Greater, effective investment in health for the poor, please<\/p>\n
Santi W.E. Soekanto
\nJournalist
\nBandung
\nsanti_soekanto2001@yahoo.com<\/p>\n
Last Saturday, the second day of the Idul Fitri holidays, when
\nmillions of people were in festive mood and celebrating,
\n14-month-old Nisa drew her last breath on the floor of a 2 meter
\nby 3 meter, bedraggled shanty that her family called home at
\nSukamulya, Bandung. Her unemployed, abusive father was nowhere to
\nbe seen, her mother was washing dirty clothes by the dirty well.<\/p>\n
Only her eldest stepsister, 14-year-old Adzkia, home for the
\nholidays from her pesantren in Bogor, and her widowed
\ngrandmother, were by the baby's side at the time of death. Nisa,
\nwho did not weigh more than a 7-month-old baby, had been sick for
\nabout a week. On the second day of her sickness, she began to run
\na fever and fell into unconsciousness four times. She refused to
\nbe nursed, drink or eat anything.<\/p>\n
Adzkia, who was given up for adoption by another family when
\nshe was 9, did her best to minister to her small sister --
\nrubbing the baby with herbal oil, feeding her a mixture of honey
\nand egg yolk, dosing her with fever syrup. She took the baby to a
\ncommunity health center (puskesmas) doctor, who threw his hands
\nup and said there was nothing he could do for Nisa as she was
\nalready too far gone.<\/p>\n
\"She's too weak already, take her to the hospital,\" the doctor
\nsaid of the child who was also born on the floor of her mother's
\npoor hut to the rear of the rich neighborhood of Mulyasari, where
\ngarages that housed expensive cars could be five or more times
\nlarger.<\/p>\n
For reasons Adzkia could not fathom, the abusive man, whom her
\nmother married when Adzkia was only 2 years old and abandoned by
\nher real father, said, \"no hospital.\" \"He probably didn't have
\nmoney, in fact he had been hitting my mom for money for days,\"
\nsaid a scornful Adzkia, who could only stand by helplessly and
\nwatch her sister lapse into a coma. Nisa was her third younger
\nsibling from her stepfather who died before the age of 5, all
\nshowing the same symptoms: low weight, distended belly, breathing
\ndifficulty and fever.<\/p>\n
Nisa and her two siblings that died before her were part of
\nstatistics of poverty and ill-health of millions of Indonesians.
\nIn the year 2000, heads of state attending the UN Millennium
\nSummit declared in the Millennium Development Goals to reduce
\ninfant and under-five mortality rates by two thirds by 2015. In
\n2000 alone, about 700 Indonesian children under five years of age
\ndied every day -- largely from preventable causes. The maternal
\nmortality rate, too, is another indication of the sorry state of
\nthe Indonesian health system.<\/p>\n
The WHO Country Office of Indonesia, in a report titled The
\nMillennium Development Goals for Health: A Review of the
\nIndicators, reveals that although Indonesia has made remarkable
\nprogress, mortality rates for children (under five years of age)
\nand infants (under one year old) remain at 51 and 41 deaths per
\n1000 live births respectively. A wide geographical variation
\nexists, however: Infant mortality rates are three times higher in
\nWest Nusa Tenggara province compared with Yogyakarta.<\/p>\n
The death of a child before the age of five results from a
\nbroad range of interrelated factors that accumulate over time:
\nsanitation, clean water, as well as poor nutrition and infectious
\ndiseases. High levels of infant mortality indicate the quality of
\nhealth care during prenatal, delivery and postnatal periods,
\naccording to the report.<\/p>\n
An overall measure of health within a community is reflected
\nby rates of malnutrition, or poor child growth. Levels of
\nmalnutrition are particularly important within the first two
\nyears of life when growth rates are higher than in later life and
\nthe immune system is developing -- implying both high nutritional
\nneeds and high susceptibility to illness. Indeed, all three major
\ncauses of infant mortality -- acute respiratory infection,
\nperinatal complications and diarrhea -- are amenable to quality
\nhealth care.<\/p>\n
The report, however, also reveals that the Indonesian health
\nsystem is poorly equipped to handle the current level of
\ninfectious illness, let alone the increasing burden of
\nnoncommunicable disease, such as hypertension and diabetes.
\nCompared with other low-income countries, Indonesia has fallen
\nbehind in investment in infrastructure and human and financial
\nresources for health.<\/p>\n
To give credit where it is due, despite low levels of
\ninvestment, the Ministry of Health has aimed for universal
\ncoverage of basic services. The polio immunization drive, for
\ninstance, has reached almost every child in the country. Efforts
\nhave been made to keep prices low to encourage use among the
\npoor. Many public facilities, however, are in urban areas --
\nwhere urban, wealthier populations have greater access.<\/p>\n
Moreover, according to the report, price is only one part of
\nthe total cost of seeking care, which includes travel time and
\ncost, and time lost from other productive activities. The result
\nis low utilization of basic public services by the poor.
\nAccording to the report, barriers in seeking care among the poor
\nare reflected in health status, which reflects large
\ndiscrepancies across regions and socioeconomic groups.<\/p>\n
The government is indeed limited in its financing ability, and
\nin its ability to deliver. Choices must therefore be made about
\nthe role of the government in health. \"The government's role is
\ntherefore to allocate resources that promote equity in access
\nrelated to need,\" according to Dr. Sarah Barber of WHO Country
\nOffice Indonesia.<\/p>\n
The poor are the most vulnerable to illness, yet the least
\nable to afford the costs of care and loss of productivity due to
\nillness. Equitable policies, therefore, provide higher levels of
\ninvestment for the poor -- to compensate for the enormous
\nbarriers the poor face in taking advantage of health and
\neducational opportunities.<\/p>\n
Barber pointed to the need to launch two-fold key activities
\nin promoting equity in access to health services, namely
\ndecentralization to strengthen the foundations of the health
\nsystem, and resource mobilization and effective use of funds. In
\n1998 to 1999, Indonesia's total health spending amounted to 1.6
\npercent of GDP compared with 4.5 percent on average among low-
\nincome countries worldwide. This translates to US$8 per person,
\nwith more than 50 percent originating from out-of-pocket
\npayments. The cost of delivering a package of basic health
\nintervention, however, is US$30 to $40 per person per year.<\/p>\n
A look at the major contributors of health financing reveals
\nwhere effective use of funds should be made.<\/p>\n
Private or household spending on health continues to be the
\nmajor contributor to the health budget, accounting for up to 80
\npercent of total health spending since 1990. People pay out of
\ntheir pockets for any health care they seek. This is followed by
\nprivate and non-governmental providers; the government views them
\nas a partner in the provision of health services, and encourages
\nthe wealthy to contribute to the cost of their care through a
\nrange of mechanisms, including legal arrangements to share public
\ninfrastructure.<\/p>\n
The government and donors are the other resources. In fact,
\ndonor assistance is a vital resource to the health sector. The
\n1997 financial crisis and decline in government funding to health
\nwas offset by the willingness of the donor community to respond
\nto health needs. However, health spending is again only a
\nfraction of the total amount of overseas development assistance
\nto Indonesia, amounting to 6 percent spent on health from $2.3
\nbillion on average annually.<\/p>\n
Any wish to prevent any more Nisas from dying a wasteful death
\nmust therefore be followed, not only by greater investments in
\nthe health sector, but also more effective use of the resources
\nalready available.<\/p>",
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