Politics and Healthcare

Political change is a double-edged sword for healthcare. Some of the big challenges affecting
the sector, as well as some of the sources of dynamism, arise from decentralisation. Since the
fall of Suhartos authoritarian government in 1998, political and fiscal decentralisation has
produced a complex set of challenges for health programming. On the one hand,
decentralisation of health services creates opportunities for visionary local leaders to develop
targeted healthcare programs for their electorates. But it has also made the system vulnerable
to local power politics and unchecked corruption, and perpetuates the divide between rich and
poor regions.

Inaccurate or late diagnoses, inadequate facilities and treatment, costs that are beyond reach:
all of this is part of the daily experience of healthcare for millions of Indonesians. As a result,
every year, countless citizens of the country die from conditions that should have been
prevented or cured. This special edition of Inside Indonesia looks at the problems that beset
healthcare, and searches for signs of hope amidst the political changes that are remaking
Indonesia as a more democratic society.

Our articles explore the social and political forces that have generated such uneven outcomes
for Indonesias health sector during the nations transition to democracy. While Indonesias
economy is growing fast, the government continues to spend less on healthcare per capita
than its neighbours with a similar economic profile; key health indicators like the ratio of
health providers to population are also lagging. All the articles in this edition address the
complex question of what is holding Indonesia back? What motivates elected officials,
health professionals and consumers to make the decisions they make? And what are the
outcomes for Indonesias most vulnerable communities?

The lead article by Elisabeth Pisani, an epidemiologist and long-time observer of Indonesias
health system, describes the varieties of dysfunction that plague the sector: from absenteeism
in health clinics to the breakdown in critical information sharing between districts and the
centre. Pisani blames skewed political incentives for much of this dysfunction. For example,
elected local officials invest in expensive and conspicuous health infrastructure to boost their
political profiles, rather than addressing more complex healthcare needs. But the democratic
transition has also brought positive change. Pisani points to how direct elections put pressure
on local politicians to answer their constituents demands for better health services. As
peoples expectations rise, she hopes, so too will the quality of care.

Edward Aspinall and Eve Warburton analyse the relationship between electoral politics and
the rise of local healthcare schemes. Populist campaigns that promise free healthcare are now
commonplace in district and provincial elections around the country. This trend reveals how
local politicians are engaging with the demands of their electorates in new and progressive
ways. Even if the costs of healthcare are coming down for many people, however, this does
not always mean that quality is improving.

Reproductive health activist, Inna Hudaya, offers insight into the plight of young women
experiencing unplanned pregnancies. She explains how social stigma and discriminatory laws
force women into the dangerous, traumatising and sometimes fatal world of illicit abortion. In
this case, too, politics plays a role, but it is a politics of social conservatism that denies
women control over their bodies. Thankfully, new organisations run by people like Inna are
struggling to change discriminatory laws and to help women find the information and
services they need.

Andrew Rosser provides an analysis of the political war between anti-tobacco activists and
Indonesias powerful tobacco lobby. Health laws are slowly changing in response to a strong
campaign by the anti-smoking movement, but the tobacco lobby has money and,
consequently, friends in high places. It is launching a counter-attack, but a growing number
of Indonesians are becoming aware of the huge toll that smoking exacts every year.

Medical anthropologists Byron Good, Mary-Jo DelVecchio Good, and Jesse Hession
Grayman present a detailed account of one of the most neglected areas of healthcare in the
country: mental health services. Though the situation is in many respects terrible, their
experience working on mental health programming in post-conflict and post-disaster Aceh
gives hope that a new model of care is emerging.

Still in Aceh, Catherine Smith explores the world of medical tourism in her piece about
Acehnese who travel abroad to Malaysia in search of better quality care. The trend not only
points to the limitations of local health services, but also reveals how many Acehnese deeply
distrust the Indonesian medical system as a whole.

Finally, in a close examination of the problems posed for disease control by political
decentralisation, Scott Naysmith looks at the challenges of managing the spread of avian
influenza in a context of fragmented governance. Indonesia cannot return to the days of top-
down, authoritarian disease eradication, as was practised during the smallpox eradication
program under Suharto. Even so, his analysis shows there is an urgent need for more
cooperation between districts, provincial administrations and the central government.

Politics is reshaping healthcare in Indonesia. Often it seems that most of the changes are for
the worse. Each of our stories, however, provides at least some signs of hope, if only by
pointing to how members of the public, health workers and activists are making new
demands for better healthcare in the context of democratic politics. One thing is clear:
Indonesians deserve much better.