Nivell Rayda – Health issues have always been a prickly subject in Indonesia and this year was no exception as the country mourned the loss of a minister, heatedly debated the need for tobacco control and fought an uphill battle in preventing the spread of HIV/AIDS and curbing maternal and infant mortality rates.

But 2012 also saw some major breakthroughs and developments in public access to health, particularly for the impoverished and those living in underdeveloped areas of the country.

The year began with the country on high alert after tests confirmed that a Jakarta resident who died on Jan. 9 had the H5N1 virus. He became the country's bird flu victim this year.

The death forced Health Ministry officials to acknowledge that despite all its efforts, Indonesia had been unable to completely wipe out bird flu in the country as long as the infection remained endemic among poultry.

Indonesia has had a hard time controlling the spread of the disease because backyard farming is such an ingrained part of the culture. The Health Ministry has found that in some traditional markets in Jakarta, traces of the H5N1 virus are found not only on sick poultry, but also on knives and cutting boards as well as the vendors, although they were not infected. By December, a total of 10 people were confirmed dead from bird flu.

Where there's smoke

But the issue generating the most headlines this year seemed to be the endless battle to curb Indonesia's prevalent addiction to smoking. The government seems to be split between factions which are against smoking and those who are say that tobacco control will cost jobs and tax revenue.

On April 18, Indonesia was forced to take a step backwards in tobacco control after the Constitutional Court forced officials in Jakarta to rewrite regulations mandating public buildings to provide smoking rooms.

Jakarta will now have to revise a 2010 gubernatorial decree that ordered an end to smoking rooms, making all public buildings in the capital smoke-free zones, but enforcement of the decree has never been vigorous.

The court's ruling on the challenge by Enryo Oktavian, Abhisam Demosa Makahekum and Irwan Sofyan will now make it obligatory for these places to provide smoking rooms. Antitobacco activists said the ruling meant they would have to restart their fight to make public buildings smoking-free.

It must have especially heartbreaking for former minister Endang Rahayu Sedyaningsih who had been battling for more tobacco control since she took office in October 2009. Less than a week after the court ruling, Endang resigned as minister to take on another battle, this time against the lung cancer that would ultimately take her life.

Endang died at the age of 57. She spent the last three weeks of her life at Cipto Mangunkusumo General Hospital in Central Jakarta.

To the minister's credit are policies such as free maternity programs for the poor, the issuance of a government regulation that makes exclusive breast-feeding obligatory and programs to fight bird flu and dengue fever.

The fight for tobacco control was passed on to former National AIDS Commission chief Nafsiah Mboi, who was appointed by President Susilo Bambang Yudhoyono on June 13 as the new Health Minister.

"I saw commitment and real work from her to make people healthy," Yudhoyono said at the Bogor presidential palace. "Therefore, I consider her to be the right person for the position of Health Minister."

Nafsiah, 72, is seen by many as too old to hold a ministerial post. However, her track record shows she is a qualified replacement.

She graduated from the University of Indonesia's School of Medicine in 1964 and became a pediatrician in Belgium. She shared a 1986 Ramon Magsaysay Award, went on to work as a civil servant at the Health Ministry and in 2006 was appointed by Yudhoyono as the head of the National AIDS Commission.

Stub it out

Nafsiah soon learned that the Health Ministry's plan to enact an implementing regulation on tobacco control would meet huge resistance, not just from tobacco companies and farmers but also from fellow cabinet members.

In June, Manpower Minister Muhaimin Iskandar claimed that hundreds of thousands of jobs would be threatened by the proposed regulation which would mandate graphic health warnings on cigarette packs and covers tobacco advertising, no-smoking zones, cigarette sale restrictions and excise levels.

The Indonesian tobacco industry employs millions and is one of world's largest cigarette-producing markets, with about 6 percent of the government's revenue coming from cigarette excise. The powerful tobacco lobby has been actively campaigning to block regulations that would restrict sales.

Activists say that despite creating more state revenue, the industry absorbs money from families in lower income brackets, trapping them in a cycle of poverty.

A recent survey by the University of Indonesia's Demographic Institute found that 57 percent of Indonesian households bought cigarettes, and that cigarettes were the country's second-largest expense after rice. According to the survey, the average household spends Rp 36.5 million ($3,800) every 10 years on cigarettes.

Agung Laksono, the coordinating minister for people's welfare, has said that the landmark regulation could be issued by July but as the year draws to a close, that regulation keeps getting postponed and the plan now faces an uncertain future.

And the cigarette industry is taking advantage of the government's weak political commitment. The cigarette industry patronized the Indonesian government with the recent World Tobacco Expo in Jakarta, with a website promoting the expo that described Indonesia as a country with no cigarette regulations.

The Global Adult Tobacco Survey released this year ranked Indonesians as the heaviest smokers in the world, with 67 percent of all male citizens more than 15 years old lighting up consistently. According to the World Health Organization, about a quarter of Indonesian boys aged 13 to 15 also smoke.

On Nov. 13, the government announced that it would increase the excise by an average of 8.5 percent next year to boost state revenue and also discourage people from taking up the unhealthy habit.

Cigarettes sell for about $1 a pack in Indonesia, far less than in neighboring countries such as Malaysia and Thailand, where a pack goes for $3 to $4. In developed countries like the United States and Australia, cigarettes can cost upward of $10 per pack. Even the excise on cigarettes, which is currently less than 40 percent, is extremely low by regional standards.

The fight for tobacco control might take another hit next year as the House of Representatives announced last week that it is formulating a bill aimed at protecting the tobacco industry and that it is included as one of 70 bills prioritized to be enacted next year.

"My question to the House of Representatives is how can a bill not accompanied by an academic paper without a draft legislation proposal can get prioritized [for deliberation]," said National Commission for Tobacco Control chief Priyo Sidipratomo last week.

Tulus Abadi of the Indonesian Consumer Protection Foundation said the bill should be dropped and called for the House to enact the Bill on Controlling the Impact of Tobacco Products, deliberation of which has stalled since July 2011.

Making progress

The year also saw some major breakthroughs and developments. On Nov. 10, the Jakarta Government introduced the Jakarta Health Card (KJS), providing impoverished Jakartans access to free health care.

Governor Joko Widodo has handed out 3,000 KJS cards. Eventually the KJS is expected to reach 4.7 million residents.

The government is also aiming to make Indonesia an international health destination because of its abundant natural beauty, which is a potentially huge draw for tourists also looking for low-cost health and medical care, said Mari Elka Pangestu, the Minister of Tourism and Creative Economy, on Nov. 29.

And Health Minister Nafsiah said that it is not a far-fetched dream, citing the rapid development of new state of the art hospitals in Indonesia this year, including in the underdeveloped eastern region. Another factor, Nafsiah said, is the fact that more and more Indonesian hospitals are receiving international accreditation from the Joint Committee International Accreditation.

But Nafsiah also said that attitudes need to change so that Indonesians seeking medical treatment will make an effort to find that treatment at home.

"I often wondered why Indonesian people like to get check-ups in Singapore," Nafsiah said. "What is it that we don't have? It turns out the answer is because of the service and the mental attitude. We don't have any pride to serve."

Nafsiah said that in Singapore, doctors were willing to spend time to listen to patients' complaints and discuss the various medical procedures that were available.