Ethics of Health Care: A Critical Review

Lessons Learned from Indonesia: A Country In Transition

Health for All denied?

by

Drs. Antonius Roy Tjiong, MDT

Medical Director of Helen Keller International - Indonesia

ABSTRACT

Over the past three decades, Indonesia has grown from one of the poorest country in the
world to become the next new tiger from South East Asia. Despite the miracle of the
economical growth, enormous health problems remain. Although health has improved
considerably due to the strong commitment to reach Health for All by the Year 2,000 through
Primary Health Care, by ensuring the accessibility of health services, the poverty alleviation
effects of health sector interventions had been modest in absolute terms. While at the same
time the private sector is flourishing and takes a lead in the provision of sophisticated health
services for those who can pay. The private sector accounts for about 67 per cent of health
expenditure in the country. This phenomenon will lead us to the ethical question, the
distributive justice, inequality and inequity.

INTRODUCTION
Indonesia is the world’s fourth most populous country, after China, India, and the United of
States. In 1993 the population is estimated to have reached almost 190 million. Life
expectancy at birth has risen to 58 years for males, and 62 years for females. Between 1967
and 1986 Infant Mortality Rate (IMR has fallen sharply from 145 to 71 infant per 1,000 live
births. Even though the IMR in Indonesia has been reduced, it is still the highest among
Asean countries, though according to the World Development Report 1992, the IMR is lower
than the average amongst country of similar income level. The major causes of child death
according to the household survey of 1992 are diarrhoea and acute respiratory infection. In
the first year ARI is the single biggest killer, whilst in the second to fifth years diarrhoea is
the major killer. The immuno preventable diseases are a smaller cause of mortality, but
tetanus still accounts for 10 per cent of infant mortality rate, and measles, diphtheria and
pertusis 9 per cent of the child mortality. The household survey did not find malnutrition to
be a cause of child mortality. However, malnutrition is rarely certified as the cause of death.
Based on a recent meta analysis of studies relating to malnutrition to mortality rates in
children it is possible to calculate that 40 per cent of the infant mortality and 60 per cent of
the child mortality in Indonesia are associated with underlying malnutrition. The average of
malnutrition rate (less than 80% NCHS) at Indonesia’s level of income should be 20 per cent
to the actual 40 per cent. Indonesia is also amongst the worst to the Asean countries for
malnutrition (Philippines only 34 per cent).1

The reduction of infant and child mortality and morbidity during the past ten years has been
possible due to the nationwide expansion of the health infrastructure (Puskesmas, Pustu, and
Posyandu); improved performance of health, nutrition and family planning sectors, and the
progress in general development.

Economic Growth a Means?

T
Presented at 11th Asian Federation of Catholic Medical Associations Congress, November 7, 1996,
RELC International House Singapore.

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Twenty-five years ago Indonesia was one of the poorest countries in the world. Indonesia
started on the path of development from a very low economical base. In 1967 the per capita
income was only US $50, about half of India, Bangla Desh and Nigeria. Since then,
Indonesia has sustained a GDP growth at almost 7 per cent a year, a rate above the average
for developing countries and on a par with those in East Asia. The GNP has grown at a rate
of 4.5 per cent a year over the past 25 year, faster than Thailand or Malaysia. Nevertheless,
disparities remain and per capita income in 1995 were around US$ 800, which classifies
Indonesia to the lowest rank of the middle income countries. Agriculture, fisheries and
forestry sectors were responsible for almost half of the GDP in 1970, with food production
comprising almost one-third. In 1980, mining and quarrying (including oil) was the most
substantial sector of the economy (the era of oil boom). In 1990 manufacturing industries,
tourism and the agricultural sector each made greater contribution than mining and quarrying
to the GDP. Food production now represents only 13 per cent of the GDP. 2

Economic growth and employment are highly independent. While Indonesia’s effort to
sustain its economic growth depends very much on its ability to employ its rapidly expanding
labour force, the 1990 Population Census revealed that there were about 73.9 million people
classified as labour force, and 2.3 million as openly unemployed. Of the total labour force,
women comprised 26.5 million, and the work force 25.5 million. The number of workers in
agriculture, however, has steadily declined since 1970 although the sector still accounted for
almost 50 per cent of employment.

Composition in Percentage of Gross Domestic Products by Industrial Classification

INDUSTRIAL CLASSIFICATION 1970 1980 1990
1 Agriculture (Forestry and Fishery total) 48.6 24.8 21.4
(Farm and food crops only) (29.7) (14.0) (13.2)
2 Mining & quarrying 5.3 25.7 12.9
3 Manufacturing industries 9.0 11.6 20.3
4 Electricity, gas, water supply 0.5 0.5 0.6
5 Construction 3.1 5.6 5.5
6 Trade, hotels, and restaurants 16.6 14.1 17.2
7 Transportation & communication 3.0 4.3 5.6
8 Banking and other financial interim 1.0 1.7 4.2
9 Ownership of dwellings 2.0 2.6 2.5
10 Public administration and defense 5.7 6.9 6.5
11 Services 5.2 2.2 3.3

Investing in Health
Primary Health Care is hardly a new concept. Over the past 30 years, village health
development activities through people’s own efforts have long been existing and rapidly
evolved over the years. Survey undertaken in 1976 revealed that over 200 community health
development activities have been existing in number of Indonesian villages long before it was
adopted as a strategy for improving the health status of the population, especially in the rural
areas in 1977 (National movement on Village Community Health Development), preceding
the Alma-Ata Declaration on Primary Health Care (1978).
To date, Primary Health Care continues to be the main thrust of the national health
development program in Indonesia, to reach the goal for Health for All by the Year 2000. 3
One of the Indonesia’s accomplishments is the extent to which the government, in short
period of 25 years, has extended its health services to virtually every village of the country.
Through a series of Five Year Development Plans starting in 1968, Indonesia has
concentrated on increasing the accessibility of health care for the 190 million people living in
more than 17,000 islands. This has been done by establishing health care centers, supported

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by sub-centers and mobile units, which constitute the first level of health care. In 1984, the
responsibilities of the health centers have further increased through the “Integrated Family
Health Package” program. This consists of maternal and child health, family planning,
nutrition, diarrhoeal disease control and immunization, which is delivered through the
Posyandu (Integrated Health Posts) - around 220,000 are serving the people in 1995. The
Posyandu is a health service unit provided by the community for the community, supported
by the health center staff. Around 1.5 million volunteers associated with PKK are actively
involved and supporting this grassroots health post in each village. 4 A new development in
the last five years is the village maternity center (Polindes), a community-owned facility
where newly placed community mid-wives work together with TBAs (traditional birth
attendants) to provide basic maternity services.

Health Policies & Health Expenditures

The total expenditure on health at 1988 was equivalent to US$ 3.40 and represented 2.56 per
cent of central government expenditure. This figure was low by regional comparison.
Although the bulk of sectoral expenditure (89 per cent) was incurred in the regions, central
government funded 86 per cent of the expenditures. The World Bank study drew three
central conclusions and identified four major health policy problems for the fifth Five Year
Plan (Repelita V). The first conclusion was that the poverty alleviation effects of health
sector interventions had been modest in absolute terms. Over half of health sector financing
went into hospitals, which are used mostly by the better off people. 5 Asian Development
Bank, concurred the findings, in 1985-86, about 34 per cent of public expenditure was used
for hospital services; 22 per cent for health centers and 11 per cents for programs. Private
sector expenditures are mostly for curative care. 6 The second conclusions was that the
changing economic environment associated with the oil crises threatened the speed of health
improvement (not to mention the impact of the World Bank’s structural adjustment). The
third conclusion was that the data base on health resources was limited and needed to be
upgraded. The policy issues raised included: a resource mobilization problem, resulting from
the sector’s heavy fiscal dependence on a low budgetary share of declining levels of central
government expenditure; an equity problem, reflected in strongly inegalitarian role of central
government spending in the increasing rather than reducing inter-regional inequalities in per
capita spending on health; an internal inefficiency problem, reflected in declining real levels
of overall recurrent expenditure, and a rapidly growing imbalance between personnel and
non-personnel expenditures; and an allocation problem manifested in significant reallocation
of spending priorities away from communicable diseases control activities in favour of
curative services. Communicable diseases control -- which is composed of predominantly
preventive services such as immunization, diarrhoeal disease control, tuberculosis and
malaria -- continue to be underfunded.

Health Service Performance

The SUSENAS survey of 1987 showed that over 50 per cent of the poor used some kind of
modern health provider when they are ill, compared to less than 40 per cent in the late
seventies. The expansion of health center has been significant factor in bringing about this
improvement. Between late seventies and eighties, the use of modern treatment by the ill
poor increased from 41 per cent to 52 per cent in rural Java; from 35 per cent to 51 per cent in
rural outer Java. The use of health centers (including sub-centers) increased from 17 to 31
per cent in rural Java, from 11 to 26 per cent in rural outer Java.

These advances have reduced the gap between the poor and the rich in access to modern
medical care. However, there are large differences in the quality of health services used by
the poor and the rich. Only 5 per cent of the poor used high quality-modern providers
(doctors and hospitals) when sick in 1990, compared with 40 per cent of the rich. The

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influence of socio-economic factors is indicated by private expenditures, as 2 per cent among
the 20 per cent poorest in rural areas go to private doctors or hospital compared to 47 per cent
of the richest 10 per cent in urban areas. The health center is utilized in the rural areas by 27
to 32 per cent of people seeking treatment for illnesses. While health centers, especially
health sub-centers, have delivered significant improvements in quantitative access to the
poor, there remains considerable scope for improving the quality of these services in terms of
availability of drugs and trained medical staff, mainly in poor and remote areas. Improved
service quality requires increased local capacity to adapt such services to local conditions.

Financing the Health Services

Per capita spending, is about US$ 12, about the same as the proposed World Bank’ minimum
package. This means that either substantial private resources will have to be used or
additional government resources will be needed; even if all public expenditures on
discretionary services were eliminated. Actually, despite significant investments in primary
level health facilities in the 1980s, only 12 per cent of public spending for health in 1990
went for services consumed by the bottom 20 per cent of house holds, while the top 20 per
cent obtained 29 per cent of the government subsidy. This bias in favour of the wealthy was
mainly a result of the distribution of the government spending for hospital inpatient and
ambulatory care, services that were used more frequently by the rich. The poor have less
access to the modern health care. In 1991, rural households in the top income decile were
three times more likely to live in a village with health center than those in the bottom decile.
Inequity in public spending for health both accounts for and reflects marked inequalities in
access to and utilization of care. To a certain extent it also reflects that consumer demand for
health care services is weak, more fundamentally it also could be explained that the
misallocation of government of resources for health is a reflection of how weak is the
bargaining position of the lowest 40 per cent income.
However, there is a large profit-oriented private health sector, this ranges from super-
speciality “corporate” medical centers and sophisticated hospitals to individual private
practitioners who are found most everywhere. The private health sector is largely curative-
oriented, preventive or promotive health services being almost exclusively carried out by the
government. The private sector accounts for about 67 per cent of health expenditure in the
country.7 Most of this sum goes for doctors’ fees, and drugs. Out-of-pocket payments are
the main source of financing for discretionary care. Except for the very rich, out-of-pocket
financing can not cover expensive care or deal with catastrophic illness.

The Health Services Paradigm

The organization of health services in developing countries is based on a modified version of

the same referral system that evolved in the West. It is based on the ideal that patients are to
be treated as close to their home as possible in the cheapest, smallest, most simply equipped
and most humbly staffed unit that will look after them adequately. 8 It is only when a
particular unit can not care adequately for a patient that he or she is referred higher up the
chain. However, the so called referral hospitals are actually serving as very expensive district
hospital for their local communities who are often the elite who least need the facilities. A
hospital-based system inevitably requires doctors and so the skewed distribution of facilities
is accompanied by the mal-distribution of medical personnel. Doctors especially are
concentrated in towns -- particularly the capital cities -- while few practice in the countryside
where the majority of the population lives. The medical contribution itself has been distorted
in accordance with the demands of the market, as a consequence cure has become
overdeveloped at the expense of care and prevention. Certain conditions susceptible to cure
are highly researched and resourced. This is especially the case with those conditions that
disproportionately affect the wealthy and powerful. The most profitable sectors of the market

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are catered for. The problem of inequalities in the health sector goes hand in hand with other
injustices that permeate every aspect of human activity. The medical industry has created
expectations and artificial needs. It has managed to establish a consumer market for
sophisticated apparatus and complex technology. The market comprises not only the medical
profession but also the public at large. A mistaken belief that sophistication and high cost is
a guarantee of quality has been forced on the people. Society, for its part, lends a greater
status and social prestige to those who practice what can be described as “spectacular”
medicine. The patients themselves demand drugs as the logical, necessary outcome of any
visit to the doctor. People often indulge in irrational self-medication directly or indirectly
suggested by the media or pseudo-scientific notes on a new medical product, apparently
addressed to the medical profession, or “solidarity campaigns,” to obtain a given make of
drug for a patient with slim resources. Furthermore, the medical training as a result of
“scientism” and professional elitism, loss their humane approach. The physician does not
view the patient as a total human being but, on the contrary, as the object of his examination
and medical praxis.9

Ethical Issues
The ethical issue in the provision of health services is clearly crucial. We have observed that
doctors have not only appropriated health services as their commodity but also determined its
value. They have ensured the profession’s near monopoly of knowledge about health, which
prevents people learning about and acting confidently on their health problem. This is further
entrenched by medical business interest. The examples of baby-foods business and the drugs
and medical equipment industries show how the transfer of largely inappropriate technology
aggravates the diversion of resources and the distortion of services in the interest of only a
few.
Man’s health is too precious to be squandered on accidentals. It demands a radical review to
the sophisticated specialization, a turning point to the basics of health: the wholeness of
human, body and spirit, and the whole of mankind. Wholeness on earth is: man in harmony
with others, with himself and nature; such harmony needs the injection of some very potent
medicines, which fortunately are not mass-produced by the drug companies or multinationals,
not sold for money over the counter, not needing expensive advertising, not causing ill side
effects but going straight to the root of disharmony. These medicines are non-violent truth
and justice-love, obtained gratis but not without continuos effort and only when there is a
greater longing for these than for anything else whatever. Only these medicines will bring
about a new mankind, a new earth, without tears or suffering, or cruelty of man towards man.
Why should man take profit of other’s suffering, they who are in the process of agony of pain
and dying?
We should build a new world, broke the spell of the alliance of medical professionals the
medical business, move from health services orientation (medical delivery: system delivery
by the professionals, where the professionals will take care, people remains passive) to health
care orientation. The new health care should become the effort and business of everybody,
business of the people. The community will take care and make a deal for their own health
(health care should be viewed as a verb). The professionals will become the facilitator, it's
the people themselves who should take care of their own health.

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1
Unicef (1993), The State of World’s Children 1994. New York: United Nations Children’s Funds.
2
World Bank (1992), Indonesia: Growth, Infrastructure and Human Resources, 1991. Washington DC. The World Bank.
3
Ministry of Health (1990), Primary Health Care in Indonesia. Jakarta: Ministry of Health Republic of Indonesia.
4
This remarkable accomplishment of PKK has been internationally acknowledged in 1988 when PKK received the
Sasakawa Prize from WHO and the Maurice Pate Award from Unicef
5
World Bank (1991). Indonesia: Health Planning and Budgeting. Washington DC: The World Bank.
6
ADB (1991). Health, Population and Development in Asia and the Pacific. Manila: Asian Development Bank.
7
World Bank (1991), Indonesia Health Planning and Budgetting. Washington DC: The World Bank.
8
M. King, Medical Care in Developing Countries. London: Oxford University Press
9
David Sanders (1992), Richard Carver. The Struggle for Health. Medicine and the Politics of Underdevelopment.
London: The MacMillan Press Ltd.