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Polio outbreak shows holes in Indonesia's healthcare

A polio outbreak that spread rapidly through Indonesia after a decade-long absence, crippling hundreds of children, has exposed weaknesses in the sprawling archipelago's long-neglected health care system, experts said yesterday.

Hampered by chronic funding shortages and chaotic decentralization efforts, local health clinics in the poorest parts of the country have been forced to scale back their operations, limiting the amount of time and money they spend on community outreach, health education and routine immunization programs.

As a result, experts say about 239 children under 5 have been infected by polio since March and cases of measles have increased tenfold since 2000.

Indonesia also saw its worst-ever dengue fever outbreak last year and there are fears bird flu, which has already killed six people nationwide, could mutate into a form that spreads easily among humans -- possibly triggering a global pandemic.

"The context for these events is a primary health care system that has suffered from a decrease in resources and is struggling to manage the expectations placed on it by the newly decentralized health systems," UNICEF's David Hipgrave said.

"What we're seeing is major inconsistencies between the rich and poor provinces," he said.

It was not always this way.

During the 32-year dictatorship of Suharto, the health system, like much of government, was highly centralized and services reached all the way down to the village level. Polio was eradicated in 1995 and key indicators like child malnutrition and poverty rates fell.

A key component was volunteer outreach efforts like the Family Education Program, where the wives of government officials would make the rounds to talk to mothers about nutrition and sanitation, while reminding them about national immunization days.

That program, like almost all others linked to Suharto, was abandoned after his ouster in 1998.

A radical decentralization program that was introduced in 2001 has added to the country's health care woes.

Almost overnight, the government handed control of public services to regional and local authorities. But their roles were often unclear, experts say, funding was inadequate and priorities left to the whims of inexperienced governments, mayors and village heads. The result, WHO and Ministry of Health officials say, is that immunization rates dropped in certain poor communities and services -- like monitoring the weight of babies or providing poor families with mosquito nets -- all but disappeared.

"We'd provide the needles and vaccines for immunization but some districts wouldn't have enough money for operations," said Jane Soepardi, who oversees immunizations at the Ministry of Health. "They could reach nearby areas but left out remote areas. So you'd find mothers who don't even know about immunization."

Money, too, remains a problem.

According to latest figures from the UN, Indonesia's public health spending in 2002 accounted for 1.2 percent of gross domestic product -- among the lowest in Asia. In contrast, impoverished East Timor spent 6.2 percent, Thailand 3.1 percent and Malaysia 2 percent.

And so when polio re-emerged in Indonesia -- likely by way of a migrant from the Middle East or Africa -- it took hold in overly poor, rural communities where entire villages were vulnerable having missed out on immunizations. "It was able to paralyze many, many kids," said Arun Thapa, the WHO Southeast Asia regional adviser.
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