Hera Diani, Jakarta/Serang/Chiang Mai – For nearly three decades, Slamet Rahayu, 58, has worked in the fight against tuberculosis by finding and monitoring TB patients in neighborhoods in Central and East Jakarta.
Slamet, who is employed at a government health clinic, says despite his efforts, the disease is still prevalent in the area. "There are often cases where whole families are infected," he said.
Also handling the clinic's administration and campaign activities, Slamet works six days a week and earns Rp 900,000 (around US$100) a month with allowances, an amount he says is barely enough to cover expenses for his six children.
He had thought about looking for other work but found it was difficult as an elementary school graduate: "I'm grateful just to just have a job," he said.
Slamet's colleague, laboratory technician Kristiana Tobing, said the pair's basic salaries were lower than city's minimum wage of Rp 700,000.
Unlike Slamet, Kristiana graduated from an X-ray technicians' academy in North Sumatra, but was later trained to work at the clinic's lab. "Maybe the clinic couldn't afford to hire a (proper) lab technician," said the 32-year-old, who moonlights as an X-Ray technician at Mediros Hospital in East Jakarta.
While the two work hard, they say the number of people they are expected to serve means they can make little impact on the spread of TB in the area.
Experts say Slamet and Kristiana's circumstances illustrate the poor state of the country's health services. Underfunding and a shortage of qualified human resources means Indonesians have far less health workers serving them than in neighboring countries.
There are only around 50,000 doctors in the country, or only 22 per 100,000 people, compared to a world average of 42. The 52 medical schools in the country produce around 7,000 to 8,000 health workers annually, of varying quality.
"Aside from limited the 'production', out of the medical schools, only 15 to 16 (schools) have programs for specialists. Many schools don't even have professors," Health Ministry head of human resources development Muharso said.
With most doctors living in big cities, mostly in Java, provinces like Papua, Maluku, East Nusa Tenggara and Southeast Sulawesi experience shortages.
While about 30,000 nurses graduate every year from some 411 nursing academies and 14,000 midwives graduate from 216 schools, only around 5,000 are recruited by the 452 government hospitals in the country. Others go to the 626 private hospitals, 112 military hospitals and the 7,500 community health centers.
Banten's Serang General Hospital head of nursing Sri Lestari said many graduate nurses could not find jobs because their qualifications were not recognized by hospitals.
"The last time, we advertised jobs for 38 nurses, but had 400 applicants. It was still tough to find the quality ones." she said. Around 70 percent of nurses nationwide come from vocational high schools. Only some 20 percent of them hold nursing diplomas while only 5 percent hold bachelor's degrees, according to last year's data from the University of Indonesia's nursing faculty.
Inadequately trained nurses result in poor medical services and poor overall community health. In rural areas nurses are often only junior high school graduates.
Under regional autonomy, local administrations were given control of health services and now they are blamed – rather than central government – for health underfunding.
"It's difficult to convince (regional) councillors to give doctors incentives to come and work in the regions. The result – in the nearby regency of Pandeglang, doctors are very few because the rate of incentives for them there is at only 19 percent, whereas it should be at least 50 percent," Sri said.
Unsurprisingly, the country comes off second best when its health statistics are compared to its neighbors.
Indonesia's infant and maternal mortality rates are among the highest in the region, with 48 deaths per 1,000 live births and 470 deaths per 100,000 births respectively. The nation has the world's third highest TB infection rate, has endemic malaria and dengue and problems with diarrheal infections, malnutrition and HIV/AIDS.
Speaking at a recent workshop in Chiang Mai, the World Health Organization's Southeast Asia director, PT Jayawickramarajah, said countries in the region could learn from Thailand, which had made good political decisions when it came to funding health human resources.
WHO's Prakin Suchaxaya said the Thai government's emphasis on education, had greatly benefited the health sector.
"We have training for teachers, and strong educational system. All nursing education is in university level and nursing is regulated by a body. We also reach out to everyone, establishing family care units in every village," she said.
The country's 750,000 people working for volunteer organizations could also be mobilized to work against specific health threats, like avian flu, she said.
Paying health workers properly recognized the work they did, she said. It also helped give them prestige, which attracted more people into the sector.