Healthy, Quality Life for All

This is what the picture of Indonesia’s health sector for 2013 and several preceding years looked like: malnutrition in rural and urban areas, the resurgence of previously eradicated communicable diseases such as measles, diphtheria, cholera, polio and leprosy; the widening gap of unequal health status, as reflected in the higher number of both over-nourished children from the upper-income segment and undernourished children from the low-income group, the perpetual disparity between western and eastern Indonesia, and disparity within provinces. 

By the end of 2013, controversy emerged over the significant increase in the maternal mortality rate, from 228 deaths per 100,000 live births in 2007, to 359 deaths per 100,000 live births, as revealed in the results of the latest Indonesian Demographic and Health Survey (SDKI) 2012. Besides, preliminary data from the latest national Basic Health Research (Riskesdas) 2013 substantiated the anecdotal news that health problems tend to have worsened over the last decade. 

What we witnessed in 2013 clearly indicates that we are still far from achieving a healthy Indonesia. The apparently deteriorating health outlook raises questions over whether the data is getting more accurate, compared to previous studies and surveys, or if it is because our quality of life is indeed getting worse.

Further, there is no simple answer to the question of what is the reason behind Indonesia’s poor health performance? Health problems are just a manifestation of many others — economic, environmental, education and other sociocultural underlying causes. For example, bad eating habits of poor families, which are due to poverty in a broader sense — lack of money, lack of access, lack of knowledge, etc. — leads to mothers being malnourished, posing higher risks of maternal deaths and reproducing children more prone to nutritional problems and diseases, resulting in more low quality and less productive human resources. 

Investing in human development is therefore critical. Our national social indicators show Indonesia is a poor performer compared to other peer economies, indicating low investment in human development. The latest available data (2007/2008) on public social spending released by the Organization for Economic Cooperation and Development (OECD) in 2013, shows that if compared with other emerging economies, namely Brazil, Russia, India, China and South Africa ( BRICS), Indonesia has an even lower proportion compared to India, already the lowest in this club, and over five times lower than Brazil, the most generous one. 

If OECD’s definition for social expenditure is “a measure of the extent to which a country assumes responsibility for supporting the standard of living of disadvantaged and vulnerable groups”, then this data shows Indonesia has been a parsimonious state toward the welfare of its population, especially the marginal ones. This figure should rise significantly in 2014, with the implementation of the National Social Security System (SJSN).

Compared with other lowe middle-income countries (LMICs) and neighboring East Asian and Pacific countries, our total health expenditure remains below 3 percent of total gross domestic product (GDP), unlike other LMICs and neighboring countries, where total health expenditures have reached over 4 percent of their GDP. 

While there is no formal threshold of how much a country must spend on health, a frequently cited recommendation from the World Health Organization (WHO) suggests 5 percent of  GDP as “an indicator that should be monitored”. A 2005 World Bank study on Ethiopia concluded that additional health expenditure, more or less 1 percent of GDP, would reduce child mortality rates and the lifetime risks of mothers dying by 30 percent. 

With our high rates of child and maternal mortality, there should be a strong political will to increase our national health expenditure to at least 3.7 or 3.8 percent to make us closer to the targets for child and maternal health, in line with the Millennium Development Goals (MDGs).

Health is one of the 31 sectors in which the management of devolved to the provincial and mostly the regental and municipal levels since the dawn of decentralization over a decade ago. Law No. 36/2009 on health stipulates that health budget allocation of the regional governments (both at the provincial and regental levels) should be 10 percent of the local budget (APBD), excluding salaries, and two-thirds of such allocation to be expended on public services. However, many studies show that decentralization does not necessarily improve health outcomes in Indonesia, in contrast with its objective of bringing public services closer to the public. 

Using the Public Health Development Index (IPKM) developed by the Health Ministry, comprising 24 health indicators such as nutritional status, access to health services and prevalence of various diseases, evidently  most of the regencies and municipalities with the highest index spent more on health matters using their local budgets. 

Seven out of 10 municipalities and regencies with the best indexes have two digit percentages of their spending for health compared to only two out of 10 districts with the worst index. As to why the regencies of Asmat in Papua and Sukoharjo in Central Java have almost similar spending rates at 9.5 and 9.7 percent, respectively, could have contrasting indexes (rank 6 for Sukoharjo compared to rank 432 of 441 regencies and municipalities for Asmat), might be explained by other factors such as infrastructure, geographical and topography challenges, population density and capacity of local governments to manage such budgets.

However, other factors that need to be put into the equation are the presence and share of other types of budgets under decentralization, such as specific allocation funds (DAK) and transfers from the central government through deconcentration funds like health block grants (BOK) and health assistance (Jamkesmas, Jampersal). The DAK are aimed at achieving national health objectives. Most of the funds are used for physical procurements such as medical equipment, drugs and medical infrastructure while deconcentration is more for nonphysical development like technical assistance, training and so on. The DAK requires co-funding from local governments (mixed grants) and has rather rigid criteria. The regions have less discretionary space with this DAK program. 

In areas with low fiscal capacity, often the DAK and deconcentration funds constitute the majority of the budget for the health sector. The regional budget or APBD is mostly used for civil servants’ wages and benefits. Many local governments find it hard to allocate the DAK for other purposes, for instance to increase the number and distribution of health workers, or to improve the quality of health workers in the field — the spearheads of public health services. 

Studies reveal the absence of clarity in decentralization as the cause of the helter-skelter health sector. Researcher Trisnantoro in 2009 pointed out that between 2000-2007, there had been no clear pattern and relationship between fiscal capacity and health budget allocation. 

Regions with high fiscal capacity do not necessarily allocate big health budgets, and do not necessarily have good health outcomes either. Maksum in his 2011 study emphasized the fact that the attempt to combine different decentralization philosophies, namely Anglo Saxon and European-Continental systems, has caused chaos and overlapping administrative authority, managerial confusion and unnecessary infusion of politics leading to rent seeking and transactional relationships in government budgeting. Health budgeting is no exception. 

In dealing with these issues, there are at least three recommendations for the national and local governments, budget wise, to enhance our health performance in 2014 and beyond.       

First, the national government needs to prioritize budget transfer to the regions with the lowest health status, pairing them with close technical assistance to improve their managing capacity. The regions must set the expected health status and amount of budget required to achieve that. For instance, the regencies of Pegunungan Bintang in Papua and Gayo Lues in Aceh need to identify which of the 24 health indicators they must tackle to improve their health indexes to say, 0.4 or 0.5 over a certain period of time.

 Is it the high prevalence of undernourished and malnourished children under five years of age? Or the low prevalence of households with proper sanitation? What sort of services are the most effective to tackle the problems? If nutrition is the issue, is it because of issues with access, availability or utilization of food? Or is it more because of a distributional problem? Is government-supported supplemental feeding or promotions to improve knowledge and  awareness of mothers more appropriate? At the programmatic level, it is important to ensure that local governments stay focused on achieving the set targets. 

Second, there must be sufficient space and flexibility for the regional governments to address their specific key issues to improve their health statuses. While it is good to have budget programs like DAK and deconcentration funds that aim to synchronize national targets nationwide, the menu must not be set rigidly by the national government, at least not at the activity or output level, but only at the outcome level. 

 For instance, the DAK are set mostly for infrastructure, but not for recruitment of additional health workers or for their incentives, which are more needed by a regency or municipality. Budget for recruitment, wages and incentives are taken from other budget posts, usually not under the authority of local governments. If the outcome is to improve nutritional status, would it be more effective to educate mothers on how to utilize locally available foods or to build therapeutic feeding centers and the subsequent procurements? 

Third, an emphasis must be given, again, to improve local governments’ capacities to manage and implement health policies and programs. What has mostly happened in Indonesia, in health, as well as in other sectors, is a contradiction: most regions have low budget absorption, while their health indicators are poor.

 East Nusa Tenggara (NTT) province for instance, is one of the provinces with the most health problems. Yet, the absorption of the health budget was less than 50 percent of the allocation. Lack of capacity of the local government to manage health programs and budget must not cause a burden to the population that they have to serve. Identifying gaps and areas for improvement in local governments will be the important first step to improve their capacity. The role of the national government should also be on facilitating cross-learning across the nation, because many regions have been able to achieve good health outcomes. 

Last but not least, it is important to bear in mind that health statuses and outcomes are just the results of many other factors. Infrastructure, environment, educational levels, culture and tradition and so on remain the influential underlying causes of health problems. Synergy with other sectors is a must to approach health problems holistically. Synergy is also needed to close the gap between different regions in Indonesia. If the regencies with the lowest health statuses are able to catch up in some significant indicators, they will cumulatively narrow the health inequality between regions. As such, all Indonesians will enjoy a healthy and high quality life, not just those who live in certain regions and those who come from certain social segments.


Victoria Fanggidae

The writer is a program and research manager at Perkumpulan Prakarsa (Center for Welfare Studies), Jakarta, and a postgraduate from the University of Melbourne’s Development Studies Program.

Published: The Jakarta Post’s Outlook 2014 – Analyses, challenges and opportunities in the year of choices, January 2014

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