When poor Indonesians lose everything

Santi W.E. Soekanto and Maya Dahlan, Contributors, Jakarta

Rika sits up in her bed at the maternity ward of a hospital in East Jakarta, crying bitter tears over the injustice at the death of her baby because her husband was Rp 2 million (US$236) short of the Rp 7 million needed for a caesarean section.

The young housewife from Cikarang, West Java, is a madrasah Islamic school teacher while her husband is an angkot (city minibus) driver.

"We had been waiting for five years for this baby, but still I thought that I could have it naturally with the help of a kampong (village) midwife," she says. "When the time came, however, the pain was such that I begged my husband to take me to the hospital for the caesarean."

The first hospital, recommended by her doctor, refused to admit her because she didn't have enough money. Rika went to several other hospitals, riding in her husband's angkot until they found one that accepted her. The doctor in attendance told her the baby had been dead for up to two hours, and that the operation was still needed anyway to take it out.

"I have become the poorest person in the world because I no longer have the most precious thing in my life," Rika, says as tears flow down her cheeks.

In Central Jakarta, Mardiyah busies herself folding a sarong as she sits on her husband's bed in the oncology ward of Cipto Mangunkusumo General Hospital.

"Blood was spurting out of his nostrils, ears, gums, even his eyes were bloodshot," Mardiyah said of the day her husband was admitted to the emergency room and the doctors ordered a transfusion to ease the hemorrhaging.

"I was shocked, when I learned that I had to buy 15 bags of blood for Rp 65,000," the 40-something-year-old woman says. "Fortunately, a nephew was willing to pay for it then ... but my husband's life now depends on the transfusions."

Mardiyah's husband suffers from leukemia, which doctors say has reached a critical stage. Mardiyah, a snack seller, says her husband would not be alive if it were not for the financial assistance of her relatives.

"I wouldn't know what to do without their help," she says tearfully. "I don't know what to do if my husband's illness worsens and the relatives can no longer help us. I don't know what to do about my two children, who are in junior school and high school."

"I am hoping that one day there will be a fully-equipped hospital dedicated to poor people like me so we do not have to bear the burden of shame (of having to beg for help)," she says.

Fitri, a 28-year-old teacher, is facing the same predicament as she lies in a bed of a third-class ward of a hospital in East Jakarta, for various ailments, including an ulcer and typhoid fever.

"My husband has health insurance from his company, which does not cover me," she says. "He now has to work hard to pay for my hospital bills because my own salary is not enough."

"If it is only possible, I would only seek care at the community health centers -- we may have to wait for hours before a doctor can see us but at least we would not be hit on the head with hefty bills," she complained.

Firmansyah, a 56-year-old self-employed man, thinks Cipto Mangunkusumo is already friendly enough to the poor. "It is quite inexpensive, it has sophisticated equipment and many of its doctors are professors. Those things really ease our fears," he says. "If I had to go to a specialist in a private practice, I would have to have at least Rp 200,000 -- that sum is enough to give me another illness."

While Firmansyah does not have any complaints about the hospital, he says at the end his family has had to spend a lot of money on other expenses, most notably the travel from home to the hospital. He also has a lot to say about how the government is failing in its duty to improve the welfare of its people.

"What government subsidies have really meant benefits for us? Electricity and telephone bills keep climbing, so I don't think the government would bother establishing hospitals for the poor," he says.

In every corner of the hospital, sob stories are to be found. But individual pains of being robbed of their rights to health, when pooled together, can either become mere statistics or a wake-up call for those responsible to introduce changes.

Ill health saps not only the energy of those individuals, but robs the country of its resources as well.

According to health expert Ascobat Gani, in North Central Timor regency, East Nusa Tenggara, malaria causes extra spending of Rp 38,981 per day while the average wage is Rp 30,000. A calculation of productivity loss and absenteeism finds that malaria "robs" the regency of Rp 800 million every year.

Indonesia has approximately 600,000 new TB cases every year, and 75 percent of all those affected are in their productive years who lose up to four months of working days in a year. Added to the missing resources are expenditures incurred when they seek treatment, and Indonesia finds itself being robbed by TB of up to Rp 8 trillion a year.

Yet another study found that in Yogyakarta in 1999, of the more than 166,000 people who fell ill every month, 50,000 of them became unproductive. This meant that in that year, Yogyakarta lost a total of 4.6 million working days. If one productive day earned a worker Rp 10,000, then Yogyakarta had been robbed of Rp 15.5 billion that year alone (Gani, 2001).

Gani said Indonesia ranks among countries with the lowest health expenditure -- less than $9 per head of population per year -- placing it at 154th out of the 191 countries studied (WHO, 2000). Neighboring countries Malaysia ranks 93rd, Thailand 64th while the Philippines ranks 124th, Gani told a parliamentarian meeting in June.

Legislator Sanoesi Tambunan agrees that despite WHO suggestions that countries spend at least 5 percent of their Gross National Product on health, Indonesia's spending had never reached even 2.5 percent. He blamed the widespread failure to view health costs as a strategic investment.

An indicator of this failure is the fact that less than 20 percent of all people with formal employment are covered by health insurance schemes of some sort. Millions of other Indonesians just have to struggle to pay for their hospital bills and make ends meet when they fall sick -- as the cases shown above.

To give credit where it is due, the health status of the population has improved significantly during the past 40 years. Whereas a child born in Indonesia in the 1960s could expect to live for 46 years, one born in 1996 could expect to live for nearly 65 years.

But not everyone has benefited equally. In 1999, infant mortality rates in West Nusa Tenggara (NTB) was 81 deaths per 1000 live births compared with 24 per 1000 in Jakarta. Inequity in access to health services also exists. In 1999, only 2 percent of the population in Jakarta had no access to healthcare while in Manokwari, Papua, 71 percent of people had no such access.

Ironically, both the government and the public spend more on health costs incurred by tobacco use by 62 percent of all adult men in Indonesia.

Former minister Farid Anfasa Moeloek said the tobacco-related health costs amounted to Rp 30 trillion a year -- but even this was a modest figure as other experts have calculated that while the government earns Rp 27 trillion this year from tobacco excise and taxation, three times as much is spent paying the health costs.

This may seem like a sideswipe, but experts of social security systems agreed in a recent workshop in Jakarta that tobacco firms -- who make trillions from the industry -- should be made to pay not only for causing the deaths of 1,100 Indonesians per day but also for the health development of the country.