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THE PRESENT STATUS OF

HEALTHCARE SERVICES IN INDONESIA

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CHAPTER 1 THE PRESENT STATUS OFHEALTHCARE SERVICESIN INDONESIA

By Prof. Dr. Azrul Azwar MPHChairperson, the Indonesian Association of Family Physicians

OutlineNational health development programBrief description of the countryNational health statusPublic health servicesMedical care services

Financing of health services

NATIONAL HEALTH DEVELOPMENT PROGRAM

The general objective of the National Health Development Program in Indonesia asstipulated in the National Health System is to provide a healthy life for all Indonesians.The specific objectives of the National Health Development Program in Indonesia are:

To enable people to maintain their own health and live a healthy and productive life To promote an environment conducive to the health of the people To promote good nutrition among the people To decrease morbidity and mortality To promote a healthy and prosperous family life

To achieve these objectives, various healthcare efforts have been implemented, includingamong others, the strengthening of the healthcare delivery system as part of an overallhealth development program. This is being carried out both by government and theprivate sector. This paper aims to assess the present status of the healthcare servicesin Indonesia.

BRIEF DESCRIPTION OF THE COUNTRY

Indonesia is the worlds largest archipelago, extending between two continents, Asia tothe North and Australia to the South. It lies between two oceans, the Indian to the Westand the Pacific to the East. The distance from the west to the east point of Indonesia is3,200 miles, and the distance from the North to the South is 1,100 miles. The total areaof Indonesia is 5,193,260 square miles, covering both land and sea territories. The totalland area is an approximately 1,904,650 square miles, comprising 13,677 islands ofwhich only 7.25% (992 islands) are inhabited. Almost 85% of the total land area isincluded in the five main islands, Kalimantan (the biggest), Sumatera, Papua, Sulawesiand Java.

Because Indonesia lies along the equator, the climate is tropical, with high humidity, slightchanges in temperature and heavy rainfall. Except at higher elevations, the temperature

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generally ranges from 20 to 30 Centigrade. Humidity ranges from 60% to 90%. Table 1summarizes the physical features of Indonesia.

Table 1. Physical Conditions of Indonesia

PHYSICAL CONDITION FIGURES

Total area (sq ml) 5,193,260

Land area (sq ml) 1,904,650

Number of islands 13,677

Number of islands inhabited 992

Temperature (celsius) 20-30

Humidity (%) 60-90

Indonesia gained its independence on August 17, 1945, after more than three and a halfcenturies of occupation by the Dutch and a further three and a half years by theJapanese. Indonesia is a republic, with a President as head of state, chosen by thePeoples Consultative Assembly every five years. The capital city is Jakarta, situated on theisland of Java.

Administratively, Indonesia is divided into 32 provinces, each with a legislative counciland headed by a Governor. The provinces are divided into Districts and Municipalities,each with a legislature and headed by a Bupati for the regencies and a Walikota for themunicipalities. At present, there are 243 districts in Indonesia, while the total number ofmunicipalities is 61.

East district and municipality is divided into sub-districts, headed by a Camat, and isfurther divided by villages. Each village is headed by a Lurah and divided into hamletswhich, in turn, are further divided by neighborhoods. The villages (except in the bigcities), hamlet and neighborhood groupings are headed by elected persons who serve ina voluntary capacity. At present, the total number of sub-districts in Indonesia is 3,839and the total number of villages amount to 65,554. Provinces, districts and municipalitiesare autonomous regions with administrative responsibilities. They have to finance publicservices, including the health sector, in their respective area of responsibility. Theinformation about the administrative divisions of Indonesia, mentioned above, issummarized in Table 2.

Table 2. Administrative Divisions of Indonesia

ADMINISTRATIVE DIVISIONS NUMBERS

Number of Provinces 32

Number of Districts 243

Number of Municipalities 61

Number of Sub-districts 3,839

Number of Villages 65,554

The total population of Indonesia in 2000 was 203,456,005, making it the fourth mostpopulous country in the world. The rate of population increase is 1.34%. The population

distribution is uneven, with about 59.3% of the population live on Java Island, althoughJava occupies only 7% of the total land area. About 69.1% of the people live in ruralareas, where health facilities and most other public infrastructure are unsatisfactory.

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INDONESIA Indonesians are basically of Malay heritage and are divided into approximately 300 ethnic

groups, about 360 languages and dialects. Islam is predominant religion and the nationallanguage is Bahasa Indonesia. Indonesia has passed law providing compulsory educationfor children. Primary school enrollment rate is 97%. It is estimated that around 15.9% ofthe population is illiterate.

The main occupation of majority of the people is in agriculture. The primary sources ofgovernments income are from export revenues of oil, LNG (liquefied natural gas) andlumber. The annual growth rate is running at an average rate of 4%, and the GNP percapita in 2000 is US$680. Information about the social and economic condition ofIndonesia can be seen in Table 3.

Table 3. Socio-Economic Condition, the Year 2000 Figures

SOCIAL & ECONOMIC CONDITION FIGURES IN 2000

Total population (millions) 203.5

Rate of population increase (%) 1.35

No. of people living in rural areas (%) 57.7

Ethnic groups 300

Moslem(%) 90

Literacy rate(%) 84.1

Primary school enrolment rate(%) 97

Annual economic increase rate (%) 4

GNP per capita (US$) 680

NATIONAL HEALTH STATUS

Due perhaps to the fact that Indonesia is still a developing country, the present conditionof Indonesian healthcare remains unsatisfactory although there have been majorimprovements compared to two decades ago. Various health indicators for Indonesia canbe seen in Table 4.

Table 4: Health Status Indicators for Indonesia

INDICATOR/VARIABLE YEAR FIGURES

Infant mortality rate per 1000 live births 1993 58.0

Under five mortality rate per 1000 1993 81.0

Maternal mortality rate per 100.000 live births 1993 425Crude death rate per 1000 1994 6.0

Life expectancy male 1993 60.8

female 1993 64.6

Low birth weight (%) 1993 15.0

Protein Calorie Deficiency per 100 Underfives 1993 40.0

Clean water supply per 100 population 1986 30.0

Latrines per 100 population 1986 37.9

Percentage EPI coverage 1993 93.6

The primary cause of death in Indonesia since 1995 is cardiovascular diseases that nowovertake predominant infectious diseases, reflecting the double burden faced today.

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The pattern of death in Indonesia is still strongly related to general poverty, low incomeper capita, high rates of illiteracy and various socio-cultural factors. According toHousehold Health Surveys, the 10 leading diseases in the country are: acute respiratorytract infection, diseases of skin, diseases of teeth, mouth and gastro-intestinal tract, otherinfectious diseases, bronchitis-asthma and other disease of respiratory tract, malaria,nerve disorders, cardiovascular disorders, diarrhoea and tuberculosis.

PUBLIC HEALTH SERVICES

The responsiblility for dealing with public health problem in Indonesia lies with thegovernment. Following the basic principle of sound public health, public health servicesprovision in Indonesia strongly encourages community participation through primaryhealth care services.

The main health body entrusted with carrying out public health services in Indonesia isthe Community Health Center (Puskesmas), situated at sub-district level serving a

population of about 30,000-40,000. There are over 7,000 such centers in the country bythe year 2000. The Puskesmas render 6 basic services (health promotion, MCH/FP, CDC,Nutrition, Environmental sanitation, Curative care) and various developmental servicesaccording to local areas need. In most instances, a doctor, with a staffing between 8-32,consisting of nurses, midwives and other auxiliary personnel, heads each Puskesmas.In densely populated areas, there are Sub-Community Health Centers (PuskesmasPembantu) at the village level, generally headed by a senior nurse or midwife, andoperated under the supervision of, and linked to, the Community Health Center.At present, the total number of Puskesmas Pembantu in Indonesia is 19,977

To serve people who live in very remote areas, there are Mobile Community HealthCenter (Puskesmas Keliling), operated by and based at the local Puskesmas. The staff ofPuskesmas Keliling consist of one doctor, assisted by two or three personnel, includingnurses/midwives and a driver. At present, there are about 6,024 Puskesmas Kelilingserving villages within the sub-district.

To support the activities of the Puskesmas, the community health effort is organized inthe form of the Integrated Services Post (Posyandu), located at the hamlet level.The responsible community institution to Posyandu is the village community resiliencecommittee. The activities of each Posyandu, assisted and supervised by local Puskesmas

staff, consist of five basic types of health services. These are: (i) MCH Services, (ii) NutritionServices, (iii) Family Planning Services, (iv) Diarrhoeal Disease Control and (v) ImmunizationServices. At present, there are about 251,459 Posyandu registered in Indonesia.The position of the healthcare delivery system responsible for combating public healthproblems in Indonesia is summarized in Table 5.

Table 5. Public Health Delivery System in Indonesia

PUBLIC HEALTH DELIVERY SERVICES POINT FIGURES

Community Health Center 7,100

Sub-Community Health Center 19,997Mobile Community Health Center 6,024

Integrated Services Post 251,459

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INDONESIA To guarantee successful operation of the Puskesmas, a referral system has been

introduced. Any public health problem that cannot be overcome by the Puskesmas willbe referred to higher health institutions/offices at the district, provincial or even thenational level.

In accordance with the principle of devolved autonomy, there are District Health Offices

at the district level and the Provincial Health Office at the provincial level. The Ministry ofInterior and the Ministry of Health at the national level coordinate the health offices thatare directly under the coordination of the local government.

The general rule is that the main function of the Ministry of Health is to provideconceptual guidance, technical guidance and material, as well as financial contributionand assistance to the local government district and provincial health offices. In brief, theorganizational structure of the health offices in Indonesia is shown in below Table 6.

Table 6. Organizational Structure of the Health Offices in Indonesia.

Central Ministry of Ministry ofHealth Interior

Province Provincial ProvincialHealth Office Government

District District Health DistrictOffice Government

Sub District Community CamatHealth Centre

Village Mobile Sub Community LurahCommunity Health Centre

Health Centre

Hamlet Integrated Head ofServices Post Hamlet

Neighborhood Community Head of

Neighbourhood

MEDICAL CARE SERVICES

The healthcare delivery system that is responsible for medical problems in Indonesia, ingeneral can be divided into three categories: (i) primary medical care facilities, (ii)secondary medical care, and (iii) tertiary medical care facilities. In contrast to public healthconcerns which are under the government, the responsibility of the government is toencourage medical care services in Indonesia to have a considerable private sectorinvolvement. Management of medical care services in Indonesia is therefore a sharedresponsibility between the public and private sectors.

The primary level personal/medical care facility managed by the government is thePuskesmas assisted by the Puskesmas Pembantu and Puskesmas Keliling. Besides the

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provision of medical personal care, the Puskesmas also makes provision for publichealthcare services in the community medical care facilities.

The primary medical care facilities managed by the private sector vary. There are privatemidwives practitioners and private medical practitioners found in almost every part of thecountry. The number of private midwives practitioners in Indonesia is estimated to be

approximately 34,000. Around 20% of the private medical practitioners are specialists,while the rest are general practitioners.

Since most of the midwives and doctors are government employees, their private practiceis usually conducted in the afternoon after the closing of government offices.In some places, although it is illegal, paramedics also have their own private practices. Mostprivate medical practitioners in Indonesia operate their practices as a sole practice, althoughin the big cities there is now an increasing trend for group practices that become morepopular. Other types of primary medical care facilities managed by the private sector inIndonesia are the MCH clinic and the polyclinic. These types of medical facilities are usually

managed by midwives or nurses, although the responsible person for these facilities is stillthe doctor. Unfortunately, the actual number of private MCH clinics and private polyclinicsin Indonesia is not available.

Table 7. Situation of Private Medical Care Facilities in Indonesia (1993)

TYPE OF FACILITIES NUMBERS

Private midwife practitioners (estimated) 45,000

Private medical practitioners (estimated) 34,000

Private MCH clinics NA

Private polyclinics NA

The secondary and tertiary medical care facilities in Indonesia are located at hospitals. Thereare around 1,200 hospitals registered in the country, of which 404 hospitals aregovernment or local government hospitals. The total number of beds available in allhospital is 111,460, which means that for every 100,000 people there are around 59.8hospital beds available. In brief, the number of hospitals in Indonesia is shown in Table 8.

Table 8. Number of Hospitals in Indonesia by the Year 2000

TYPE OF HOSPITALS NUMBER OF HOSPITALS NUMBER OF BEDS

Government 404 58,912

Army 111 11,427

State-Owned 83 7,874

Private 589 34,247

Total 1,187 113,460

Government hospitals are divided into five categories, namely the A, B, C, D and E type.Type D (with 25-100 beds) and type C (with 100-400 beds) government hospitals areconsidered to be secondary level medical care facilities in Indonesia. These hospitals aresituated in the district capitals, of which there are 305 in the country. Type D hospitals are

in transitional period and ought to be promoted to a type C hospital. Type C hospital areexpected to be able to provide at least six major specialty services, namely internalmedicine, pediatrics, obstetric and gynecology, surgery, radiology and clinical pathology.

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INDONESIA Type B (with 200-500 beds) and the type A (with 100-400 beds) government hospitals

are considered as secondary level medical facilities in Indonesia. Type B hospitals arelocated in the provincial capitals and are expected to be capable of providing a broadspectrum of specialist services, while type A hospitals are expected to provide a broadspectrum of sub-specialist services. At present, the total number of type B governmenthospitals is 23 and the total number type A government hospitals is 4.

Type E hospitals are specialized hospitals, numbering 72 throughout the country. Thespecialized hospitals operated by government are predominantly for specific diseasescommonly found in the community, such as leprosy, TBC and mental illness. The numberof government hospitals in Indonesia is shown in the following table:

Table 9. Number of Government Hospitals in Indonesia (1992)

TYPE OF HOSPITALS NUMBER OF HOSPITALS NUMBER OF BEDS

Type A 4 3,510

Type B 23 12,050

Type C 121 20,058

Type D 184 11,654

Type E 72 11, 651

Total 404 58,912

Most of the private hospitals in Indonesia, belong to missionaries and charity foundationsand are usually general and specialized hospitals, managed on voluntary basis. In therecent years, the government has introduced a new policy that allows private hospitals tobe managed on a profit-making basis, the majority of which are found in the big cities.

FINANCING OF HEALTHCARE SERVICES

Health Services in Indonesia are operated under a fee for service system. The number ofpeople covered by health insurance schemes is still limited mainly to civil servants and someprivate employees. In brief, the number of people covered by health insurance schemes inIndonesia can been seen in the following table.

Table 10. Number of People Covered by Health Insurance Schemes

TYPE OF HEALTH INSURANCE SCHEMES NUMBER OF PEOPLE COVERED

Government civil servant 15 millionPrivate employee social security scheme 2.5 million

Public health funded scheme 14 million

Private health insurance scheme 1 million

Total 31 million

Annual health expenditure in Indonesia is still very low. It is estimated to be around 2.5% ofGNP or about US$18 per capita, a level far under the WHO recommended expenditure levelof at least 5% GNP. A big portion of total health expenditure in Indonesia comes from thepeople, whereas the contribution of government is only around 30%. The smallcontribution of government are utilized for all-line subsidy that creates unfair healthfinancing for the poor. Most of private spending on health care is out-of-pocket, because

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only around 20% are protected by various types of prepaid care.

CONCLUSION

Indonesia still faces various health problems. To overcome these challenges, Indonesiahas implemented, since 1969, a series of Five Year National Development Programs,

including the National Health Development program. Significant progress has beenachieved in health care sector, both in public health services as well as in medical services.The management of the healthcare delivery system in Indonesia is carried out both bygovernment and the private sector, including some forms of public-private mix.

The low level of health spending, the misdirection of government subsidies, and the bigportion of population with out-of-pocket spending indicating low proportion of peopleprotected by prepaid care, are challenges in that needs to be reformed gradually towardsmore fairness in health financing.

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