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Assessing the health of Indonesia

Interview - June 12, 2014
A former director at the World Health Organization, Dr. Nafsiah Mboi has brought her substantial experience to the challenging role as Minister of Health if Indonesia. In this interview with Unites World, she discusses Indonesia’s Millennium Development goals, her priorities as Minister of Health, the introduction of universal health coverage and the potential of the pharmaceutical sector in Indonesia
DR. NAFSIAH MBOI, MINISTER OF HEALTH OF INDONESIA
DR. NAFSIAH MBOI | MINISTER OF HEALTH OF INDONESIA
How is Indonesia progressing in achieving the Millennium Development Goals (MDG) related to health?

First of all, we are very committed to achieving the Millennium Development Goals. However, we acknowledge that there are some targets we have not yet reached, specifically those regarding maternal mortality, infant mortality, HIV, and water sanitation. We have good strategies and we have allocated ample resources, but much of the difficulty is due to the size of the population; even a very small percentage can be a few million people in Indonesia. Additionally, the logistics of providing healthcare across the archipelago presents challenges. We try to ensure equity across all regions, but there are still a lot of very remote areas that are very difficult to reach.

We are now concentrating on the most populous provinces with the highest maternal and infant mortality rates and focusing our resources there. We have actually improved health and delivery facilities, by having more trained midwifes, equipment, and postnatal care. However, we have not yet focused enough on the health of the women before their pregnancy. We need to provide better education and improved healthcare both before and during pregnancy.

Has your international experience contributed to your priorities as Minister of Health?

Yes. I’ve been working in this area for a long time and as the director of the World Health Organization in Geneva I was exposed to many international health issues. I think it is very fortunate that I have been able to apply this experience to health issues in Indonesia. It has also been useful in terms of networking; I have many friends who are willing to help us with technical advice and resources.

You were recently appointed chair of Global Fund. How do you balance your ministerial mandate and your Global Fund responsibilities?

The good thing about the Global Fund is that we have a very strong secretariat in Geneva; I only have a small unit here. A lot of the management is done over the internet, through emails and video conferences. It is sometimes challenging to balance both roles and at the moment it is difficult for me to travel internationally. As the Indonesian Government is now decentralized domestic travel is increasingly necessary. In addition to general travel, the operational part of the Indonesian National Health Strategy requires a lot of time in the field. I really enjoy that part of the job; out in the field we see the reality of the situation. Most of my travel is about having dialogue. It is very important to speak to all the different people I meet from each region, as they understand the realities of their particular community better than anyone in our Jakarta office. Travelling around Indonesia has also been a great way to motivate my colleagues in the field and say, ‘yes, we can do this.’

Indonesia’s aim of universal health coverage is very ambitious. How has this been structured and implemented and what are the main challenges?

Fortunately, this process started ten years ago with the Social Security Act. At that time we decided that the social security system was to be managed by two social security authorities, one specifically for health (BPJS Kesehatan), which is responsible for the Social Health Insurance Scheme. The other is responsible for workers, old age, pensions, death, and accidents at the work place.

Our responsibility is the Social Health Insurance Scheme. We started by integrating the existing schemes for civil service, military, pensioners and workers into a single national system, with a standard set of regulations. This has been very ambitious, but our targets are achievable. By 2019 we aim to have universal health coverage. We gave ourselves 10 years preparation, and 5 years to really achieve universal health coverage. At the moment membership is 117 million; 86.4 million of the members are poor or near poor, and in this case the government pays the premium. It is then the responsibility of the local government to contribute on behalf of 4.5 million members, and the remainders have co-contribution agreements with their employers.

We learnt much from our prior experience, so the social health insurance scheme in its new form is much improved. We didn’t only look at the financial aspect; we realized the need to improve human resources, medicines, equipment, facilities, and systems. Even the referral and the information management system had to be changed. Of course, in the first month of the new scheme there was confusion and many complaints. As soon as there was a complaint, our team went there and explained things and made whatever revisions and changes we need to make. As a result of this the number of complaints we receive has fallen significantly.

What opportunities exist in the pharmaceutical sector in Indonesia?

We are trying very hard to increase the domestic production of pharmaceuticals as we actually have the resources and basic ingredients for pharmaceuticals. We also have significant demand, which will only increase in the future. However, we need to invest more in research. We have drawn up a plan outlining the sectors direction, and we hope that by 2025 we will be able to increase national production.

For distribution within the social health insurance scheme, we have established a national formulary and the price has been established. This is all listed on an e-catalogue that facilities can buy from. We have been able to eliminate markups and corruption, reducing the price by 30 to 40 percent. Keeping the cost of good quality medications low is very important for the sustainability of the scheme.

Tobacco use in Indonesia remains a health issue. How can you address the issue when the industry is so economically significant?

Historically the tobacco industry in Indonesia has been very powerful, and it remains so because it’s a huge industry here in Indonesia. In the past much of our national budget was funded by the tobacco industry. Fortunately, today, this is not so much the case. We now have very good data on the effects of smoking on children, women and others who inhale secondhand smoke. Smoking is clearly linked to non-communicable diseases and this is the fourth highest cause of death in Indonesia. Preventing these non-communicable diseases is very expensive.

Fortunately, there is now greater public awareness of the harm caused by smoking. The rate of smoking amongst the educated middle class is very low. However, amongst the poorer and less educated the rate of smoking remains high. We now have a strategic campaign targeted at this demographic. The campaign is more systematic, and we have passed additional government regulations to support it. These steps would have been impossible in the past, so I think with this progress we are moving in the right direction.

Following this election, what health sector issues should the leadership of Indonesia focus on?

Previously there has been much focus on curative care, we have to change to a focus on health and look at prevention rather than cure. The Indonesian Government needs to provide the environment and support for better healthcare. This means a greater focus on the poor, because if they have better access to healthcare they can be more productive and work to their full capacity. Of course, under this administration, the poverty rate has dropped significantly, but it’s still very high, 8-9 percent of around 200 million people. So, I hope the next President will prioritize young people and give them the opportunity to push themselves out of poverty. We have a huge population and if they are healthy we will have a strong work force. Another major issue that deserves attention is population growth. We need better education and awareness around family planning because we are growing much too fast.

You have had a very interesting and unique career with many high level positions. What is your advice to women in Indonesia seeking high office?

Work hard, keep learning, enjoy what you are doing, and do the best you can. It does not matter what position you are aiming for. I have always done that, I have worked hard and enjoyed my work, it is very important that you enjoy what you are doing.

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