phenomenon. Thirteen percent of people living with HIV in the Asia Pacific lived in Indonesia, which ranked only after China (17 percent) and India (43 percent). New HIV infection increased by 48 percent and made Indonesia’s share for new HIV infections in the region second only to India with 38 percent. The UNAIDS reports an increasing trend of deaths that are due to causes related to Acquired Immune Deficiency Syndrome (AIDS), which increased between 2005 and 2013 in Indonesia and was a contrary trend compared with most countries in the region. Indonesia’s increase reached 427 percent in the above period — worse than Pakistan (352 percent), which is often labeled as a failed state. Indonesia’s position is in contrast with India’s, where declining deaths due to AIDS-related causes reached 38 percent), and even with Cambodia’s and Myanmar’s, where such deaths declined by 72 and 29 percent respectively. This is in line with the fact that less than 20 percent of those living with HIV/AIDS have access to treatment and anti-retroviral (ARV) therapy. Indonesia is one of the poorest performers in the region, with access to ARV on par with Afghanistan, Pakistan and Bangladesh, for instance. The second wake-up call should be about access to safe drinking water and basic sanitation. While the target was to have at least 68.87 percent of households having access to drinking water by 2015, the latest Primary Health Research (Riskesdas) by the Ministry of Health indicated the rate was only 66.8 percent in 2013. For access to sanitation, in comparison to a target of 62.41 percent for 2015, Indonesia only achieved 59.8 percent in 2013. This means less than 60 percent of Indonesians have access to toilets and proper waste management, for instance — as can be witnessed when strolling through the slums in any Indonesian city. Failure to provide adequate access to both safe drinking water and sanitation means more risk of communicable diseases such as respiratory infection and diarrhea, both of which contribute heavily to child mortality. The third and foremost alarm is related to maternal and child mortality and health. The latest Indonesian Demographic and Health Survey (SDKI), for instance, showed a setback in Indonesia’s maternal mortality ratio (MMR) from 228 per 100,000 live births in 2007 to 359 per 100,000 live births in 2012. The MDG target was to bring down the death rates related to pregnancy and child birth to at most 102 per 100,000 live births, meaning the recent ratio must be cut to less than a third. Severe post-natal bleeding, pre-eclampsia and infection are the main causes of maternal mortality in Indonesia. While regular check-ups can help pregnant women avoid these risks, the increased rate of antenatal and post-natal visits apparently do not always correlate with a decline in maternal deaths. To save mothers’ lives, the quality of health service and health facilities should also be prioritized. A study by the Australia-Indonesia Partnership for Maternal and Neonatal Health in East Nusa Tenggara, for instance, showed that 50 percent of maternal deaths were in health facilities and 59 percent of neonatal deaths took place in district hospitals. Of total maternal deaths, almost half of the women had undergone one to four antenatal visits and slightly more than half even had more than four visits and their deliveries were assisted by midwives. What is often ignored is that the underlying causes of birth complications like anemia, severe bleeding and infection are related to nutrition and sanitation. Last year’s study by Prakarsa showed that while the Takalar district of South Sulawesi had pushed its MMR to zero since 2009, chronic energy deficiency was high among pregnant women. Reports from East Nusa Tenggara also highlighted the absence of clean water in health centers in rural areas, which has discouraged deliveries at health facilities.  The 2012 survey also showed that the mortalities of children younger than 5 years old per 1,000 live births had declined to 40, but that was still too high compared to the target of lowering it to 32 per 1,000 live births. The infant mortality rate was 32 in 2012, still higher than the target of 23 per 1,000 live births needed to reach the MDG target. Nutrition deficiency is another big hurdle in the way of Indonesia achieving the MDGs. Data from the three latest Riskesdas showed little progress in improving children’s nutrition over the last nine years. Instead, malnourished children under 5 increased between 2007 and 2013. Rates of stunted growth and underweight children are still high — potential threats to future human resources and workforces (graph 2). To overcome the challenges, the MDG targets were incorporated into the country’s mid-term development plan for 2010 to 2014. Among others, a preventive program to improve nutrition for pregnant women and children called Gerakan 1,000 HPK (the 1,000 first days of life movement), which is globally known as scaling-up nutrition, was launched in 2012. However, the government should also improve the steps by ensuring the following: First, for the HIV/AIDS indicators, the government must ensure that the national health coverage (JKN) ties up with efforts to achieve MDG targets on access to treatment and anti-retroviral therapy (ARV). For instance, people with HIV/AIDS should also be provided access to treatment and ARV through JKN and supporting ARV treatment tests that are not affordable for most people living with HIV/AIDS. Further, procurement of ARV is still managed by the Ministry of Health, and not the Social Security Management Agency (BPJS). This has caused some problems that hinders access to ARV for people living with HIV/AIDS. Second, for the maternal and child health target, the government must also aim to achieve universal coverage for access to reproductive health and maternity services. The government launched childbirth insurance (Jampersal), in 2011, which covered prenatal, delivery, postnatal and contraceptives for all women who did not have any other insurance. However, not all the benefits of Jampersal are included in JKN and only members of the former Jamkesmas scheme (health insurance for the poor) are automatically transferred to JKN. Those not covered in JKN for the first years have to rely on their regional health insurance (Jamkesda), which mostly offer fewer benefits than Jampersal.  Third, preventative action programs, such as the scaling-up nutrition movement, must be closely monitored to ensure effectiveness, since the idea is similar to other programs established since the 1960s. Fourth, the government must prioritize infrastructure vital for public health improvement, such as water and sanitation facilities. The current government claimed to have increased hospitals, health centers and pharmacies to more than 600 percent during the decade under President Susilo Bambang Yudhoyono. It is a remarkable achievement, indeed, yet they are mostly for curative purposes. The already sparse infrastructure budget allocation for public infrastructure, such as for drinking water, in contrast, has suffered from recent budget cuts.  The future government should ensure that Indonesia will be a truly developed country — not only with more harbors, but also with much more channeling of clean water to homes, enough toilets and better waste management in our cities.  Access to decent sanitation facilities seems so difficult to provide, yet sometimes it looks very simple. Cities have not managed to enforce scheduled waste pick-ups for household waste and school managements have found it hard to ensure clean toilets in their buildings, for instance. The cut off date of 2015 is fast approaching for countries to meet all the targets of the MDGs. Our government has done a lot to achieve what it has committed to do 14 years ago, but more hard work remains for all the good policies and programs that have been left without sufficient budgets or political will. As president-elect Joko Widodo has said, “We need to implement, monitor, implement, monitor,” because there have been good policies and programs already. We should not be left behind in the global competition to make human development the center of development. ●