News reports on Indonesia’s response to COVID-19 refer to the country's lack of health infrastructure and limits of trained medical staff, including doctors and nurses, and the uneven access to health care across the archipelago.
When compared with other nations in the region, this view is, on the surface, correct. However, this does not reflect the real improvements that have been made in primary health care in the past two decades.
These have included the upgrading of community health centres, and the role of these centres and GP clinics as a first point of entry for outpatient and inpatient services and a wider range of specialist medical care.
Access to district and provincial hospitals is through these referral centres or emergency departments.
Health coverage
On a recent specialist consultation I attended at a private hospital 25 minutes in the direction of Semarang, I met a poor farmer woman in the waiting room who lives on the higher slopes of Merbabu mountain. She had been through successful chemotherapy and was nearing the end of her radiology treatment for breast cancer. She had been able to access this treatment free of charge through the universal health coverage scheme, Jaminan Kesehatan Nasional (JKN), under the care of one of the best oncology specialists in Central Java.
Members of my own family have previously had excellent inpatient care in the Salatiga General Hospital for concussion and dengue fever. I am also currently registered to access free medication programs for active tuberculosis (TB) as an outpatient at one of the provincial hospitals located in our home town.
If I choose to consult a specialist doctor privately for my TB treatment I can do so for AU$10 a visit, with medication costing approximately AU$15 per month. This program is nine months in duration and the drugs provided are produced in Indonesia, more or less guaranteeing supply.
At the same time, I should not understate the challenges of negotiating the health system in Indonesia.
Like anywhere, access to doctors does not guarantee good health care. I have had mixed experiences with doctors and medical care but, just as I would in Australia, I have spent time finding a good doctor I can communicate with and who can help me to access free or affordable health care.
To date, I remain one of the 15% of Indonesian residents without any form of health insurance. I will, however, have cover for myself and my family when I officially become a staff member at a local university: this medical cover is a legislated responsibility of my employer. With a modest income by Indonesian standards, my family has been able to access good quality medical care, including diagnostic and pathology services.
In the past 20 years, there has also been a significant reduction in the contribution of communicable diseases (excluding TB) to the overall national healthcare burden, as well as risk factors for poor health outcomes and improved life expectancies.
At the same time, the focus for health care programs has been curative care and allocations for public health and prevention campaigns is low, reflected in the limited reduction in TB cases for example. My own experience being a case in point, as I had no idea that TB cases were so high in Indonesia, nor that it was so easily transmissible.
Decentralised health care
The top three contributing risk factors for disease burden in Indonesia in 2010 were dietary risks, high blood pressure and tobacco smoking. Arguably, the decentralised health system, which leaves limited responsibility for health-care management at a central level and devolves responsibility to provincial and then district and municipal level, has been critical to many of these improvements.
While the Ministry of Health operates some tertiary and specialist hospitals, its central function has increasingly been in regulation, coordinating distribution of resources, including medical personnel, policy and training development and in the supervision of social insurance schemes (such as JKN).
Provincial government health offices (PHOs) play a coordinating role for health issues within a province and across the districts within its jurisdiction, as well as managing their own provincial level hospitals.
District health offices are responsible for the management of district hospitals and the critically important community health centres (Puskesmas) which operate, at least in Central Java, in every sub-district (Kecamatan).
The relationships between these levels are not hierarchical; each level has its own mandate and areas of authority.
The focus of Puskesmas programs is to provide six essential service areas: health promotion, communicable disease control, ambulatory care, maternal and child health, family planning, community nutrition and environmental health, including water and sanitation.
The majority of people attending these centres have limited, or no, out of pocket expenses. Kampong, or village-level health cadres trained by village midwives and Puskesmas staff provide local level assistance in maternal and child health and healthy living, including nutrition.
There are private sector health providers, including hospitals, GP clinics and specialists in private practice. Many of these private providers are registered to provide subsidised care through the JKN.
In addition, many non-governmental organisations are active with regards to HIV/AIDS, heart disease, women’s health. Religious groups also provide health support and advocacy to poorer communities.
There is active coordination between national, provincial and local levels for the management of communicable diseases such as tuberculosis, HIV/AIDS, malaria and dengue fever, with delivery being at the district and sub-district level.
Here, there is an active surveillance and outbreak response system which, in normal times, measures and monitors key aspects of population health.
According to local sources, it is this system, as well as cross-agency collaboration in health management at district and municipal levels, which has allowed many regions to respond reasonably effectively to the COVID-19 outbreak in more regional areas.
While initial cross-agency responses in January and February were slow, after the first official reported case of COVID-19 in early March, these systems, as well as locally formed COVID-19 emergency response groups, ramped up their coordination with our local mayor and city council.
They have actively lobbied for provincial resources, including protective equipment, coordinated the monitoring of people in self-isolation, and responded to people requiring testing or medical support after potential contact with COVID-19-positive people. This has been, in the first instance, through special puskesmas hotlines registered with WhatsApp, which a majority of even the poorest households use for day-to-day communication, making it accessible to the majority.
Virus spread
Salatiga city council releases daily updates of the status of COVID-19 within our municipality, including in which village councils (kelurahan) there are positive COVID-19, ODP (people under monitoring) or PDP (patients under supervision) cases.
In the last few days, we received concerning news about the spread of COVID-19 within our small town.
The director of Health for the Salatiga municipality said on April 20 that the third and fourth COVID-19 cases were members of a family that had actively engaged in public activity, while they were supposed to be in isolation.
Cases 2, 3 and 4 (all from one family) had travelled to China and Europe, including Italy, Germany, France and Spain in February and early March. None reported to local authorities on their return home.
One family member then went to Bali and, on their return, reported their travel to Bali to local authorities. They were instructed to self-isolate, however, they then went to the local city market, attended a kampung women’s group meeting and participated in a large group visit to a patient in hospital, among other activities. This person later tested positive for COVID-19.
COVID-19 case 3 was hospitalised (in a general ward) with stomach complaints for four days, before developing lung problems. Only then were they tested for COVID-19. When the test returned a positive result, they were moved to an isolation ward. This person failed to report that a family member was currently in self-isolation, or that they had a recent international travel history. Five family members have now tested positive (cases 2,3,4,5 and 6 in Salatiga), with two more related PDP cases expected to return positive test results.
The actions of these people have increased the People Without Symptoms (OTG) group to more than 200 people, as the result of local tracing and these numbers are expected to increase as the movements of patients 5 and 6 and the two PDP cases are traced further.
This illustrates how easily even a well-coordinated and managed COVID-19 monitoring system can fail to provide public health security when the some people refuse to provide accurate information that allows for an effective assessment of risk for the spread of the virus.
We can only hope that those individuals, and others, have learnt from their experience and that they work with local health and other government authorities to identify, trace and track those with whom they have had close contact, and that timely mitigation efforts can help to stop the further spread of infection.