TRAPPED IN THE QUICKSAND

Policy Review on Health Sectors in Indonesia within A Decade of Millennium Development Goals

Study Group of MDGs and Policy Advocacy

Christian Foundation for Public Health

Christian Foundation for Public Health Yayasan Kristen untuk Kesehatan Umum

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TRAPPED IN THE QUICKSAND

Policy Review on Health Sectors in Indonesia within A Decade of Millennium Development Goals

Writers: Study Group of MDGs and Policy Advocacy Christian Foundation for Public Health © Yayasan Kristen untuk Kesehatan Umum (Yakkum) Solo, Indonesia September 2010 Pictures: Chairul (5) victim of malnutrition. Live in Distric of Pariaman, an earthquake affected area which now become one of catchment area of Yakkum Emergency Unit. Yayasan Kristen untuk Kesehatan Umum Jalan Adi Sumarmo No. 51 Tohudan, Colomadu, Surakarta Central Java, Indonesia www.yakkum.or.id blog: http://www.healthmdgs.wordpress.com/

Supported by Evangelische Entwicklungsdienst

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Preface Health, as stated in the Preamble of WHO (1948), covers the physical, mental (appreciation and dignity) and social, overall, does not only mean the absence of disease or weak body. Referring to the International Covenant

on Economic, Social and Cultural Rights (1966), each member state has an obligation to respect, protect and fulfill the right of health, described as the right to the enjoyment of the highest attainable standard of physical and mental health, which are guided by a system that provides equal opportunities to all citizens for the right of health. Although health becomes the key sector to success in

achieving the MDGs’ target, however, this sector also gives the Government of Indonesia the toughest challenges. Indonesia is still faced with major issues that potentially threaten the successful achievement of the MDGs. The fact about Indonesia’s ‘on track’ or ‘off track’ in achieving the MDGs’ target, remains a hot debate between government and civil society.

The Government, through the Ministry of Health, claimed to have made progress in fulfilling the MDGs’ target. One of which was delivered by Minister of Health of Indonesia in the WHO Executive Board Meeting in Geneva, Switzerland, in January 2010. At that time, the Government declared maternal mortality rate has

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decreased 58% from 1990 to 2007 period. Meanwhile, the infant mortality rate decreased 50% in the same period. The government also declared the progress in term of reducing the number of people with TB, Malaria, and HIV and AIDS, as stated above the average of other developing countries.1 This review will not dispute the government's claims

about progress in achieving the MDGs’ target. However, will be more of an effort to invite all parties, especially the government to consider dynamic aspects in the efforts to achieve the MDGs’ target in Indonesia. This note also works with different logical variables as well as technical indicators used by the government in viewing the achievement of the MDGs’ target.

The main intention of this note is to offer an alternative view of looking at the process and the results that have been achieved by Indonesia. The main question posed by this note is, whether the claim that the Indonesian government has stated support a sustainable basis or not? Therefore, what are the steps that need to be taken -both by government and civil society- to establish a solid foundation for policy? These steps are required to dismiss the assumption that may develop, which saw the

MDGs and particularly the health development targets, only as "projects" with a validity period which will expire in 2015.

1 See WHO Sambut Positif… http://beritasore.com/2010/01/20/who-sambut-positif-indonesia-capai-target-mdgs/

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After A Decade of MDGs: On Track or Off Track? Before going on an analysis of Indonesian health policy in the context of achieving the MDGs, it is worth paying attention to some of the facts reported by the mass media and other sources during the year 2009,

regarding the important issues in terms of achieving the MDGs. By looking at the facts below, perhaps the magnitude problems faced by Indonesia in order to achieve the MDGs’ target, particularly in the health sector, can be clearly seen. Starting with health indicator of the first goal, eradicate the number of hunger. One of the dimensions of hunger

that often reported by the mass media in Indonesia is malnutrition. Government's achievements in reducing malnutrition among infants and children were still unsatisfactory. Until now, some provinces are still in the bad records of malnutrition reduction. NTT, for instance, is still classified as the highest malnutrition levels in Indonesia. Local Health Department Data stated that malnutrition

in NTT reached 32.6 percent, higher than the national rate of 18.4 percent. Provincial Health Department of East Nusa Tenggara (NTT) stated that until October 1, 2009 the number of patients with malnutrition in the province had reached 4.496 people. Number of patients with malnutrition, he added, spread over 21 districts in

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NTT. District with the highest number of malnutrition is South Central Timor (TTS) with 559 infants, while the lowest in Lembata with one case of malnutrition with clinical disorders.2 However, the problem of malnutrition is not only happening in NTT, similar cases can be found in the cities and other provinces in Indonesia. In Mojokerto, for

example, in the first quarter in 2009, 60 cases of children with severe malnutrition were found, an increase from the same period of the previous year with only 48 cases. In the city of Semarang, Central Java, 44 cases of severe malnutrition were found from January to May 2009, jumped from the year 2008 that were only 30 cases. Still in Central Java, until the first semester of 2009, 610 infants suffered from malnutrition, 165 were treated,

and 22 children died. Total for the year 2009, patients with malnutrition in Central Java were 1106.3 In Bantul, Yogyakarta, hundreds of children under five suffered from malnutrition each month. In August 2009, 213 cases were recorded, in September 2009 increased to 219 cases, while in November 2009 decreased slightly to 201 children. In Pontianak, throughout the year 2009, 39 cases of malnutrition were found. Two of these

infants died. This number increased from the previous year, which was found only 29 cases. In Surabaya, one

2 See "4.496 Balita di NTT Derita Gizi Buruk". Suara Merdeka. 23 Nopember 2009. 3 See “2009, Terjadi 1.106 Kasus Gizi Buruk di Jateng”. tvOne. Senin, 9 November 2009.

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infant (29 months), patients with malnutrition, was known to suffer from AIDS. Indonesia was still listed as the largest contributor to maternal mortality due to childbirth. Indonesia's claim that there was a decrease maternal mortality, from 307 per 100.000 live births to 228 per 100.000, according to the achievement report of the Millennium Development

Goals (MDGs) of Indonesian’s Government in 2009, denied by the United Nations Population Fund (UNFPA). In the World Population Report 2009, published by UNFPA, the escalation rate of maternal mortality in Indonesia was not decreased, but instead jumped to 420 per 100,000 live births.4 Program on combating HIV and AIDS, malaria, and other

contagious diseases in Indonesia are still facing severe challenges. Number of HIV and AIDS in Indonesia tends to increase. The main factors that cause HIV and AIDS transmission are through sexual intercourse and sharing needles. Ironically, among which that are often infected with HIV and AIDS actually came from those who often received discrimination during their lives, such as commercial sex workers and migrant workers. Nowadays, the disease began infecting housewives and

the children they gave birth to.

4 See “Data Pencapaian MDGs Indonesia dibantah”. Dalam Suara Pembaruan Online edisi 24 November 2009.

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In 2008, it was reported that two-thirds of districts in Indonesia with population more than 100 millions, are malaria endemic areas. High endemic areas with Annual Paracite Incidence of more than five per thousand scattered in Maluku, North Maluku, Papua, West Papua, North Sumatra and East Nusa Tenggara. However, the provinces of Nanggroe Aceh Darussalam, Bangka Belitung, Riau Islands, Jambi, Central Kalimantan,

Central Sulawesi, Southeast Sulawesi, West Nusa Tenggara, Central Java and West Java, are classified in the medium endemic area with the API of one to five per thousand. Only some areas in Java, Kalimantan and Sulawesi, are classified in low endemic areas with API less than one per 1000. While the non-endemic areas are only in DKI Jakarta, Bali and Riau Islands.

Other contagious diseases in Indonesia that quite frightening is the epidemic of dengue fever. Dengue Fever or Dengue Haemorrhagic Fever (DHF) is a febrile illness that often found in the tropics, with a geographical spread similar to malaria. The disease is caused by one of the four serotype viruses and flavivirys genus, family flaviviridae. Each serotype is quite different that there is no cross-protection and an epidemic caused by multiple serotypes

(hyperendemicity) can occur. Dengue fever is spread to humans by the mosquito Aedes Aegypti. Dengue cases are usually found in big cities such as Jakarta, Yogyakarta, Medan, and several other large cities. In the year 2009, in South Jakarta itself, there

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were 6171 cases of DHF in January with details of 947 cases, 764 cases in February, March 815 cases, 872 cases April, May 1067 cases, 922 cases in June, July 668 cases, 380 cases in August, September 184 cases, and 98 cases in October. In West Jakarta, within the period of January until the first week of July 2009, 2548 cases were found with two people died. In Central Jakarta, starting in January until December 2009, it was recorded 3138

cases of DHF with a mortality rate of 5 cases per day. DHF cases were also found in other areas. In North Sumatra, the number of DHF patients in the province had reached 3115 people, with 37 of them died. In Wonogiri, throughout the year 2009, this number reached 342 cases, with 2 of them died. This number tended to increase, 328 cases, compared to the year

2008. In Serang, DHF took the lives of four people, while there were approximately 600 people had to get treatment in hospitals and health centers. Besides malaria and dengue fever, the Philariasis has also returned to threaten Indonesia. Officials from the Directorate General of Disease Control and Environment, Health Department of Republic of Indonesia, stated that the prevalence average of filarial endemic is 19 percent,

with the highest prevalence rate in Papua, by 38 percent. Based on data from the health department, until the year 2008, cumulatively reported that the number of chronic Philariasis cases has reached 11.600 cases, which have spread across 378 cities/counties. Recently, the Ministry

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of Health launched a free treatment of Philariasis in order to reduce the number of patients. This effort began with free treatment in West Java. However, these medications actually caused another problems when dozens of people had been hospitalized and about eight people died after mass treatment. The government has denied the death was caused by filarial vaccine, but people did not seem to believe that.

"Need Only Three Months" Swine Flu Spread in Indonesia

June 2009. Health Minister Siti Fadilah Supari confirmed the news saying the H1N1 virus had entered Indonesia. The first case of H1N1 virus afflicted a pilot of a national airline and then a foreign citizen, an Australian tourist that was in Bali, reportedly was also infected with swine flu. July 2009. The spread of swine flu happened very quick. July 14, 2009, there were 122 positive patients of swine flu. A total of 40 Indonesian’s choir contingents that were sent to South Korea also reportedly suffering from flu. Nevertheless, Siti hoped the outbreak of swine flu need not be exaggerated. August 2009. Swine flu patients in Indonesia continued to grow. August 2009, the Ministry of Health confirmed 18 new cases of influenza A H1N1 positive. These new cases made the number of patients cumulatively reached 948 people, spread across 24 provinces. The Government stated that the H1N1 influenza disease can

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be transmitted through human to human contact. From various sources.

Then, in the middle of avian flu (H5N1) threat, that has not entirely disappeared, Indonesia was also faced with new problem, which was the spread of swine influenza (H1N1). Swine flu was first stated entered to Indonesia

in June 2009, that was carried by a tourist from Australia and a pilot of a national airline. It took three months, the number of swine flu patients in Indonesia were stated already approaching a thousand numbers. Unlike the case of H5N1, the efforts to overcome swine flu tended to be underestimated. Citing WHO analysis, the government stated that the case fatality rate due to swine flu was 0.5%, far below the avian flu that reached

80%. Therefore, the government suggested people not overly concerned with the case of swine flu. However, considering the rapid spread of swine flu and the avian flu prevention experiences in Indonesia, we should be worried. Moreover, when referring to the state's obligation to provide the highest standard of health services, the

analysis of the swine flu case fatality rate which was lower than the avian flu should not be an excuse by the state to ignore the existence of similar cases that indicate the spread of swine flu in Indonesia.

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Another problem related to the achievement of MDGs is, the prevention of tuberculosis. In 2005, the External TB Monitoring Mission team stated that Indonesia had made remarkable progress in the response to tuberculosis disease compared with the previous two years. The team considered, the recommendations that were

released two years earlier had been implemented properly by the Government of Indonesia, with the expansion of the implementation of tuberculosis treatment with DOTS (Directly Observed Treatment Shortcourse) in Clinics for Lung Diseases (BP4) and hospitals. Further, the team noted that Indonesia in 2004 also made the progress in achieving new tuberculosis case detection rate of 51.6% of the targeted

60% and in 2005 could reach 70% in accordance with the world target. While the success of tuberculosis treatment in 2004 has reached 85.7% of the global target of 85%.5 Nevertheless, essential notes about tuberculosis still need to be read by us. Some of these notes are that Indonesia has ever been on a record as the world's third largest country with tuberculosis. In addition, each year

at least a quarter million of new tuberculosis cases were found and estimated 140 thousand deaths each year.

5 See “Indonesia Capai Kemajuan Dalam Penanggulangan Penyakit TBC”. Rilis tanggal 16 Maret 2005. Diunduh dari http://www.depkes.go.id/index.php?option=news&task=viewarticle&sid=801&Itemid

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Therefore, tuberculosis is still the second largest cause of death in Indonesia. In the context of contagious diseases, TB is the leading cause of death. In essence, the hard work and efforts to overcome tuberculosis disease remains to be done in Indonesia. In term of sanitation, until now at least 30 thousand villages in 440 districts in the country has a poor

environmental sanitation. It means not one district where the society has been behaving a healthy life. That number, from the health department, does not have much different from the number of underdeveloped villages in Indonesia, which is 32.379 villages (45 percent) or almost half of the total villages in Indonesia that up to 70.611 villages. This demonstrates that the underdeveloped villages are identical to the region with

poor sanitation. Most of the villages are located in central and eastern part of Indonesia. One of the consequences, diarrhea remains a problem in the year 2009. Among the cases of diarrhea which were reported by the mass media, perhaps the most tragic case was diarrhea-cholera in Nabire and Paniai Papua. At least 105 -other source stated 239- people died because of the spread of diarrhea in two districts in

Papua. In addition, the spread of diarrhea also occurred in 16 villages in the Dompu District, West Nusa Tenggara. In that area, four people died, 130 hospitalized, and 244 people undergoing outpatient treatment due to diarrhea. Another illustration of the problem of diarrhea can be seen from the box below.

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Diarrhea Outbreak in 2009 January 2009. Serang, Banten-- Since entering the year 2009, reportedly there were 128 patients with diarrhea in Serang, with 93 cases in January and 35 patients were hospitalized up to February 9. One of the patients with diarrhea, Adi Apriansyah, 10 months, villagers of Baros, Serang Kabupten, died. In Surabaya-- A number of hospitals and health centers experienced the increasing number of patients suffered from diarrhea. It was noted that 476 diarrhea patients treated at several hospitals. Based on monitoring at four hospitals and one clinic, there were 476 patients with diarrhea. Al Ershad Hospital reported 214 patients with diarrhea, Soetomo Emergency Unit Hospital 106 patients, 38 patients in Soewandhi Hospital, Haji Hospital 92 patients, and Wonokusumo health center treatied 26 patients with diarrhea. 60% of those diarrhea patients were children. In Soetomo Emergency Unit Hospital, approximately 45 diarrhea patients were children. April 2009. East Lombok, West Nusa Tenggara. Patients with diarrhea in East Lombok district has expanded to eight working area of community health centers (Puskesmas). The number of patients became 858 people, and undergoing treatment patients were 171 people. Three people died because of diarrhea. Generally, those who suffered from diarrhea in the northern area of East Lombok, located in a watershed of Reban Aji that flows from Aikmel, Swela and Pringgabaya sub-districts.

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June 2009. Polman, West Sulawesi-- Case of diarrhea in Polewali Mandar has caused approximately nine people died. This disease affected many people who live in remote areas, far from the district, such as Barumbung and West Seppong. They were already in the level of alert that made Promkes (Health Promotion) Matakali held intensive counseling to the community and distribute posters about the prevention of diarrhea in the local language (Mandar) and Indonesian language. July 2009. Blitar, East Java. From January until July 2009, at least 1000 citizens suffered from diarrhea. Two of them died. September 2009. Depok, West Java. Health Center Executive Doctor in Cipayung, Mira Miranti, stated that on September 2009, from 6000 patients who visited health center, 60 of them suffering from diarrhea. Pancoran Mas health center doctor, Dece Feriani, stated that in the same month, diarrhea patients who visited the hospital has reached 5 to 10 patients, an increase from the usual, which wascjust one to two patients each day. October 2009. Purwokerto, Central Java. 69 residents of Pamijen Village, Sub-district Sokaraja, Banyumas, Central Java, had to undergo outpatient treatment for diarrhea. The diarrhea in the village has also took the lives of six people. November 2009. Jember, East Java. Due to heavy rains that continue to occur in Jember, patients with diarrhea have increased drastically. According to the Head of

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Public Relations of Health Service in Jember, Yumarlis, on previous month was just 60-70 cases of diarrhea. However, since the past two weeks it has increased to 90 cases. Sumenep, East Java. November 2009. Sumenep District Health Services, Madura, recorded the number of diarrhea patients in 2009 reached 25 thousand. Majority are infants, toddlers and the elderly. However, the local Health Services claimed to successfully reduce the number of diarrhea, which was previously based on diarrhea-prone map of East Java Health Services, predicted to reach 35 thousand. Labuang wedge, South Sulawesi. Between the months of September-November 2009, 293 people reported affected by diarrhea and received treatment in Hospital Labuang wedge. Three of these patients reportedly died. Compiled from various sources.

It should be noted, in fact, sanitation is not as simple as a “pipeline”. Sanitation in essence involves various aspects of the society’s social life, where the key to solve the problem closely related to the empowerment and social structuring of society. Pipeline in the midst of a general

policy of management of water resources that has been privatized will not be able to answer the problem of community needs for water and adequate basic sanitation facilities.

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Another issue in the context of achieving the MDGs’ target is the problems related to international cooperation. In the last reign, there was a conflict between the Minister of Health and WHO, in term of the management of avian flu vaccine. This conflict was ended with an agreement between both parties, but still left a question in public about what really happened. Learning from glimpses of the problems when that

problem surfaced, the Indonesian government is likely to be doing a review of the procurement system of essential drugs for the implementation of comprehensive health care system. So far, the main raw material components of essential drugs required by the community were still coming from abroad, that were obtained through imports. Therefore,

the effectiveness of this still needs to be examined, considering the national and international economic conditions are not stable and may have an impact on the procurement of essential medical needs for the Indonesian people. If viewed from the overall picture of the achievement of MDGs’ target as reported by many parties, including the mass media, it seems that Indonesia has not fully "on-

track". There are several problems, both from policy and social, economic conditions including natural growth due to climate change, which potentially restrain the achievement of the MDGs in Indonesia. Besides continually updating the situation, the government also

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needs to sharply examine the potential barriers derive from policies taken. Health Reform Stroll in Place Perhaps we still remember Ponari phenomenon, a boy who got flooded with thousands of visitors because,

because the believed he can cure various kinds of diseases through water that has been put with his magic stone. Until now, there is no clarification from anyone regarding the magic of Ponari’s stone. However, the public witnessed how thousands of people willing to stand in line at Ponari’s residence for getting water they believed can bring healing to a variety of illnesses. The question that intrigues us from the phenomenon is why

are there some members of society –which is in thousands– who believe in treatment pattern as Ponari did? Is not modern medication that is supported by scientifically medical researches should be more convincing? Some of the society members who were queuing in front of Ponari’s house, probably did not fully believe in the “magic” Ponari. The motivations were probably just an

attempt/effort and trial. In this context, we can take a hypothesis, that what really happens is “fatalism”. The next question, why the forms of fatalism can grow in the modern era like now? The answer can be predicted if we reverse the questions about why the public did not trust the system of modern medication. For example, by

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asking whether modern medication which is supported by scientific research can guarantee someone’s healing? The next question that may arise, is there any modern medication that can be obtained cheaply? “Cheap” and believed to be “efficacious” are two keywords that are likely to be the main motive of some members of the society who tried Ponari’s treatment

style. Efficacy of Ponari’s treatment tends to be relative. Considering there is no valid proof of it, but the cost of his treatment was surely cheap. “Patient” is only applied dole money, Rp 5.000, for one treatment. Why public did not make a great deal of the efficacy of Ponari’s treatment, the answer is because the modern medication system also relatively can not be considered “efficacious”.

Especially after the emergence of Mrs. Prita Mulyasari’s case, modern treatment system conducted by a private hospital of international standard, not only adding the suffer due to the increase of disease but also giving legal implications that must be bear by Mrs. Prita. No need to ask about the cost, because it is definitely above average in economic ability of millions of poor patients. That means the public with its wise, not too concerned about

aspects in terms of treatment efficacy. Moreover, some people still hold on to the concept of “destiny” and believe that the estuary of all the efforts is actually determined by the will of the Almighty.

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Ponari phenomenon actually reflects the quality of primary health care system in Indonesia. Fatalism–just say so–as a form of “blind submission” that is spread in the rural area (and even urban) actually occurred due to a system that tends to focus on curative care (medical treatment) and rehabilitation (treatment). This phenomenon is very clear mirror that described the “powerlessness” of society in term of health.

In fact, curative and rehabilitation aspects are only part of a comprehensive health service. The government actually has an obligation to also conduct promotional activities and health prevention that in substance can only be implemented if supported by serious efforts to empower the community.

The gap between the medical treatment (curative) and rehabilitation (treatment and therapy) with health promotion and prevention leads to an increasingly health funding pressures, especially when Indonesia is still facing problems of availability of services and dependence on imported drugs supply. In the midst of the growing health challenges, such as climate change and severe environment that create more complex disease patterns, the pressure on healthcare financing

are becoming more and more severe. In the economic crisis situation, a qualified and cheap health service is like a dream. Back to the key words; “cheap” and “efficacious”. Like it or not, those words should be acknowledged by the

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government as the main challenges in building a democratic health system and based on respect, protection and fulfillment of human rights in Indonesia. Health is not a commodity that can only be enjoyed if a person has purchasing power. Health is the right of all people and groups without exception. Thus, the WHO defined health as a state of physical, mental (appreciations and dignity) and the complete social, not

only means the absence of disease or a weak body, can be realized entirely in Indonesia. The challenges are certainly not an easy job to be done. Overview the World Bank’s study (2009), the health in Indonesia is faced with the complicated circumstances. These circumstances include: (1) a complex pattern of disease, (2) high economic and social regional

disparities among regions within the health system, (3) decreasing in the condition and usage of public health facilities also the tendency of the main providers of health facilities to switch to private parties; (4) health financing is low and unequal; (5) decentralization, (6) an increasing HIV and AIDS infection rate.6 However, the Indonesian government has given some efforts. In 1999, Indonesian Ministry of Health launched

an ambitious program in health sector, called “Vision of Healthy Indonesia 2010”. That vision was stipulated in the Decree of the Minister of Health number 574/Menkes/SK/IV/2000 regarding “Health

6 leaflet: “Peningkatan Keadaan Kesehatan Indonesia. Bank Dunia. 2009.

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Development Policy toward Healthy Indonesia 2010”. Based on the preamble contained in the decision, the vision of health development policy is an effort to align with the changes of governance, to support decentralization and local autonomy. In 2003, Decree of the Minister of Health number 1202/Menkes/SK/VIII/2003 was stipulated regarding

the Indicators of Healthy Indonesia 2010 and the Indicator Determination Guidelines of Healthy Provinces and Healthy Districts. Within this vision, there are 50 indicators established with targets to be achieved in the year 2010. These indicators are divided into three general indicators, which are (1) Indicator of Health Degree as a final result consisting of the indicators of mortality, morbidity, and nutritional status; (2) result

indicators between the environment, healthy life behavior, access, and health services quality, and (3) process and input indicators of health services, health resources, health management, and contribution of related sectors.7 There are many similarities between the indicators listed in the Vision of Healthy Indonesia 2010 with the MDGs’ target indicators. For instance, an indicator of

mortality in Indonesia Healthy Vision 2010 which outlines the target reduction of infant mortality rate,

7 See Keputusan Menteri Kesehatan Nomor 1202/Menkes/SK/VIII/2003 tentang Indikator Indonesia Sehat 2010 dan Pedoman Penetapan Indikator Provinsi Sehat dan Kabupaten/Kota Sehat.

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toddlers, and pregnant and give birth mothers is similar to the fifth and sixth goals in the MDGs. There is also a prevention target of Malaria, TB, and HIV and AIDS that is similar to the seventh target in the MDGs. This is not surprising, because if you carefully look at the time, the issuance of Decree of the Health Minister regarding Vision of Healthy Indonesia 2010 Indicators performed after the global agreement about MDGs.

The Vision of Healthy Indonesia 2010 is also the basis for Health Department Strategic Plan 2005-2009 preparation, then Basic Health Research in 2007 (which is currently also being prepared the implementation of the Basic Health Research 2010), then the National Health System in 2008 and to align with the local autonomy policy, the government are also preparing

Minimum Service Standards in Health Sector in the district level in 2008. Department of Health's Strategic Plan is a medium-term policy guideline in the health sector as a translation of the National Medium Term Development Plan (RPJMN) to achieve the Vision of Healthy Indonesia 2010. There are several activities based on the strategic plan, such as Basic Health Research (Riskesdas) in 2007, as an effort

to improve surveillance systems, monitoring, and health information which are also used as an input for the preparation of the National Health System (SKN) in 2008. When studying these documents, it is apparent that the government has put efforts to adjust the Indonesian health system with the trends and demands

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of the times. The government started to adapt some demands, such as the fulfillment of human rights, gender mainstreaming, good governance, and to reactivate or revitalize primary health care system. New problems that occur afterward are pursuing the harmonization of program performance, implementation, and financing. Another issue is making

development plans effective which have been compiled with the potential of regional diversity and disparity through a decentralized system. The government is also difficult to mobilize all available potential resources in the center of political interests, both at national and local level, which was never completed. Global economic conditions, climate change, disaster, and the increasingly heavy burden on society are also burdening the efforts

to push health reform in Indonesia. In the documents such as the health department's strategic plan 2005-2009 and the National Health System in 2008, the government admitted if the amount of the health budget from the state budget, despite an increase of 0,81% of GDP to be 1,09% of GDP, but still below the standard established by WHO, amounting to 5% of GDP.8 The government also recognized if the

proportion of government funding has not prioritized the aspects of promotion and prevention of health problems. 9

8 See “Sistem Kesehatan Nasional 2008” 9 Ibid.

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In the midst of limited resources, the governments -especially center government--tend to keep their reputations by realizing the development programs of physical infrastructure of health facilities more because they can be “easily seen” than to consistently apply the decentralization policies with consequence to encourage more participation through community empowerment.

Central government budget allocation in the health sector aimed to support more availability of physical facilities and infrastructure, while the problems of programs, accessibility, and quality, are handed to local governments to give financial support. Unless supported by the quality of resources and creativity of local governance, health decentralization policy turns out to

be the factor of health reform in Indonesia tends to stroll in place, without any significant change to the fulfillment of health’s right. Rather than creating a health system that guarantees the fulfillment of health’s right, the government tends to hand over health problems in the market mechanism. The main problem underlying this phenomenon is the government's financial limitation in providing facilities

and physical infrastructure of health services in Indonesia. In the Ministry of Health’s strategic plan 2005-2009 document, it was acknowledged that Indonesia is still facing a variety barriers of physical access, such as the ratio of health workers to total population is still far below neighboring countries like

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Malaysia and Singapore. According to World Bank study, Indonesia has only 13 doctors for 100,000 people, one of the lowest ratios in Asia. In Lampung Province, the ratio is six doctors for 100,000 people. Other fact that was found in the World Bank, almost 40% of doctors were found absent from their posts without legal justification during government’s official working hours.10

However, policies that focus on achieving the fulfillment of availability will impact on the increasingly powerful commercialization and health care disparities in Indonesia. Certainly, there will be no investors willing to invest their money if there is no guarantee of profits that can be achieved. Incoming investment, including building hospitals’ facilities, clinics or medical centers, pharmacies, including the establishment of medical and

health high schools, to health insurance are located in urban areas with limited market segments, tends to prior the middle and upper economic class. This phenomenon also causes health workers prefer to work in private health service companies that are profit-oriented rather than serve in the institutes of public health services. It is also conditioned by the high cost of health education in medical faculties in universities both

public and private. As a result, public health service support resources become smaller. The government even acknowledges this. Minister of Health Dr. Endang 10 Bank Dunia. 2008. “Berinvestasi dalam Sektor Kesehatan di Indonesia. Tantangan dan Peluang untuk Pengeluaran Publik di Masa Depan”. Bank Dunia. 2008, p. 4.

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Sedyaningsih, in an interview with Suara Pembaruan Newspaper December 23, 2009 edition, stated that the distribution of health workers is still not equitable. Yet every year, there are approximately 6000 new doctors, while the number of health centers in are approximately 8000 units. At this time, according to the Minister, every new doctor

has an obligation to provide services in the district area for three to six months. After that, most doctors choose to open a practice in urban areas with a reason to get their high incomes. Consequently, there are many health centers that do not have doctors. To answer this, Minister of Health, Dr. Endang R. Sedyaningsih was thinking to formulate laws that require doctors to remain up for several years in remote areas. “There

must be a power force in order to ensure public health services,” said dr. Endang on Suara Pembaruan Newspaper. On the other hand, in the name of public services professionalism and accountability that are adjusted to the demands of local autonomy, the government is trying to develop minimum service standards that are applied to all districts and cities in Indonesia. However,

the good intention to set minimum service standards based on professionalism and accountability principles in fact is a “backfire” when it is not supported by adequate resource support.

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Not all local governments, particularly the level of counties and cities, have the economic capacity, inadequate resources and political will to sustain the implementation of minimum service standards. This situation is compounded by the expansion of new districts that are not patterned during the last 10 years. Many local governments rely on local revenues from health service retributions which are pulled through

health centers and hospitals. There are also areas that use the health budget to finance activities outside the health sector, such as for the election of the head local government.

Health Cost Rises Effectiveness for Health Improvement is Questioned Jakarta, Kompas - Indonesia's health expenditure in recent years was increasing. However, the effectiveness of that expenditure to improve people's health is questioned. To control health costs, economic evaluation is needed to be done and further research. This was reflected in the result of research on “National Health Accounts” by public health experts from the University of Indonesia Prof. Ascobat Gani, Prastuti Soewondo, and Mardiati Najib. During the year 2002-2008, according to them, total health expenditures was increased by an average of 19,76 percent per year with an average population increase 1,33 percent per year. Gross domestic product raised an average 20.8 percent per year.

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Prastuti, after a media workshop “Health Economics”, Tuesday (12 / 1), stated that the datas were just an estimation and needed further study. “It's the macro picture. We're still analyzing the details,” he said. Also occurred a shift in the ratio between the portion of the public (government and social security, such as Jamkesnas, PT Askes, and PT Jamsostek) and non-public (private, such as corporate, insurance, and household). In 2002, public sector and non-public ratio is 35:65. In 2008, became 54:46 percent. Expenditure in the public sector increased by an average of 27.2 percent. Household For private health spending portion, household’s spending is the most dominant. Health expenditures themselves was Rp 30,4 trillion of total health expenditure of around Rp 101 trillion in 2008. Mardiati stated, on one hand it could mean that health awareness and purchasing power increases. But it's also worrying because it describes that not all communities have health insurance. FKM UI professor, Prof. Hasbullah Thabrany, stated, the effectiveness of health expenditure still must be measured with the approach of the economic evaluation of health through research in the related fields. “Has it obtained maximum result through that funding,” he said. In the midst of increasing government expenditure, for example, the issue of maternal mortality is still high.

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Chairman, Department of Pharmacotherapy University of Utah, USA, Diana I Brixner stated, with an allocation of limited health care costs and increasing population, thing that can be done such as improving the efficiency of the system. That means reducing the use of products and services that are less valuable. About drugs, for example, once a medical decision based on the level of treatment efficacy and side effects without cost considerations. However, with limited costs, that factor should be considered. (INE) Source: Kompas, Wednesday, January 13, 2010.

The problem increases when the government actually limits the space for participation of the community in assisting the government in providing health care to its

citizens. Government tends to interpret “public participation” as an increase in the potential contribution of community health financing. No wonder people think that health reform means the more expensive health care costs. As a result, health services are very “segmented”, that can only be gained by the financially sufficient people. While for the lower class that does not have the economic ability, is forced to wait

to die and give up on the circumstances. The other restriction is made through the establishment of the Foundation Law. This law was motivated by the tendency of exploiting legal foundation for the activities of for-profit to avoid high tax. This law affects hospitals

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and medical centers that are owned by the Foundation. The most concrete pressure due to the establishment of this law is the high tax burden that must be remitted to the government. As a result, many hospitals that were originally built for social interests were forced to change their services orientation toward profit. According to the regulation, the income of foundation or

similar organization which is the Object of the Income Tax is all income received or accrued by the foundation or similar organization in accordance with the provisions of Article 4 paragraph (1) Income Tax Law includes: a. income received or accrued from business, jobs,

activities, or services; b. deposit interest, interest on bonds, discount SBI and

other interests; c. rent and other benefits in connection with the use of

property; d. benefits from the relocate of property, including

benefits of property relocation which originally came from aid, donations or grants;

e. sharing of the benefits of business cooperation. For foundation or similar organization in health service

sector, which include income and can be taxed is as follows: a. Registration fee for health services b. Rent a room in hospital, polyclinic, and health care

center.

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c. Earnings from health care such as money for doctor's examination, operations, Rontgen, scanning, laboratory examinations, etc.

d. Money for medical examination including “general check up”.

e. Income from rental of medical equipment, ambulances, and so forth.

f. Income from the sale of drugs.

g. Other income in connection with the implementation of health services with and in any form.

In 2009, the Government of Indonesia passed a Law No. 44 of 2009 on the Hospital. In this Law explained that the Hospital is an institution for the community health service with its own characteristics which are influenced by the development of medical science, technological

advances, economic and social life of the society that still must be able to enhance a better quality service, affordable by the community towards health status as high as possible.11 This law passed in the middle of the controversy case between Mrs. Prita Mulyasari with Omni International Hospital. Accordingly, the provisions concerning the rights of patients reflected in a relatively clear.

In addition to provide a law umbrella for the management of the hospital, the Hospital Law is also aimed to improve hospital services in general, through

11 See Bagian Menimbang poin b UU Nomor 44 tahun 2009 tentang Rumah Sakit.

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the establishment of institutional service standards and competency standards of health resources, as well as open space for foreign investment and also involves in the health service industry in Indonesia. The problem is, the Law narrows the hospital organizer actor that only becomes the government and private. The existence of private foundations or organizations that carry out religious mission and non-profit are not explicitly

mentioned in this Law. Hospitals under the Christian Foundation for Public Health (YAKKUM) for example, no longer freely carry out the mission “tolong doeloe, oeroesan belakangan” to serve the poor patients. This mission is still conducted despite the burden becomes increasingly heavy. Special hospitals, such as hospitals for disabled leprosy or

rehabilitation institutions for diffable people, were forced to change their targets or eventually bankrupt due to the duty to pay very high tax.

Toelong Doeloe, Oeroesan Belakang Starting in 1890, Betheda Hospitals which being followed by other Yakkum Hospitals developed a motto: ”Toelong Doeloe, Oeroesan Belakang”. Which not only free the down-payment money for all patients both in the ER or in the hospitalization, but also other exemptions to the poor, that is the right of cost reduction, have the opportunity to repay the cost, a social

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rehabilitation extramural cooperate with the community, get medical social services, receive primary health care hospitals and other social services. The implementation of social services was faced by serious challenges when Indonesia was in the 1997-1999 economic crisis. At that time, almost all religious hospitals faced the dilemma of continuing the mission to the poor or to survive economically in times of crisis. At that moment, all feared that doing the social function in times of crisis would bring hospitals collapsed, on the other side TS founder church worried about the lives of poor people if all the religious hospitals only thought of themselves to survive? To answer this problem, Wijayanta Sigit, who was then a student in the Department of Finance, Faculty of Business and Economics Malaysian University of Science, directing his dissertation to solve this problem, by conducting research to all religious hospitals in Indonesia. In the dissertation entitled “The impact of the 1997-1999 Economic Crisis on Religious Hospital in Indonesia” (USM, 2003) and the book “Medical Dilemma: The Challenge of Economic Crisis to Social Mission of the Religious Hospital in Indonesia” (Difam-Germany, 2002), concluded that religious hospitals was still doing the social function in times of crisis, however their financial performances did not decline significantly. This is

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because many hospitals were aware of the threat of crisis and did a lot of efficiency in the rationalization of the diagnosis and treatment so that poor people still could get affordable unit cost. Concluded in the second book that in fact the main problem of expensive health services and inaccessibility of health services is liberalization, health service industrial cartelism and health professions. Hospitals would still survive if they want to go back to first principle as part of the fulfillment of basic human rights to healthy living on this earth. From the business perspective, hospitals can also be managed with Fortune principle from the Bottom of Pyramid. Doing business with small people does not have to lose, as long as it was managed properly that adjust to the poor patients, and has become the responsibility of the state as the recipient of the tax, to overcome the problems of poor people (SW).

The high tax plus many retributions added by the local governments specified causes foundations that wish to carry out the mission of health care services are no

longer dare to open new areas to expand health care coverage. As a result, the problem of availability of services becomes increasingly unsolvable. The high tax burden is not matched by the government's

seriousness in implementing the National Social Security

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System (Jamsosnas), whereas the Law on Jamsosnas has been enacted since 2004. As well as the Jamkesnas problem, not only the insurance coverage is limited, both in quality and quantity, the government also often postponed the payment of Jamkesnas claims, from government hospitals or private hospitals or the foundation’s hospital. Complicated claims procedures often hinder the work of health services, especially for

the poor. Another limitation comes from the Law of Health number 36 of 2009. Misran, health nurse who worked in the rural area of Borneo, had to go to prison because he was considered violating the provisions in Health’s Law number 36 of 2009. Misran was charged with violating Article 82 (1) the letter D Jo Article 63 (1) of Act number

32 year 1992 regarding health. Based on these articles, Misran was believed to have acted outside the authority for providing heavy drugs which should be given based on a doctor's prescription. Three-month prison sentence punishments, a fine of 2 million rupiah a month substituted on 19 November 2009 which imposed in Tengerang Court, which was supported by the High Court of East Kalimantan

occurred when the country could not realize the actual responsibilities to comply as stated in article 17 of Law number 39 year 2009 about providing access to information, education, and health care facilities throughout Indonesia. Misran during eight years of dedication in serving the interests of rural communities

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for health services as if it does not mean anything in the eyes of the Law which only exists for one year. Misran case shows fundamental weaknesses in the paradigm of health policy and law in Indonesia that partials and positivist. Law enforcement officials do not see the reality of social reality can not be changed quickly and directly in accordance with the ideal picture

as stated in the legislation. What Misran did was a tolerated action because the social conditions for realizing the provisions as stated in the article which Misran was convicted still not been fulfilled. Any verdict should not be inflicted Misran to prison, because it will not have a significant impact on changes in the system.

Climate Change and Health Another big challenge to face on health sector is climate change and its related calamities. Climate change is transition symptom for world temperature increase as a result of the changing atmosphere’s physical condition that layers the earth.12 Climate change brings wide-ranging impact on ecological balance, therefore, it is largely effecting the social life of the people.

12 The terminology of climate change is often misused as “global warming”, whereas “global warming” is only part of climate change. Temperature is not the only parameter for climate, there are others parameters like precipitation; condition of cloud, wind and radiation. Global warming is average increase of atmosphere temperature contributes to global climate change. Greenhouse gasses increase in the atmosphere causes global warming.

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Climate change brings two extreme impacts, in particular health condition of the community, i.e. community resiliency declines both economic and social for imbalance support between natural resources and community adaptation capacity; and on the other hand, threats toward health and human life as well as other living creatures, caused by climate related disasters and

diseases, especially vector-borne diseases. Indonesia, as an archipelago located in tropical area, climate change brings various negative impacts, especially to the poor and marginalized. Economically, climate change brings millions of people, whose living depend on natural productive resources like farm, forest and marine, into idleness. Extreme weather changes

such as extensive drought, flood, storm and increasing sea level, happen beyond community’s adaptation ability in general. Climate change indirectly narrows working field in rural areas. This caused migration and urbanization trends of those having low education. Currently, there are more than 6 million Indonesian low educated migrant workers. Mostly, they have no adequate information that

caused them living in hazard prone areas, like slum areas and do not have sufficient sanitation nor clean water. They also work in susceptible sectors, one of which is household sector, without any adequate health insurance. As a consequence, many migrant workers

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return with nothing, dead, or get into worse living condition. Furthermore, phenomena of migration, these days, are dominated by woman in the midst of patriarchal society. Women migration does not automatically shift the domestic role and function of women –especially for the housewives— of her reproductive affairs in the

patriarchal families. Women share common problem i.e. inadequate treatment toward family health. Many children and toddlers of the migrant families suffer from malnutrition due to lack of attention from the parents. Politically, climate change leads to changing power relation of productive resources, to which people are depending for livelihood. Clear example is tropical

rainforest and peat-land that are changed into palm plantation to meet the need of Crude Palm Oil (CPO), the main raw material for bio-fuel. As previously known, climate change issue has fostered the change in consumption pattern of world’s energy, from fossil fuel to bio-fuel. More than 6 million hectares tropical rainforests are converted into palm plantation in almost all biggest

islands in Indonesia.13 Conversion of rainforests into mono-cultural palm plantation certainly brings various impacts i.e. loss of biodiversities, reduction of people’s

13 According to plan, the government will continue open rainforest areas to expand palm plantation up to 20 million hectares by 2020.

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livelihood sources, social conflicts, and threat of diseases due to massive herbicide usage –especially Paraquat—in palm plantation.14 Furthermore, land clearing, in particular peat-land, whether forest burning or logging, caused methane emission that contributes to level of greenhouse gasses in the atmosphere. From health sector, climate change, especially global

warming, plays significant role to the extent of endemic areal of vector-borne diseases. Based on various community reports, global warming has contribution to the extension of the breeding area of anopheles, Malaria’s borne vector. Beside Malaria, global warming contributes to the extension of Dengue and Filariasis’ larva dispersal. Also, we need to count diseases threat caused by climate-related disasters such as leptospirosis

and diarrhea as an impact of flood and sea inundation. In Indonesia, during 2002 to 2009, there were 29 cases of philariasis in 13 sub districts, 7 of whom died and 2 patients got their legs amputated. Since then, Kabupaten15 Malang becomes a philariasis endemic area. Worse, not only phiilariasis became epidemic in Malang but also in other areas in Indonesia for many

14 Paraquat is kind of herbicide that is used widely througout the world. This herbicide has bad impact toward health. It causes acute oral toxicity to many plantation workers, especially in palm plantation. Information about paraquat can be accessed in “Paraquat Factsheet” di http://www.pan-uk.org/pestnews/Actives/paraquat.htm 15 Kabupaten = Regency

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mosquitos—philariasis borne vector—grew largerly in at least 316 regencies and cities.16 As known, phiilariasis is caused by three worm species, i.e. Wucheria bancrofti, Brugia malayi, and Brugia timori. In Indonesia there are 23 borne-vectors (mosquito) that belong to genus Anopheles, Culex, Mansonia, Aedes, and Armigeres. World Health Organization (WHO) recorded

filariasis as one of the diseases that will reoccure, even become epidemic, especially in tropical countries as an impact of recent global warming. According to WHO, during 1976 to 2008 there were 30 diseases emerged and recorded as impact of climate change and killed about 150.000 people each year. Such condition will develop twice in 2030. This problem will primarily affect the third world countries.

Fundamentally, climate change worsens poverty as well as increase people’s susceptibility on health (whether physically, nutritionally, microbiologically and mentally), at the end.17 Biology and economy dependence toward stability, productivity and environment resilience are absolute. Farming, clean water supply, air quality, supply of wood and fiber, natural medicinal substances, and climate stability, are

all linked to human health and get negative impacts of 16 See “Bumi Memanas Penyakit Mengganas”. Koran Tempo, 13 Desember 2009. 17 Complete explanation on climate change impact toward health can be accessed in WHO site http://www.who.int/mediacentre/news/notes/2009/climate_change_20090311/en/index.html

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climate change. Therefore, appropriate and aimed mitigation and adaptation strategies, in reference to objective, geographical, clinical, and sociological condition, of Indonesia. Government has determined stages to climate change mitigation, so far. One of the stages is formulation of Dewan Nasional Perubahan Iklim (DNPI / National

Board for Climate Change). This board is formed based on the Peraturan Presiden Nomor 46 tahun 2008 (Presidential Decree). According to its mandate, this board has tasks to coordinate the implementation of climate change jurisdiction and to strengthen the position of Indonesia in international forum of climate change jurisdiction.

Flood Smashed Down the Gate of Mamuju Hospital Media Indonesia, Friday, 25 December 2009 MAMUJU--MI: Flood due to heavy rain that hit Mamuju, Sulawesi Barat, Friday (25/12), drowned hundreds of house and Mamuju hospital. The flood smashed down hospital’s 100 meters fence. It also drowned the patients’ ward, brought mud and waste inside.

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According to one of the Mamuju’s residents, Fathur, flood started to flow at Friday’s early dawn following heavy rain that hit Mamuju since Wednesday (23/1) night. Beside heavy rain, Fathur said, bad drainage system of the Sulawesi Barat’s Capital worsened the impact. It caused rain water inundated many regions. "This time flood is worse than three years ago. One day heavy rain caused about a meter flood level," said Fathur. Flood drowned some residentials, like Asrama Kodim 1401 Mamuju (military compound), BTN Ampi complex in Kelurahan Rimuku, Kelurahan Binanga, and Kelurahan Mamunyu. All are located in Kecamatan Mamuju, Kabupaten Mamuju. "Continuous heavy rain will cause larger damage. We worry about this, because it’s just the beginning of rainy season. What could happen in January, when the rainy season comes to its climax?" Said another resident, Anjas. (M-FH/OL-01)

DNPI’s efforts, so far, is limited to formulation of policies in the context of adaptation, such as alternative model

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for energy consumption, other than fossil-based fuel. DNPI, which coordinates nearly 18 ministries and departments, has not had any concrete step yet. As if get stuck in the stream of discussion about the global level climate change, the focus of DNPI then tends to study the economical aspects that becomes the hot theme in the global climate discussion. Only little attention draws into the study on the impact of climate change towards

health. As an archipelago and a developing country where the people have a relatively high dependency on the ecological and climate balance, in fact, government should goes against the stream of discussion in the global level, focuses the attention to studies the specific impacts of climate change toward Indonesian people,

especially on health. This should also be followed by capacity building for governmental agencies –particularly those in health sector—to have more sensitivity and alert in observing the developing situation of social-health as impacts of climate change. Failure in understanding complete picture on the impact of climate change toward human life is not surprising. There is a big gap in understanding risks caused by

climate change toward basic health and conventional understanding on diseases breeding. A relevant example to the case is post mass health-care for filariasis in Kabupaten Bandung, Jawa Barat. The mass media reported, 9 people died and tens were hospitalized after they consumed filariasis’ vaccine. Although government

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argued the indication that said filariasis vaccine caused patients’ loss, the community seemed reluctant to believe. The fatal incident perhaps not because of the filarial vaccine, as stated by the health minister, dr. Endang Rahayu Sedyaningsih, the vaccine will not cause mortality. Therefore, in the midst of difficult situation, there are

some matters that government needs to deal with in term of adaptation and mitigation towards the impacts of climate change on public health condition. First, government needs to have structural study upon the impacts of climate change on increasing risks of health. The study needs to broad to cover aspects related to climate change impacts on human health. It is actually one of recommendations in the WHO 2008 meeting,

which mandated WHO to launch climate change and health program. Concerning the impacts of climate change that tend to be specific and local, Indonesian government had better to initiate a study on the same issue in Indonesian context. Second, government needs to compose climate change adaptation strategy or policy that covers mitigation strategies on the primary, secondary and tertiary levels.

Inevitable health risks had better to be dealt by reducing risk level, and increasing observation and modification of risk effect or impact on health, as well as providing good response to actual threats of climate change on health. As stated by WHO, strengthening health care is

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the main component that must be listed in the climate change adaptation strategy.18 Third, government should campaign the importance of reducing greenhouse gasses emission in the global level and consistently reduce greenhouse gasses emission in national level by enforcing the principles of sustainable development, environmentally friendly, and fulfilling the

domestic need oriented economy. Right Based Primary Health Care The above description shows that health reformation effort in Indonesia in fact has not provide significant progress yet. The government of Indonesia has yet able to free from classics trap, such as minimum budget, lack

of resources, effectiveness and flexibility in optimizing various potent to accelerate the health reform that guarantee the health rights fulfilment for the people and at the same time locate fundamental health development base. Therefore, the MDGs achievement as claimed by the government might not provide much significance for health development. Referring to the human rights approach, the Indonesia’s

health system has yet able to guarantee protection, respect and individual right fulfilment, both man and woman, the right to the enjoyment of the highest

18 see WHO. “Protecting Health From Climate Change: Global Research Priorities”. World Health Organization. 2009.

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attainable standard of physical and mental health. The government of Indonesia needs to work hard in order to meet the responsibility in providing inclusive health care, respecting freedom, without discrimination and entitlement, supported by provision of accessible means and facilities both physically and economically, acceptable, and having good quality.

High cost of health in Indonesia caused by poor primary health care system, especially community based primary health care. Indonesia is actually one of initiator who put community based primary health care. The concepts of Community Health Center (Puskesmas) and Comprehensive Health Care (Posyandu) are conceptual findings arise from the experience of health development in Indonesia. The concepts are one of the

important contributions of primary health care as stated in the Alma Alta Declaration in 1978.

The History of Community Health Center (Puskesmas) The community health center is one of the important findings in the history of health, not only in the Indonesian context, but also internationally. This concept started from the idea of dr. J. Leimena—the former health minister in Indonesia in the decade of 1950s—and dr. Patah about primary health care system. This concept was known as Bandung Plann

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(1951). In 1956, a pilot project on the primary health care for village community was started in Lemahabang, Bekasi. The project then developed into 8 areas i.e. Inderapura (Sumatera Utara), Lampung, Bojongloa (Jawa Barat), Sleman, Godean, Mojosari, Kesiman (Bali), and Barabai (Kalimantan Selatan). The eight projects were the initial of current community health center. In the initial period of Soeharto’s era, a seminar was held to discuss and formulate comprehensive health that affordable and sufficient to Indonesian condition and capacity. A concept about community health center was presented by dr. Achmad Dipodilogo that referring to Bandung Plann and Bekasi Project. The conclusion from the seminar delivered the system of community health center that currently exist. Learning from its history, the idea of Bandung Plann 1951 and the birth of community health center came first than Primary Health Care Declaration or known as the Alma Alta Declaration in 1978. Purportedly, the dr. Laimena’s idea inspired WHO to compile the concept of primary health care. compiled from many sources

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The Alma Alta Declaration (1978) on Primary Health Care reffirmed health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of diseases or infirmity, is a fundamental human right and the attainment of the highest possible level of health is a most important worldwide social goal whose realization requires the action of many other

social and economic sectors in addition to the health sector. All governments must put into reality the policies, strategies as well as national plan of action to launch and support the sustainability of primary health care as part of comprehensive national health system. In order to achieve this, we need high political will to mobilize the

resources of a country to use available national external resources.19 The success of MDGs target achievement, in fact, cannot be determined by graphics and statistics only. Poverty reduction as main target of MDGs supposed to be achieved by approach that involved all potent of existing resources and utilizing focused community empowerment strategy.

The achievement of MDGs will be impossible with approach by sector, but must be integrated in one holistic system. The decreasing number of people with

19 Deklarasi Alma Ata (1978) tentang Pelayanan Kesehatan Dasar.

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less than a US dollar income will mean nothing when there is no increasing quality of mother and child health. The same thing happens with other indicators. As an example, the increasing elementary school participation number will also mean nothing when there is gender inequality and inequity. The MDGs target achievement on the health sector, for

example the HIV/AIDS control will unable to be conducted when the proportion of population living in extreme condition is still in high number. The same thing happens with the impact of gender inequality and gender inequity toward the mortality of mother and child. Meaning to say, one target to the others, even one indicator to the others are truly connected and almost imposible to separate one to the others. Meanwhile, the

interconnection problem between each sectors becomes the main problem in the health development in Indonesia. Indonesia is in fact unable to achieve the MDGs targets, and at the same time must locate the effective, in harmony, democratic, right based oriented and sustainable development base. Nevertheless, the substance of MDGs targets is an experiment on the

national and global level to put the base of development as stated above. The 10 years experiments of MDGs target achievement in Indonesia, especially on health sector provides clear pictures about disorientation of health development in Indonesia.

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Closing United Nations Summit on the MDGs concluded in 22 September 2010 with the adoption of a global action plan to achieve the eight anti-poverty goals by their 2015 target date and the announcement of major new commitments for women's and children's health and other initiatives against poverty, hunger, and disease.

The outcome document of the three-day Summit – Keeping the Promise: United to Achieve the Millennium Development Goals – reaffirms world leaders’ commitment to the MDGs and sets out a concrete action for achieving the Goals by 2015.

In a major push to accelerate progress on women’s and children’s health, a number of head of state and

government from developed and developing countries, along with private sector, foundation, international organization, civil society and research organization pledged over $40 billion in resources over the next five years. Mentioned by the closing UN’s press release, the Global Strategy for Women’s and Children’s health has the potential of saving the lives of more than 16 million women and children, preventing 33 million unwanted

pregnancies, protecting 120 children from pneumonia and 88 million children from stunting due to

malnutrition, advancing the control of deadly diseases such as malaria and HIV and AIDS, and ensuring access for women and children to quality health facilities and skilled health workers.

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However, the main issue facing by the world and Indonesia is not merely due to limited resources. From the various experiences in the last ten years, the main barriers that potentially thwart the achievement of MDGs are first the lack of ownership of the people in the programs of the MDGs. Second, lack of harmonization in the policies of poverty alleviation. In particular in Indonesia, poverty remain be approached by sectoral

policies. And the third, the lack of effectiveness in almost all policies of poverty alleviation. It is also necessary to redesign the concept of development by promoting rights-based approach and sustainability. These efforts must be made in line with the comprehensive correction of the current development practices at this time.

The achievement of MDG targets in the health sector is a major factor of fulfillment of all millenniums’ promises to alleviate poverty. Health and poverty have a reciprocal relationship. Therefore, the correction of past design health development, by promoting rights-based approach, sustainability, and harmony, will be key to the fulfillment of the promise the millennium in the alleviation of poverty.***

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Yayasan Kristen untuk Kesehatan Umum Jalan Adi Sumarmo No. 51 Tohudan, Colomadu, Surakarta Central Java, Indonesia Yakkum Jakarta Liaison Office Jalan KH Wahid Hasyim No. 02 Jakarta Pusat. 10340 www.yakkum.or.id blog: http://www.healthmdgs.wordpress.com/ e-mail: yakkum.jakarta@hotmail.com