Polio outbreak exposes weaknesses in Indonesia's health-care system

Radical decentralization in 2001 has added to the country's health-care woes.

JAKARTA, Indonesia -- A polio outbreak that spread rapidly through Indonesia after a decadelong absence, crippling hundreds of children, has exposed weaknesses in the sprawling archipelago's long-neglected health-care system.

Hampered by chronic funding shortages, clinics in the poorest parts of the country have been forced to scale back, reducing the time and money they spend on community outreach, health education and immunization programs.

As a result, 239 children under 5 have been infected by polio since March, prompting a series of vaccination campaigns that were completed Tuesday.

Measles cases have increased tenfold since 2000, while the country saw its worst-ever dengue fever outbreak last year. There are also fears bird flu, which has already killed six people nationwide, could mutate into a form that spreads easily among humans.

"The context for these events is a primary health-care system that has suffered from a decrease in resources and is struggling to manage the expectations placed on it," UNICEF's David Hipgrave said.

"What we're seeing are major inconsistencies between the rich and poor provinces," he said.

It was not always this way.

During the 32-year dictatorship of Suharto, the health system, like much of government, was centralized and services reached down to the village level. Polio was eradicated in 1995 and key indicators like child malnutrition and poverty rates fell.

A key component was volunteer outreach efforts like the Family Education Program, where wives of government officials talked to mothers about nutrition and sanitation and reminded them about national immunization days.

That program, like almost all others linked to Suharto, was abandoned after his ouster in 1998.

Radical decentralization, introduced in 2001 in response to demands for increased autonomy, has added to the country's health-care woes.

Almost overnight, the government handed control of public services to regional and local authorities. But their roles were unclear, experts say, funding was inadequate and priorities left to the whims of inexperienced governments, mayors and village heads.

According to the latest figures from the United Nations, Indonesia ranks 110 on its human development index just ahead of Uzbekistan and Nicaragua. Public health spending in 2002 accounted for 1.2 percent of gross domestic product -- among the lowest in Asia -- compared to impoverished East Timor which spent 6.2 percent, Thailand 3.1 percent and Malaysia 2 percent.

The result, World Health Organization and Ministry of Health officials say, is that immunization rates dropped in poor communities and services at village clinics, like monitoring the weight of babies or providing poor families with mosquito nets to protect against malaria, all but disappeared.

"We'd provide the needles and vaccines for immunization, but some districts wouldn't have enough money for operations," said Dr. Jane Soepardi, who oversees immunizations at the Ministry of Health. "They reached nearby areas but left out remote areas. So you'd find mothers who don't even know about immunization."

As a result, Indonesians have increasingly turned to the private sector for health care, according to the World Bank. But the poorest Indonesians lack insurance and are routinely denied access to top-notch hospitals or kicked out because they cannot pay, health officials say.

"I was really upset because I couldn't get my baby into the hospital," said Sari Laela, who carried her sick 3-week-old son to five hospitals in Jakarta earlier this year before one admitted him. "It's a pity this health care system can't help people like us. Maybe this will open the eyes of the government."

The media coverage of Laela's case prompted President Susilo Bambang Yudhoyono's wife, Kristiani, to pay for the child's care and the Health Ministry to begin drafting a bill that would bar hospitals from rejecting patients.

The polio outbreak has also served as a "wake up call" to the government, according to Dr. Arun Thapa, WHO's Southeast Asia regional adviser. Since the outbreak, Indonesia has embarked on an ambitious plan to gradually introduce national health insurance, revive community health clinics and boost immunization programs.

To some, the polio vaccination campaign, which began in August, was a sign the system is not beyond repair.

Despite having only weeks to prepare, about 95 percent of the 24 million children under 5 were vaccinated -- helped in no small part by the cadres of volunteers who publicized the effort.

"There was realization with health officials that there was much more to dealing with this outbreak than what they were used to in the past," Thapa said. "It made them realize that business as usual was not good enough."