When poor Indonesians lose everything

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.