Greater, effective investment in health for the poor, please

Santi W.E. Soekanto, Journalist, Bandung, santi_soekanto2001@yahoo.com

Last Saturday, the second day of the Idul Fitri holidays, when millions of people were in festive mood and celebrating, 14-month-old Nisa drew her last breath on the floor of a 2 meter by 3 meter, bedraggled shanty that her family called home at Sukamulya, Bandung. Her unemployed, abusive father was nowhere to be seen, her mother was washing dirty clothes by the dirty well.

Only her eldest stepsister, 14-year-old Adzkia, home for the holidays from her pesantren in Bogor, and her widowed grandmother, were by the baby's side at the time of death. Nisa, who did not weigh more than a 7-month-old baby, had been sick for about a week. On the second day of her sickness, she began to run a fever and fell into unconsciousness four times. She refused to be nursed, drink or eat anything.

Adzkia, who was given up for adoption by another family when she was 9, did her best to minister to her small sister -- rubbing the baby with herbal oil, feeding her a mixture of honey and egg yolk, dosing her with fever syrup. She took the baby to a community health center (puskesmas) doctor, who threw his hands up and said there was nothing he could do for Nisa as she was already too far gone.

"She's too weak already, take her to the hospital," the doctor said of the child who was also born on the floor of her mother's poor hut to the rear of the rich neighborhood of Mulyasari, where garages that housed expensive cars could be five or more times larger.

For reasons Adzkia could not fathom, the abusive man, whom her mother married when Adzkia was only 2 years old and abandoned by her real father, said, "no hospital." "He probably didn't have money, in fact he had been hitting my mom for money for days," said a scornful Adzkia, who could only stand by helplessly and watch her sister lapse into a coma. Nisa was her third younger sibling from her stepfather who died before the age of 5, all showing the same symptoms: low weight, distended belly, breathing difficulty and fever.

Nisa and her two siblings that died before her were part of statistics of poverty and ill-health of millions of Indonesians. In the year 2000, heads of state attending the UN Millennium Summit declared in the Millennium Development Goals to reduce infant and under-five mortality rates by two thirds by 2015. In 2000 alone, about 700 Indonesian children under five years of age died every day -- largely from preventable causes. The maternal mortality rate, too, is another indication of the sorry state of the Indonesian health system.

The WHO Country Office of Indonesia, in a report titled The Millennium Development Goals for Health: A Review of the Indicators, reveals that although Indonesia has made remarkable progress, mortality rates for children (under five years of age) and infants (under one year old) remain at 51 and 41 deaths per 1000 live births respectively. A wide geographical variation exists, however: Infant mortality rates are three times higher in West Nusa Tenggara province compared with Yogyakarta.

The death of a child before the age of five results from a broad range of interrelated factors that accumulate over time: sanitation, clean water, as well as poor nutrition and infectious diseases. High levels of infant mortality indicate the quality of health care during prenatal, delivery and postnatal periods, according to the report.

An overall measure of health within a community is reflected by rates of malnutrition, or poor child growth. Levels of malnutrition are particularly important within the first two years of life when growth rates are higher than in later life and the immune system is developing -- implying both high nutritional needs and high susceptibility to illness. Indeed, all three major causes of infant mortality -- acute respiratory infection, perinatal complications and diarrhea -- are amenable to quality health care.

The report, however, also reveals that the Indonesian health system is poorly equipped to handle the current level of infectious illness, let alone the increasing burden of noncommunicable disease, such as hypertension and diabetes. Compared with other low-income countries, Indonesia has fallen behind in investment in infrastructure and human and financial resources for health.

To give credit where it is due, despite low levels of investment, the Ministry of Health has aimed for universal coverage of basic services. The polio immunization drive, for instance, has reached almost every child in the country. Efforts have been made to keep prices low to encourage use among the poor. Many public facilities, however, are in urban areas -- where urban, wealthier populations have greater access.

Moreover, according to the report, price is only one part of the total cost of seeking care, which includes travel time and cost, and time lost from other productive activities. The result is low utilization of basic public services by the poor. According to the report, barriers in seeking care among the poor are reflected in health status, which reflects large discrepancies across regions and socioeconomic groups.

The government is indeed limited in its financing ability, and in its ability to deliver. Choices must therefore be made about the role of the government in health. "The government's role is therefore to allocate resources that promote equity in access related to need," according to Dr. Sarah Barber of WHO Country Office Indonesia.

The poor are the most vulnerable to illness, yet the least able to afford the costs of care and loss of productivity due to illness. Equitable policies, therefore, provide higher levels of investment for the poor -- to compensate for the enormous barriers the poor face in taking advantage of health and educational opportunities.

Barber pointed to the need to launch two-fold key activities in promoting equity in access to health services, namely decentralization to strengthen the foundations of the health system, and resource mobilization and effective use of funds. In 1998 to 1999, Indonesia's total health spending amounted to 1.6 percent of GDP compared with 4.5 percent on average among low- income countries worldwide. This translates to US$8 per person, with more than 50 percent originating from out-of-pocket payments. The cost of delivering a package of basic health intervention, however, is US$30 to $40 per person per year.

A look at the major contributors of health financing reveals where effective use of funds should be made.

Private or household spending on health continues to be the major contributor to the health budget, accounting for up to 80 percent of total health spending since 1990. People pay out of their pockets for any health care they seek. This is followed by private and non-governmental providers; the government views them as a partner in the provision of health services, and encourages the wealthy to contribute to the cost of their care through a range of mechanisms, including legal arrangements to share public infrastructure.

The government and donors are the other resources. In fact, donor assistance is a vital resource to the health sector. The 1997 financial crisis and decline in government funding to health was offset by the willingness of the donor community to respond to health needs. However, health spending is again only a fraction of the total amount of overseas development assistance to Indonesia, amounting to 6 percent spent on health from $2.3 billion on average annually.

Any wish to prevent any more Nisas from dying a wasteful death must therefore be followed, not only by greater investments in the health sector, but also more effective use of the resources already available.