We would like to begin this chapter by recalling an important message related to maternal health as quoted by the United Nations Secretary-General during the High-Level Forum on Accelerating Millennium Development Goals (MDGs-5) on 24 September 2013. He quoted a statement from Professor Mahmoud Fathalla, an international campaigner for safe motherhood and a founder of the Safe Motherhood Initiative. The key message of this quote is that no one should be left behind in health matters, including women and mothers. Our main question is then ‘What about the progress of maternal health in Indonesia today?’.

This chapter attempts to answer that question by assessing how maternal health in Indonesia has changed over time and its potential trends in the future.

Maternal health commonly refers to the health of women during motherhood, starting from pregnancy, through to childbirth and the postnatal period. These are the most important stages during the parenthood experience. In actuality, maternal health starts when a woman enters adolescence, long before her motherhood period, and remains throughout a woman’s reproductive life and beyond menopause. Moreover, maternal health does not stand alone. It is influenced by many factors, including women’s living conditions, their early-age health status, as well as support from their family and partner. Therefore, maternal health–related issues should be a concern of societies at every level: micro (individual and family), meso (community) and macro (national and global).

At the macro level, maternal health has been a global priority as indicated in the United Nations MDGs (2000–2015) and subsequent Sustainable Development Goals (SDGs). Before then, the Safe Motherhood Initiative was introduced in 1987 at the Safe Motherhood Conference in Nairobi, Kenya (Sai and Measham 1992). Maternal health was covered in the fifth MDG, specifically a goal to ‘reduce maternal mortality by 75 percent by 2015’. Most recently, maternal health is covered in the third goal—ensure healthy lives and wellbeing for all—of the seventeen SDGs.

Since the fall of Suharto’s New Order in 1998, Indonesia’s political elite has made significant changes to Indonesian law affording greater recognition to the right to health (R2H). Between 1999 and 2002, the People’s Consultative Assembly amended the 1945 constitution to introduce new rights to ‘obtain health services’, ‘have a good and healthy living environment’, have access to social security and ‘develop oneself through the fulfilment of basic needs’. In accordance with these new rights, it also imposed a new obligation on the state to provide ‘health service facilities’ and declared that the state would develop a social security system for all people. In the midst of and following these amendments, the national parliament (DPR) enacted a number of laws that reaffirmed—and in some cases expanded upon—these rights and obligations (Rosser 2017: 6–7). These included Law No. 36/2009 on Health which stipulates, among other things, that the government has obligations to provide health services, ensure resources for the health sector, and try to realise the highest possible standard of health (Pūras 2018: 5).

These legal commitments have been accompanied by health policies and programs that have sought to promote R2H in various ways. As the United Nations’ (UN) special rapporteur on R2H, Dainius Pūras, noted in a 2018 report, the Indonesian government has ‘made considerable progress with regard to the realization of the right to health, particularly by expanding universal health coverage’. It has also promoted R2H by increasing health expenditure as a share of the government budget. However, many commentators have suggested that the government has stymied progress vis-à-vis R2H by failing to address discrimination and inequality in access to health services, improve the quality of health services, address the growing burden of non-communicable diseases, enhance access to clean water and sanitation, control addictive and harmful substances, ensure healthy environmental conditions, and— particularly since the onset of the COVID-19 pandemic in 2020—ensure the country is protected from emerging infectious diseases.

The purpose of this chapter is to shed light on the reasons for this outcome and the likely future trajectory of health policy in Indonesia by examining the political dynamics that have shaped health policy in post–New Order Indonesia.

Mental illness has historically dwelt in the shadows of global health and international development. Only recently has it moved from the margins to become a central priority in both research and policy. Mental disorders account for a significant proportion of the worldwide non‑fatal and overall disease burden, which includes death and disability. By 2030 the annual cost to the global economy is estimated to be as high as US$6 trillion (Ferrari et al. 2022; Marquez and Saxena 2016). Large middle- and low-income countries like Indonesia continue to confront a plethora of challenges in delivering adequate mental health care. This chapter is a brief introduction to how, and how well, Indonesia has met, and is currently meeting, that challenge. Specifically, using two vignettes (which are composite portraits based on actual experience), we clarify the current state of knowledge on mental health needs in association with existing infrastructure, including a preliminary sketch of the current legislative framework. We touch on the impact of the COVID-19 pandemic and conclude with a firm call to action. Without urgent reform, Indonesia’s mental health system will continue to risk failing tens of millions of Indonesians with mental health issues.

Please note, although the following vignettes are not actual cases, they are composites of real people either met directly by the authors or appearing in recent Indonesian media. We caution readers that the following chapter contains confronting themes, and we urge our readership, if you experience any subsequent distress, to contact your local mental health care provider. Some links are provided at the end of this chapter. The other people included in the vignettes, together with their current roles in Indonesian mental health care and the institutions mentioned, are real and can also be contacted for mental health assistance.

Ahmed

Ahmed is 43. He farms a small plot of land in Kebumen, Central Java. He lives in a separate household to his wife and two children, who are currently attending junior secondary school. This separation is a result, he tells us, of ‘his episodes’. They start the same time every year, in July, his birth month.

Law No. 9/1960 on Basic Health declared that all Indonesians had the right to be physically, mentally and spiritually healthy, while Article 8 declared the government responsible for ensuring that all Indonesians had access to health services. Four decades then passed before President Megawati Sukarnoputri, in her last act as head of state, signed legislation supporting universal health insurance. Although her successor did little to advance the health care agenda nationally, initiatives at the district level established that the provision of ‘free’ health care played very well at the ballot box (Rosser et al. 2011). One of the beneficiaries was Joko Widodo. As governor of Jakarta, he enthusiastically rebranded a city health insurance scheme inherited from his predecessor, taking credit for the popular Jakarta Health Card (Kartu Jakarta Sehat, KJS). When Widodo ran for president in 2012 under the banner of Sukarnoputri’s Indonesian Democratic Party of Struggle (Partai Demokrasi Indonesia-Perjuangan, PDI-P), he promised to extend the scheme nationwide should he win, thus cementing universal health coverage as a PDI-P legacy (Pisani et al. 2017).

When Indonesia’s mandatory, universal, single-payer insurance system (Jaminan Kesehatan Nasional, JKN) was formally launched in 2014, it was thus freighted with political importance. Many vested interests were involved in preparing for that launch, including those of the powerful state insurance firms which preceded JKN’s implementer, Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS-K). The details of the scheme’s implementation were thus hammered out largely on the anvil of political expedience rather than through careful technical calculus (Aspinall 2014). The result was a generous insurance program that could not cover its costs. For Rp 25,500 a month (covered by the government for the poor and near-poor), all Indonesians had a right to full coverage for a wide range of care, including sophisticated procedures such as hip replacements. Many hospitals provided private rooms for patients paying ‘first class’ premiums of Rp 80,000 per month. The price of diagnostic tests and all 300-odd medicines on the national essential medicines list was included at all levels, with no co-payments required (Mboi 2015).

Unsurprisingly, the scheme ran at a deficit from its inception until premiums rose in 2020.

The global burden of dengue

Dengue, a systemic viral infection transmitted from person to person by the Aedes mosquitoes, presents a persistent and escalating problem in many parts of the world. Globally, the dengue infection has been predicted to reach 100 million cases in more than 110 countries, and the incidence rate, death and disability-adjusted life years (DALYs) lost have all increased during the past two decades (Zeng et al. 2021). Although dengue transmission occurs mainly in tropical regions, it has been highest in Asia (Simmons et al. 2012), where more than 75% of the world’s population infected with dengue live. Eight countries in the Southeast Asian region are classified as hyperendemic areas, including Indonesia (Murray et al. 2013). Recent studies indicate that dengue has the highest DALYs lost in Southeast Asia compared to other neglected tropical diseases such as schistosomiasis, leprosy, trachoma, hookworm and ascariasis (Shepard et al. 2013).

In addition to the morbidity and mortality, evidence shows that dengue significantly impacts the economic burden. A systematic review estimated the global cost of dengue illness was US$8.89 billion annually, consisting of 46% non-fatal cases admitted to hospital, 33.6% non-fatal ambulatory patients, 8.5% non-fatal non-medical cases and 11.9% fatal cases (Shepard et al. 2016). Asian countries experienced productivity losses of US$6.7–$1,445.9 for inpatients and US$3.8–$1,332 for outpatients per dengue episode. The cost of productivity losses associated with fatal dengue episodes in Asia is around US$12,035–$1,453,237 (Hung et al. 2020).

Dengue also affects quality of life, mainly psychological and social functions. From the quality of life perspective, dengue infection causes discomfort and nervousness. During the acute phase of the disease, the physical symptoms of dengue have several effects on personal mobility and social activities that persist into the late-acute stage of the disease. The most common symptoms sometimes last beyond the period of fever. These disorders often worsen, especially in those who do not seek treatment (Elson et al. 2020).

Environmental conditions and community behaviour can also affect the development of dengue, which affects the prevalence of dengue yearlong. All age groups are vulnerable to this disease.

Ensuring timely access to quality health services is a basic human right. All people, regardless of their social location, race, economic circumstances, cultural background, sexual orientation or gender, should have equitable access to essential health services (WHO 2015a). From a government perspective, safeguarding responsive and appropriate access to essential health services is one of the key objectives of health systems (WHO 2000, 2007). In most instances, people interact with health systems as patients who require expert opinion and treatments about their health concerns. People’s access to such services is influenced by at least three key dimensions of access: availability, affordability and acceptability (WHO 2015b). Availability refers to the physical presence and reach of the health facilities, workforce and services, whereas affordability refers to the ability of patients or communities more broadly to pay for the health services (ibid.). Acceptability deals with the sociocultural components of health services to ensure the delivery of quality, appropriate, timely and responsive health services (ibid.).

Inequitable access to health care is a recurring health system challenge in Indonesia, given the country’s demographic, geographic, economic, sociocultural and political characteristics. The emergence of the COVID‑19 pandemic in March 2020 has amplified existing access and health inequities within communities and between different population groups across Indonesia. As observed in other countries, the pandemic has led to disproportionate consequences, both mortality and morbidity, among socially and economically disadvantaged populations (Bambra et al. 2020; Dorn et al. 2020). The inequitable access to health care during the pandemic is exacerbated further by the interconnected systemic risks such as inequities in wealth, lack of social protection, unfair employment structure, food insecurity, and maldistribution of health infrastructure and resources (Bambra et al. 2020). For instance, existing government priorities and decisions embedded in sociopolitical infrastructure and economic forces have allowed the pandemic to discriminate against marginalised groups.

Ensuring access to affordable and comprehensive health services, therefore, requires interventions beyond the individual level to include these interrelated structural and political determinants of health. Designing new institutions and mechanisms to address the structural causes of access inequities requires critical examination of how problems and their solutions are framed.

It is a matter of great pride and frequent comment that Indonesia is the fourth most populous nation and the third most populous democracy in the world. This factoid, much beloved by journalists and schoolchildren, opens the door to bickering among other nations’ politicians, but it lays out two vital issues: Indonesia as a nation and Indonesia as a democracy. Both point to the importance of reliable population estimates for the workings of health, education and electoral systems. Demography provides tools to measure population dynamics. The demos in both demography and democracy refers to people—the citizens of a nation. For Indonesia, the demographic story goes back to the early nineteenth century when Sir Thomas Stamford Raffles’ short-lived British administration of Java included a census count. In the subsequent hundred years a restored Dutch administration, riding the trends of modernisation, industrialisation and enlightenment, adopted many innovations to improve the counts of the rapidly growing population, initially in Java but inexorably spreading through the archipelago.

In the historical effort to understand disease and death, doctors and governments used these census results to measure and analyse human experiences of health challenges. At the core of recording disease and death is the importance of understanding population size, characteristics and trends. Public health was growing as a discipline in European medical schools, and administrators were learning to use rates and ratios to evaluate the impact of their actions. Numerators were counts of the blows to the individuals suffering from infectious diseases, nutritional insults or violent attacks. But they gained rational explication when denominators turned them from simple reports into forms of logical analysis. More often than not these denominators were measures of the population including age and sex structure. In the face of pandemics and hunger, the government fostered ever more demographically informed health data throughout the late nineteenth and twentieth centuries.

In this chapter, the history of censuses and health statistics is followed through to the innovations of the reform-era political leaders of the twenty-first century. Two themes stand out. First, following five decades of progress in building statistical strengths in government, bureaucrats have recently backtracked in important ways.

Canvassing health transition in Indonesia

In 1950, about 189 out of 1,000 babies born alive in Indonesia would not have survived past their first birthday. Such a high infant mortality rate overwhelmingly contributed to the population’s low life expectancy for the newly independent nation at the time. Assuming the prevailing age-specific patterns of deaths, for the same year, life expectancy at birth was estimated to be 39.4 years. By 2022, Indonesia’s infant mortality rate has fallen to 17.7 deaths per 1,000 live births, and life expectancy at birth has risen to 68.25 years.

If we go by these trends in infant mortality rate and life expectancy, the future trajectory for the general health and wellbeing of the average Indonesian is looking rosy. After all, the two indicators are meant to capture the underlying factors and contexts that shape the health of the nation. At the outset, gains in life expectancy—and correspondingly, the reduction in infant mortality rate—reflect a narrative of improvements in income per capita, living conditions, nutritional intake and education, as well as access to and quality of health care in recent decades. But focusing only on these two broad indicators may also obfuscate the complex history of Indonesia’s health transition, where wins are often coupled with setbacks, and where health-related innovations regularly intersect with novel conundrums.

What do we mean by health transition, and why do we often hear that Indonesia’s health transition has been marked by increasing complexity over time? The term health transition is often used interchangeably with epidemiologic transition. The latter was first conceptualised by Abdel Omran in 1971 to refer to the long-term shifts in the mix of diseases as people live longer through the course of economic development and social change. More specifically, Omran coined the term epidemiologic transition to describe ‘the complex change in patterns of health and disease and on the interactions between these patterns and their demographic, economic and sociological determinants and consequences’ (1971: 510). In the first iteration of the epidemiologic transition theory, Omran proposed that there are three distinct stages in the transition: the age of pestilence and famine, the age of receding pandemics, and the age of degenerative and man-made diseases.

The increase in government spending associated with the COVID‑19 pandemic between 2020 and 2021 has reduced the Indonesian government’s fiscal capacity for financing welfare programs, including financing a much-needed health sector transformation, for at least the next four years. In the past two decades, the health sector in Indonesia has been affected by a number of major reforms. These include multisectoral reforms outside the health sector, such as changes in public service organisation following the 1999 decentralisation, to reforms that focus specifically on the health sector, such as the introduction of universal health care in 2014 (Mahendradhata et al. 2017). Following these health system changes, new and remaining challenges such as the financing of universal health care and the changing landscape of disease have been identified, and the need for further reforms acknowledged. These challenges and the gaps in the health system exposed by the pandemic have prompted the national government to commit to a health sector transformation that involves reorienting and restructuring the health system through a series of reforms (Ministry of Health Regulation No. 13/2022 about the Strategic Plan of the Ministry of Health 2020–2024).

Drawing upon the government’s projected fiscal space and data canvassing the health sector conditions before the pandemic, this chapter examines the post-pandemic trajectory of health reforms in the country. I outline lessons learnt during the past two years of the pandemic, and consider pre-existing (i.e. pre-COVID-19) health sector challenges, to assess the financing of the health sector transformation. This chapter demonstrates that the costs associated with financing the reforms are huge, and that the pandemic has negatively affected the government’s capacity to finance such spending. Although the narrowing fiscal space due to COVID-19 has put pressure on public funding, the government is likely to prioritise the development of the health sector through various policies. One likely policy is the use of private financing. Better-off members of society would pay more for their health services through pre-paid schemes, while the limited public funding would be allocated to preventive and promotive public health services. In the future, a health sector funded by both public and private sources should be examined.