JAKARTA, 6 August 2009 (IRIN) - Indonesia's health system is failing to provide even the most basic care to vast swathes of the population, say specialists.
Many who cannot afford doctors' fees often receive no treatment at all, while the wealthy fly abroad for a check-up.
The system is plagued by under-funding, decentralization, lack of qualified staff, rising medical costs and outdated medical equipment, say insiders.
"The health system desperately needs improvement," said Kartono Mohammad, a senior doctor and former chairman of the Indonesian Medical Association (IDI), adding that it is hard to even speak of a healthcare system since there is no regulation or quality control.
"There are no laws that protect the patient," he said.
In June, the system's failures were the focus of nationwide debate when a patient was sued by a hospital after her complaints about poor treatment were published on the internet.
In 2008, Prita Mulyasari checked into the Omni International Hospital in Tangerang, a satellite city of the capital Jakarta, where she was misdiagnosed with dengue fever and given injections that made her hands and neck swell and made breathing difficult. Later, it emerged that the mother-of-two had mumps.
Omni sued Mulyasari for damaging its reputation, but after an outpouring of public support, including from parliament, the lawsuit was dropped.
"Doctors are very protective of each other. It is a conspiracy of silence," says Mohammad. "Doctors here don't want to testify against their own colleagues."
And though it is unclear how many patients are misdiagnosed each year, many disputes are believed to be settled under the table.
Those who have a choice fly to Singapore, Australia, Malaysia and even the United States or Europe in search of better care.
According to Fahmi Idris, chairman of the IDI, at least one million Indonesians are estimated to seek medical care oversees each year.
Access and cost
But for most of Indonesia's more than 250 million inhabitants, even the lowest quality healthcare is often inaccessible.
Access to health facilities across Indonesia's 6,000 inhabited islands varies greatly.
While cities usually offer a range of services for most medical problems, in remote areas such as the easternmost province of Papua it can take several days to reach a doctor.
Some islands or remote mountain villages can be inaccessible for months at a time during the monsoon season.
In addition, many low-income earners or the unemployed avoid going to a doctor, explained Ajriani Munthe Salak, from the Legal Aid Institute for Health (LBH). "They stay at home, hoping the illness will disappear. They are afraid of bills and the bureaucratic system."
According to the World Bank, about 100 million Indonesians live on less than US$2 a day.
Critics say a new health insurance scheme for the poor, Jamkesmas, launched by the government in early 2008 is too complicated, requiring a patient to provide documentation on income, identity, hospital registration, family records and a doctor's referral notice.
The Health Ministry has spent seven years drafting an ambitious new universal healthcare bill, but it has faced delays, budget problems and technical hurdles, such as a lack of a common definition for malpractice, said Mariani Akib Baramuli, a member of parliament.
"The country still faces significant challenges in developing and implementing effective and sustainable health-financing reform," according to Joachim von Amsberg, World Bank country director for Indonesia.
Lawmakers hope the bill will pass during the current term that expires in October, but there is a huge backlog of other work.
Meanwhile, as politicians debate the bill, the problem of affordable care is becoming more entrenched.
Indonesian hospitals are even known to keep patients "hostage" until family members can settle their bills.
Since 1999, Salak's organisation has handled almost 500 cases, mostly in Jakarta.
"But that is just the tip of the iceberg. There are probably millions of people who don't have real access to healthcare," she said.
With the vast distances involved, it is impossible reach everyone, she said. "We get calls from Papua, but we don't have money to fly over there, it is just too costly," she added.