As access to education improved throughout the archipelago, use of modern forms of health care also increased. Statistics show a correlation between the rise of education levels and the increased use of hospitals, physicians, and other health resources. Indeed, in the 1970s and 1980s, health in Indonesia showed overall improvement. Life expectancy for men was 58.4 years and for women 62.0 years in 1990, up 7.3 years and 7.6 years, respectively, since 1980. By the 2000-04 period, life expectancy was projected by the World Bank to reach 66.5 for men and 69.7 for women. However, the distribution of those improvements, as well as the resources for health maintenance and improvement, were unequal. Whereas infant mortality fell from an average of 105 per 1,000 live births in the 1980 to 75.2 per 1,000 in 1990, according to the World Bank, and was expected to decrease to 55 per 1,000 by 1994, these rates varied dramatically depending on location. The poor, rural, and uneducated classes generally suffered much higher mortality rates than their more educated counterparts.
The number of health care personnel gradually increased in the 1980s. By the end of the decade there were more than 23,000 physicians; 76,000 midwives; and nearly 70,000 medical assistants, paramedics, and other health care workers. The ratio of health care personnel per capita compared poorly with the other ASEAN nations except Brunei.
Improvements in the health of Indonesians have been realized largely without the benefit of enhanced hospital services. Indonesia's ratio of hospital beds of 0.06 per 1,000 population in the late 1980s was the lowest among ASEAN nations--which ranged from a high of 5 per 1,000 for Singapore to the second lowest, 1.4 per 1,000 for Thailand. Hospital beds were unequally distributed throughout Indonesia, ranging from a low of 0.18 beds per 1,000 in Lampung Province to 1.24 per 1,000 in Jakarta. In addition, the better equipped urban hospitals tended to have more physicians and higher central government spending per bed than did hospitals in the rural areas.
Community and preventative health programs formed another component of Indonesia's health system. Community health services were organized in a three-tier system with community health centers (Puskesmas) at the top. Usually staffed by a physician, these centers provided maternal and child health care, general outpatient curative and preventative health care services, pre- and postnatal care, immunization, and communicable disease control programs. Specialized clinic services were periodically available at some of the larger clinics.
Second-level community health centers included health subcenters. These health centers consisted of small clinics and maternal and child health centers, staffed with between one and three nurses and visited weekly or monthly by a physician. In the early 1990s, the Department of Health planned to have three to four subcenters per health center, depending on the region. The third level of community health services were village-level integrated service posts. These posts were not permanently staffed facilities, but were monthly clinics on borrowed premises, in which a visiting team from the regional health center reinforced local health volunteers.
Although the community health situation was improving slightly- -the number of health centers increased from 3,735 in 1974 to 5,174 in 1986, and the number of health subcenters reached 12,568--the provision of community services remained low by the standards of developing countries. China, for instance, had sixty-three health centers per 1 million population, while Indonesia had only thirtytwo per 1 million in 1986. In particular, fiscal year (FY) 1987 saw a dramatic reduction in government spending for communicable disease control. Thus, vaccines, drugs, insecticides, and antimalarial spraying programs were dramatically cut back.
The distribution of Indonesian health care workers was also highly uneven. To alleviate the problem of physician maldistribution, the government required two to five years of public service by all medical school graduates, public and private. In order to be admitted for specialist training, physicians first had to complete this service. Only two years of public service were required for those physicians working in remote areas such as Nusa Tenggara Timur, Sulawesi Tenggara, Kalimantan Timur, Maluku, or Irian Jaya provinces, whereas three to five years of service were required for a posting in Java, Bali, or Sumatra. Despite such incentives, it was difficult to attract medical school graduates to these remote, understaffed regions, particularly without additional cash incentives.
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