Indonesia's infant and maternal mortality rates remain unacceptably high, with the latest data showing 24 deaths per 1,000 live births in 2017 for infants, and 305 deaths per 100,000 live births in 2015 for mothers. (Antara Photo/Syifa Yulinnas)

Challenges for Indonesia's New Health Minister


OCTOBER 31, 2019

The appointment of Terawan Agus Putranto, an expert radiologist, as health minister in the cabinet of President Joko "Jokowi" Widodo has raised many questions, especially among doctors.

The ethics council of the Indonesian Doctors Association (IDI) determined that Terawan had violated the ethics of medical conduct for his use of a diagnostic tool, digital subtraction angiogram, for stroke therapy.

Nevertheless, the president ignored that and placed his trust in Terawan to lead the ministry. Other than his ethical controversy, what challenges await the former director of Gatot Soebroto Army Hospital?

Stunting, a condition of impaired growth and development in children, has attracted the president's attention. Stunted children have heights below the average of their same-age peers. Indonesia ranks first in Southeast Asia and fifth in the world in terms of the proportion of stunted children.

Because of its long-term consequences, the World Health Organization recommends every nation to lower stunting to below 20 percent. We have reduced stunting to 30.8 percent the in five years of Nila Moeloek's leadership, the previous health minister. The sensitive and specific intervention in stunting must be conducted intensively to achieve optimum results under Terawan's leadership.

Infant and maternal mortality rates are the president's second health concern. The latest data shows both rates are high, 24 deaths per 1,000 live births in 2017 for infants, and 305 deaths per 100,000 live births in 2015 for mothers.

Strengthening the "continuum of obstetric and infant care" in private and public health care has proven to reduce both mortality rates. It starts with improving coverage and the quality of care before childbirth and ensuring safe delivery, while increasing the capacity of the medical workforce, evaluating the referral system, and investing in health care infrastructure.

The president's third concern is the growing deficit in the national health insurance scheme, or BPJS Kesehatan. Two days after his appointment, Terawan surprised the media by announcing that he would donate his first month's salary to BPJS Kesehatan as a moral gesture. This drew skepticism, as many health economists and the National Social Security Council (DJSN) – the entity supervising BPJS Kesehatan – determined that the problem lies in inadequate funding and premium collection.

Moreover, noncommunicable diseases, such as stroke, heart disease and diabetes, have excessively contributed to our national health insurance expenditure. Diabetes and stroke will cost $5.8 billion in 2020.

Indonesia has had multiple health issues in the past five years, but health development has progressed. Average life expectancy in the archipelago has steadily increased by 0.8 years to 71.2 years in 2018. It aligns with a 3.08-point increase on the Human Development Index to 71.39. Among Southeast Asian countries, average life expectancy in Indonesia is only ahead of the Philippines, Laos, Myanmar and Cambodia.

President Jokowi will focus on building human resources in his second term. Ten years from now, Indonesia's demographic bonus will peak, when 70 percent of its approximately 300 million citizens at the time are projected to be at a productive age. Health policy should not be limited to child and maternal health, but also focus on other health issues to generate and maintain productive generations.

On a global level, world leaders have adopted the United Nations Sustainable Development Goals, which consist of 17 objectives that are significantly related to health. The Ministry of Health can be the leader in advocating those goals, bring multiple stakeholders to collaborate, and engage in thinking about strategic policies on health.

On a national level, Indonesia has at least three policies that should be evaluated early in Terawan's leadership. The first is the People's Movement for a Healthy Lifestyle, or Germas. According to a 2017 presidential instruction, Germas should be systematically implemented by everyone to encourage healthy behavior and better quality of life.

Second is the minimum health service standard, or SPM, policy contained in a 2018 government regulation and a 2019 health minister regulation, which mandates provincial and district governments to provide universal basic health coverage to mothers, children, adolescents, persons of productive age and the elderly, people with hypertension, diabetes, severe mental disorders, tuberculosis and HIV.

Third is the Healthy Indonesia Program Through Family Approach, or PIS-PK. The program has reached and assessed more than 37 million families, or about 57 percent of the country's households in five years. Furthermore, the collected data must be disseminated to generate meaningful interventions.

This convoluted health care system should be disentangled and re-organized. From a framework perspective, numerous health policies are embedded as foundations. The roof of this framework is the national medium-term development plan, while as pillars, we suggest the new minister strengthen four substantial issues.

One, improve access to and the quality of primary health care. The government has built 279 public primary health care centers, or Puskesmas, in rural areas. Nearly 9,000 health workers were assigned to 1,661 rural Puskesmas through the Nusantara Sehat program. A further challenge is making quality improvements for better care.

Two, evaluate eight points on the national health insurance roadmap after five years: operational continuity; universal coverage; standardized service benefits; number of health care facilities contracted; effective regulation; member satisfaction; facility satisfaction; and accountability.

Three, reflect on the national prevention and promotion strategies. Both the health ministry and BPJS Kesehatan have community-based programs for promotion: the ministry's Posbindu PTM, which focuses on preventing noncommunicable diseases, and BPJS Kesehatan's Prolanis, which focuses on chronic diseases.

These two national programs must be synchronized for effective and efficient case detection and early intervention.

Four, adopt health care technology and innovation that address inequality, scattered nondigitized data and service quality.

We knew Terawan as an expert radiologist with an astonishing background. Leading an arduous bureaucracy and playing the role of chief decisionmaker for national health policy is different from being a clinician, researcher, or health care director. We place enormous hope on him.

Thank you, professor Nila Moeloek. Best of luck, doctor Terawan!

Aqsha Azhary Nur is a member of the World Health Organization's Young Leaders Network. He and Jeslyn Tengkawan are currently both pursuing master of public health degrees at Johns Hopkins School of Public Health in Baltimore.