Addressing inequalities on the road to ‘health for all’ in Indonesia
Almost every day a white van painted with brightly-coloured hibiscus flowers sets out from the ‘puskesmas’ or community health centre in Senen, a sub-district of Jakarta, Indonesia. The van looks ordinary from the outside, but inside it is actually a medical clinic, equipped with essential supplies and staffed with health workers ready to offer health services to local populations. Indonesia has taken significant steps towards improving access to health care in recent years, including the introduction of a national health coverage scheme. However, a WHO report, jointly published with the Indonesian Ministry of Health, shows that inequalities persist and many people, such as those in urban neighborhoods like Senen, remain at a disadvantage. Peoples’ age, sex, economic status, educational level, employment or place of residence can all impact their health status and access to services.
When the government found that only 30% of local residents in Senen were using the community health centre, it launched a mobile health initiative called Hibiscus in an effort to increase access to care. Launched in July this year, Hibiscus aims to deliver quality services, such as antenatal care, HIV testing, mammograms, immunization, blood pressure screenings and health education, directly to the more than 120 000 local residents.
“The health problems we see in the puskesmas indicate that community members do not prioritize preventive health measures,” says Ms Widyaningsih (Wida), a midwife and field coordinator for Hibiscus. “We need to be proactive in reaching and educating them. They may not be able to come to the health centre, so we go to them.”
Addressing health inequalities throughout Indonesia
In order to reduce health inequalities and identify priority areas for action to move towards universal health coverage, governments first need to understand the magnitude and scope of inequality in their countries. From April 2016 to October 2017, the Indonesian Ministry of Health, WHO, and a network of stakeholders assessed country-wide health inequalities in 11 areas, such as maternal and child health, immunization coverage and availability of health facilities.
“While some Indonesians have easy access to health services and prevention initiatives, others are at a disadvantage,” says Dr Siswanto, Head of the Indonesia Agency for Health Research and Development, Indonesian Ministry of Health. “Monitoring inequalities is a fundamental part of improving the health of those who are disadvantaged, and ensuring the country fulfils its commitment of ‘no one left behind.’"
A key output of the monitoring work is a new report called State of health inequality: Indonesia, the first WHO report to provide a comprehensive assessment of health inequalities in a Member State. The report summarizes data from more than 50 health indicators and disaggregates it by dimensions of inequality, such as household economic status, education level, place of residence, age or sex.
The report finds that the state of health and access to health services varies throughout Indonesia and identifies a number of areas where action needs to be taken. These include, amongst others: improving exclusive breastfeeding and childhood nutrition; increasing equity in antenatal care coverage and births attended by skilled health personnel; reducing high rates of smoking among males; providing mental health treatment and services across income levels; and reducing inequalities in access to improved water and sanitation. In addition, the availability of health personnel, especially dentists and midwives, is insufficient in many of the country’s health centres.
Now the country is using these findings to work across sectors to develop specific policy recommendations and programmes, such as the mobile health initiative in Senen, to tackle the inequalities that have been identified.
Indonesia: a case study for other countries
Understanding the state of health inequality in countries is a key step in achieving the Sustainable Development Goals (SDGs). Among the 17 goals, SDG 3 focuses on ensuring healthy lives for all people at all ages, while SDG 10 calls for a reduction in inequality within and between countries.
“The capacity-building process for health inequality monitoring in Indonesia and the development of this report can be used as an example for other countries on how to integrate health inequality monitoring into their national health information systems,” says Ahmad Reza Hosseinpoor, who leads WHO’s work on health equity monitoring.
WHO has developed a package of resources and tools to support Member States to monitor health inequality. This includes the Health Equity Assessment Toolkit, a software application that enables countries to assess inequalities using the built-in WHO Health Equity Monitor database or using their own data; a step-by-step manual on how countries can embed health inequality monitoring in their health information systems; and the statistical codes needed to analyze household survey data to reveal where inequalities lie.