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Empower local leaders to improve health services
Health Minister Nafsiah Mboi, the former executive secretary of the National AIDS Commission, started her term in mid-2012, replacing the late Endang R
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em>Health Minister Nafsiah Mboi, the former executive secretary of the National AIDS Commission, started her term in mid-2012, replacing the late Endang R. Sedyaningish. She reflects on the achievements of the country's health sector and the health challenges facing the new government under president-elect Joko 'Jokowi' Widodo and Jusuf Kalla. The following are excerpts, as told to The Jakarta Post's Ati Nurbaiti and Elly Burhaini Faizal.
Universal health coverage is about delivery of comprehensive and quality healthcare service.
Initially we were quite surprised about the significant increase in the maternal mortality rate from 228 per 100,000 live births in 2007 to 359 per 100,000 live births as presented in the 2012 Indonesian Demographic and Health Survey (SDKI). However, the recently released Global Health Statistics report cites that Indonesia's maternal mortality rate stands at 190 per 100,000 live births, which means that we are on track and will achieve Millennium Development Goal (MDG) number five on reducing maternal deaths. I don't know which data I should hold on to, but I keep telling fellow health workers at all levels that percentages are not the only issue. Every single woman must be saved. We should not only focus on figures because the most important thing is to save both mothers and children.
Secondly, antiretroviral (ARV) treatment has been provided in all 34 provinces with Nunukan, North Kalimantan, being the latest region to have access to ARV treatment for patients living with HIV/AIDS. What we are very proud of is what we call 'new HIV infections averted'. Of the total 1,630 HIV-positive pregnant women we tested as of June 2014, only 91 babies they gave birth to were HIV-positive, thanks to the ARV treatment they received. This means we are managing to protect the babies of HIV-positive pregnant women from becoming infected. With expanded access to ARV treatment, the rate of fatalities caused by the infection was reduced to 0.4 percent of total cases as of June 2014.
We are one of only a few countries in the world that dares to administer a 'strategic use of antiretroviral' treatment. We first offered HIV tests to key populations, such as gay men, transsexual and transgender people, commercial sex workers and their clients, pregnant women at high risk of contracting HIV, patients with chronic tuberculosis and people with sexually transmitted infections. Once someone is confirmed as being HIV-positive, we give them the antiretroviral treatment.
I personally don't trust the effectiveness of condoms in preventing new HIV infections. It is unlikely that significant progress can be made in the control and prevention of HIV if we depend solely on condom use. This is not due to low condom awareness and use, but simply because high-risk men do not want to use condoms as they still believe in the myth that condoms reduce sexual pleasure ' it's 'mobile men with money and a macho environment'. That's why it would be much more effective if we could detect infections early on, to be able to provide early treatment. The ARV treatment is indeed very costly, but without early treatment HIV/AIDS would explode. We are very open, all the ports have brothels and no one wants to use condoms. So ARV is a very good investment (currently at Rp 7.5 million (US$637) per person per year). As we are now a middle-income country, all the donors are decreasing their assistance. So we must try to speed up control of the epidemic.
The new government will need to prioritize closer attention to efforts to develop Indonesia's overall health system as it will have a longer-term impact. If we look at health infrastructure, facilities, human resources, referral systems, information management and monitoring and evaluation, there are three issues we must deal with.
First, equitable access to health services for people in urban and rural areas, remote and cross-border provinces and the outermost islands; second, improved access to primary health care, and third, an improved referral system. In every regency and municipality, there should be at least one type-C hospital with specialist care services, comprising four basic specialist services ' pediatrics, obstetric gynecology, surgery and internists ' and two supporting services, such as radiology and anesthesia. These plans are not completed, but we have laid the foundations.
We also aim to build a regional hospital-referral system in each province so that patients who need a sub-specialist service do not have to travel too far. Despite delays which have mostly been caused by a shortage of funds, I admire the efforts taken by a number of administrations at regency, municipal and provincial levels to increase their health budgets.
We also aim to develop at least eight national referral hospitals that are equal to the Cipto Mangunkusumo General Hospital, a type-A hospital in Jakarta, so that the national referral services can be more evenly distributed across Indonesia.
Then regarding the financial side, I'm very proud to say that we have more than 126 million people covered by the National Health Insurance (JKN). I think the new government will review the amount of premium payment assistance for impoverished and low-income people, which has been set at Rp 19,225 per person per month. We hope that the premium payment assistance can be set at Rp 25,500 per person, or equal to workers' premiums for third-class facilities. I've received reports that a few health facilities have discriminated against assistance beneficiaries; that is why I hope that the government can set an equal amount of premiums for assistance beneficiaries and patients in third-class facilities.
However, 'universal health coverage' should not only mean the extent of coverage but also how we can deliver a comprehensive and quality healthcare service. It is comprehensive if it covers preventive, promotive, early diagnosis and treatment, curative and rehabilitative healthcare measures.
Frankly, I'm not yet satisfied with the quality of care; however, I'm happy to say that within just two years, 15 private and state hospitals have been awarded Joint Commission International accreditation. We hope there will be more hospitals internationally accredited, or that receive at least national accreditation, so that they can provide international standards of health care.
People ask about constraints in the education and health sectors, given the rise in energy subsidies planned for next year's state budget. I don't know. I don't want to comment on uncertainties. I have seen a lot of misinformation created by the media. One example is the controversy over Government Regulation No. 61/2014 on reproductive health, which has been accused of paving the way toward legalizing abortion. This view is baseless. [In line with the health law] the regulation prohibits abortion except in specific circumstances, namely in the case of a woman facing a life-threatening medical condition and for victims of rape; and even then, pursuing an abortion will involve strict procedures.
If the new health minister asks for my input, I will give it because we have the data.
Regarding the health budget, for example, 84 percent of the total budgetary allocation for the Health Ministry is channeled to local administrations. From the total Rp 47 trillion we receive annually, almost Rp 20 trillion is spent on the Social Security Management Agency (BPJS) and of the remaining Rp 27 trillion, 84 percent goes to local administrations. We have to encourage local administrations to allocate more budget funds for healthcare development. Above all, I just want to work on what I have to work on. We still have to strive to achieve our MDG targets and to prepare the post-MDG 2015 agenda. But we will have to be patient to hear directly from the president-elect [as to what specific health agenda he wants to pursue].
What is very rarely mentioned is that the new health minister must have the capacity to work with, support and empower local administrations. This is a very important. By law, local administrations are responsible for delivering health services. And to be able to carry out that responsibility they need to be empowered. I'm very proud that in my short term in office I've met all the governors and heads of provincial health offices. Their complaints have included a lack of resources, quality of resources and their distribution. In 2012, the local leaders said they wanted big hospitals, I said no. For the Rp 500 billion needed to build a big hospital, we could have 10 smaller type-C hospitals closer to where people live.
We showed them that we need to build the system. And several of the local administrations have now increased the percentage of their budget allocation for health, such as East Kalimantan. Some local administrations don't have enough resources for health because their locally generated revenue is so small, while some prioritize the development of housing for their regents and legislative councilors instead of improving their healthcare services. This is the case for almost all new provinces, regencies and municipalities; some may have 13 percent of their budget allocated for health, others may have 2 percent by law, but their allocation for health should be at least 10 percent.
