Greater, effective investment in health for the poor, please
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.