Challenges Remain in Indonesia's Health Care System: UN Expert


APRIL 05, 2017

Jakarta. Following his first visit to Indonesia, UN Special Rapporteur Dainius Pūras said on Monday (03/04) that Indonesia is on the right track to develop an equitable and sustainable health care system, but warns that "the country’s ambitious goals can be reached only if challenges are addressed."
Indonesia still faces a number of challenges in securing the right to health for every citizen, Pūras noted. In particular, the UN health expert highlighted issues in sexual and reproductive health rights, mental health, HIV/AIDS, the health care situation in Papua and the right to health of drug users. 
Indonesia aims to achieve universal health coverage by 2019, but to ensure that no one in the country is left behind, Pūras said "public authorities need to step up efforts to address structural and systemic issues."
Pūras visited Indonesia for two weeks – from March 22 to April 3 – and observed health facilities in Jakarta, Padang, Labuan Bajo and Jayapura to assess public satisfaction on the services, especially within the framework of health-related Sustainable Development Goals (SDGs).
Health care in Papua
In his preliminary report, Pūras expressed his concerns regarding Papua, where generalized epidemic and infection rates are the highest throughout the country. 
"Ethnic Papuans are two times more likely to have HIV/AIDS than the rest of the population, and new infections are increasing among this group," Pūras said. 
Due to historical, socio-economic and cultural factors, Papuans still face challenges both in access and effectiveness of response given to testing, treatment and health-related services.
Pūras said Papua "deserves special attention and efforts" in order to build trust between service providers and users as well as to scale up investment in the health sector and enhance access, which he reminds need to be done "in a culturally-sensitive manner."
Right to health of drug users
In his report, Pūras also criticized Indonesia’s tough anti-drug policy, describing it as "excessively punitive." He said the current approach undermines the right to health for people who use drugs and overall public health efforts in the country.
Alternatively, he said drug use should not be criminalized and the reporting on — as well as the rehabilitation for — drug use should not be compulsory, as it currently is. 
The drug policy in Indonesia is largely based on law enforcement, therefore limiting realization of the right to health which includes informed consent and the right to refuse treatment. 
"Indonesia should invest more in prevention, education and information programs about drug use," Pūras said, adding that health care sectors have to take an active role in promoting evidence-based prevention, services and treatment for people who use drugs with respect to their autonomy, dignity and privacy. 
Sexual and reproductive health rights
Education on sexuality in Indonesia is often limited to biology and reproduction, without addressing aspects of human rights and discrimination, sexuality or gender norms, Pūras added.
According to him, these elements are essential for "young people to make informed decision on their reproductive health and adopt healthy sexual behaviors."
Gender-based violence, and discrimination toward women and girls due to their social, cultural, and religious backgrounds – including those who are exposed to harmful practices such as child marriage and female genital mutilation (FGM) – are some of the key concerns brought up by the UN expert. 
To advance the right to health, in line with SDGs related to women, he urged the Indonesian government to pass the Elimination of Sexual Violence bill (RUU PKS). The bill is currently included in the priority list of the 2017 National Legislation Program (Prolegnas). 
Pūras found that over the past fifteen years, HIV transmission in Indonesia has overall started to decline and seem to have stabilized. 
However, prevalence of the auto-immune disease is still high among certain key affected populations; in particular men who have sex with men, transgender people and those who use drugs. 
Discrimination toward individuals and groups based on their sexual orientation and gender identity or gender expression contributes to increased vulnerabilities, including increased stigma and harassment in health care settings and HIV infection, Pūras said, quoting reports by the National Commission on Violence Against Women (Komnas Perempuan) and National Commission on Human Rights (Komnas HAM). 
Furthermore, while HIV testing has increased in Indonesia, the numbers are still low.
"Normative, policy and institutional changes are necessary to remove serious barriers that hinder the effectiveness of the HIV response," Pūras said, adding that increasing efforts in reaching out to most-at-risk populations are needed. 
There is also reason to be more concerned with the National AIDS Commission ending its term next year. Although the commission’s function and responsibility will be absorbed by the Ministry of Health, Pūras argued that an independent body is crucial in addressing the issues surrounding HIV/AIDS and urged the Indonesian government to reinstate the commission with a strong, independent mandate and sufficient resources. 
Pūras will elaborate on the health care gaps and challenges in Indonesia and ways to address them in a comprehensive report, which he will submit to the UN Human Rights Council in June 2018.