Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental healthMr. Dainius Pūras

Bahasa version

Country Visit to Indonesia, 22 March to 3 April 2017

Preliminary observations

Jakarta, 3 April 2017

Members of the press,
Ladies and gentlemen,

I would like to begin by sincerely thanking the Government of Indonesia for inviting me to assess, in a spirit of dialogue and cooperation, the realisation of the right to health in the country. During my visit, I met with high-ranking Government officials, members of the Parliament and relevant health-related institutions at central, provincial and local levels. I had a meeting with the National Human Rights Commission (Komnas Ham), National Commission on Violence against Women (Komnas Perenpuan) and the Indonesia Child Protection Commission (Komisi Perlindungan Anak Indonesia). I also met with representatives of international organizations, diplomatic corps, and with a wide range of civil society actors, including professionals of the healthcare sector.

I had the opportunity to visit health facilities at different levels in Jakarta, Padang, Labuan Bajo and Jayapura, including health posts at village level, primary care centres (puskemas), general hospitals including psychiatric units, a mental hospital, HIV/AIDS clinics, and a drug rehabilitation clinic. I have also visited two polytechnics or education centres for health workers. I take this opportunity to thank the UN Resident Coordinator and the UN Country Team for their crucial support to my visit. 

You will find in this room a short document that explains my responsibilities as the UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (the right to health), as well as the focus issues for this visit. I am an independent expert who reports to, and advises, the UN Human Rights Council and UN General Assembly on the realisation of the right to health.

After two weeks in the country, I have collected a wealth of information and testimony that will enable me to assess the realisation of the right to health in Indonesia. Today, I will only present some of my preliminary observations, which I will elaborate in more detail in the report I will present to the UN Human Rights Council in Geneva, in June 2018.

General context: achievements and challenges

Indonesia gained independence from the Dutch in 1945 and it is a diverse archipelago nation of over 260 million people from more than 300 ethnic groups.  Since 1990, it has achieved impressive economic growth and has become the largest economy in Southeast Asia. Today, it is the fourth most populous nation in the world and an emerging middle-income economy which has halved poverty since 1999. 

Indonesia has focused its economic growth and development until 2025 on infrastructure development and social assistance, including programmes related to healthcare and education with a particular focus on the poor.  With a strong commitment to public health policy, the country has made important achievements in improving the health status of its population. 

The health sector in Indonesia has developed with a strong focus on primary care and universal access for the poorer sectors of its population. Considerable investments have been made to develop health infrastructure and make services available and accessible, as well as to address the underlying determinants of health, including poverty, education, food and nutrition, through different policies and programmes.

Indonesia has signed and ratified almost all international human rights treaties, except for the Convention of Enforced Disappearances, the Optional Protocol to the Convention against Torture and the second Optional Protocol to the International Covenant on Civil and Political Rights on death penalty.  During the past ten years, the country has received the visit of one independent expert of the Human Rights Council, on the right to adequate housing, and it has yet to issue a standing invitation to the Special Procedures of the Human Rights Council. Indonesia has not ratified the UN Framework Convention on Tobacco Control and the ILO Indigenous and Tribal People’s Convention (No.169).

Since 1990, most indicators under the Millennium Development Goals showed considerable improvement although MDG5 on the reduction of maternal mortality rates was not achieved.  Indonesia has been actively involved in the Sustainable Development Goals and Agenda 2030 for Sustainable Development since their inception and is taking part of the 2017 National Voluntary Reporting of the High Level Political Forum on Sustainable Development.

In recent years, the continued decline of the global demand for commodities has led to moderate economic growth.  During this time, job creation and poverty reduction have slowed down contributing to inequalities and compounded forms of discrimination, in particular amongst groups in vulnerable situations.

Despite commendable efforts, availability, access to, and quality of, health services remain a challenge in a country where population is spread throughout thousands of islands and remote areas.  Important barriers persist, in law and practice, for the realisation of sexual and reproductive health rights, consequently women and other groups are exposed to different forms of violence and discrimination.

HIV-AIDS is concentrated amongst certain key affected populations, as well as ethnic Papuans, who still face stigma and discrimination, including in healthcare settings. The approach to drug policy remains excessively punitive undermining the right to health of people who use drugs and public health efforts.

Mental health is an emerging issue but the State needs to invest additional commitment and resources to develop a system that promotes the mental health of everyone and effectively treats and prevents common mental health conditions at the community level, respecting the rights of persons with psycho-social and intellectual disabilities.

Healthcare system

Indonesia made a bold commitment to develop a universal healthcare insurance system with single-payor and to reach universal health coverage (UHC) by 2019. This is a very ambitious plan which is to be commended, as reaching universal health coverage and moving away from fragmentation in healthcare to a universal system is the best possible solution on the path to the realization of the right to health and Agenda 2030 for sustainable development.

The fact that Indonesia has been at the forefront of the global movement towards SDGs and the Agenda 2030 and the fact that it is now leading the path to universal health coverage, is an illustration of political will and a sign that country’s leadership understands the intrinsic link between sustainable and inclusive development and the need to invest in the right to health and equitable healthcare. In this context, it is very important to identify obstacles and challenges and to address numerous gaps. I will now just mention some of challenges which need to be addressed and will elaborate in my report.

While there are many important managerial and economic questions to be addressed in the current system, in my report I will highlight other important issues which should not be ignored by policy makers. These are the principles of non-discrimination, accountability, participation and empowerment, informed consent, and the need to go beyond the narrow biomedical model so that a holistic, equitable and ethical care is provided to participants of the BPJS.

The focus on reaching the poor and addressing financial exclusion and mitigating catastrophic expenditures should not undermine the attention given to systemic challenges stemming from patterns of discrimination on other grounds, such as ethnicity, sex, religion, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation and gender identity, as well as legal status.

Mutual trust among all participants of the universal healthcare insurance system, including the population, policy makers, civil society and public and private providers, is a decisive element of success. It is the best remedy against fraud, corruption, discrimination and stigma, and various disparities and imbalances within the system of healthcare.
For example, in Indonesia regional disparities need to be addressed to avoid disproportionate utilization of BPJS health funds in urban and western parts of the country. Mental health needs to be addressed as equally important part of general health and this needs to be reflected in developing and reimbursing modern mental health services. Reproductive health services need to be scaled up with particular focus on adolescents and youth. The changes in trends of morbidity and mortality, with non-communicable diseases emerging and communicable diseases still high, need to be addressed in creative manner.

These and other challenges can only be effectively addressed if all elements and principles of the right to health framework are mainstreamed in health policy formulation and implementation, including non-discrimination, equality, participation, and accountability. 

I recommend increasing national budget allocations for health and reduce out-of-pocket payments.  However, increased investments in healthcare system only make sense if the system is efficient as well as transparent, friendly and responsive to those who use it. For healthcare systems to be efficient, sustainable investment in primary care is a first priority. The existing system of primary health care, with nearly 10,000 puskesmas is an impressive network of infrastructure which needs to be supported so that most health conditions are effectively managed at the primary care level and only complicated cases are referred to specialists and hospitals. Primary care and the BPJS system should not only serve the poor but it should win the trust of the more affluent sectors of society. This is an important precondition for universal healthcare systems to be sustainable.

Last but not least, substantial investments are needed to improve quality and quantity of healthcare workforce. Skills training and geographical deployment, with innovative incentives, of doctors and other healthcare workers remains a challenge. I will elaborate more on this in the report, for now, I would like to commend the efforts made to invest in training of frontline healthcare workers.

Sexual and reproductive health rights

The country has made several attempts to increase the life expectancy of the population. While infant and child mortality rates have considerably reduced over the past decades, the maternal mortality rate has remained high and continues to pose problems in improving women’s quality of life, with maternal health in Papua lagging behind other parts of Indonesia.

During my visit, I learned about positive initiatives towards creating a supportive environment for young people’s sexual and reproductive health, such as youth friendly services in puskesmas to prevent and protect young people from risks related to their sexual and reproductive health, as well as school-based sexuality education. However, I was discouraged to hear that the planning and delivery of comprehensive sexuality education and services is being influenced by certain religious groups who continue to oppose policies, instruments and mechanisms for the promotion and protection of sexual and reproductive health rights arguing that it promotes sexual promiscuity or homosexual propaganda.

I also found that the sexuality education curriculum is often limited to biology and reproduction with no content to address human rights and discrimination, sexuality or gender norms to enable young people to make informed decisions on their reproductive health and adopt healthy sexual behaviours. Policy or legal restrictions on access of unmarried young people to some services, including contraception, legal requirement for parental or spousal consent and criminalisation of professionals who provide education, information or advice relating to abortion (except in a medical emergency) has created additional barriers for women and key populations to access information and services on healthcare contributing to unplanned and unwanted pregnancies and vulnerabilities to sexually transmitted infections.

Gender based violence affects men, women and transgender people and it is an issue of public health concern. According to Komnas Perempuan, domestic violence in the home and in the context of personal relationships constitutes an overwhelming majority of the reported cases involving sexual violence, including rape. I am also particularly concerned about the situation of women and girls who face compounded forms of discrimination due to their social, cultural and religious backgrounds. These include women and girls who are exposed to harmful traditional practices, such as child marriage and female genital mutilation. I will elaborate on these issues in my report to the Human Rights Council. I welcome the inclusion of the Elimination of Sexual Violence Bill (RUU PKS) in the priority list of the 2017 National Legislation Program (Prolegnas) for discussion in the parliament. I urge the Government to pass the Bill, as a matter of priority to further advance the right to health, in line with the Sustainable Development Goals (SDGs) related to women.

During my visit, I was apprised about the deeply entrenched discriminatory and violent attitudes that exist in society towards individuals and groups based on their sexual orientation and gender identity or gender expression. Reports by Komnas Perempuan and Komnas Ham, indicate that discriminatory attitudes contribute to increased vulnerabilities to ill health, including HIV infection, and to increased stigma and harassment in healthcare settings while seeking treatment and services for sexual health, including refusal of admission or services. I have received reports and testimony indicating that transgender women (waria) face harassment from law enforcement officials and legal uncertainty when accessing identity documents. In healthcare settings, they are forcibly tested for HIV/AIDS, identified on the basis of their ID which does not reflect their current sex status, and are placed in male wards where they are exposed to serious violence and abuse.

I am also very concerned about information received on the use of pathologizing classifications for persons based on their sexual orientation and gender identity, including labelling them as mentally ill. Such classifications have been used as a pretext for abusive forced treatment, psychiatric evaluation and procedures to change the sexual orientation of people, so-called “corrective therapies”. Such therapies are unacceptable from a human rights perspective, are unscientific, and have a serious negative impact on the mental health and well-being of people.

The Constitutional Court is currently examining a review petition seeking to criminalise consensual same-sex behaviour and increase penalties for sexual activity out of wedlock which will risk creating additional barriers for women and certain key populations in the realisation of their right to health and will be counterproductive from a public health perspective.

Mental health and persons with psychosocial and intellectual disabilities

Indonesia is in a strong position to develop a mental healthcare system based on human rights and modern public health principles and standards. However, in order to achieve this, mental healthcare needs to be recognized as a priority in the framework of the national health policy and the implementation of Agenda 2030.

I would like to emphasize that when we speak about mental health, we address two important themes. One is the right of everyone to the enjoyment of (the highest attainable standard) of mental health which is about mental health promotion and prevention of common mental health conditions, and the other issue  is about integrating mental health in all policies, including in poverty reduction and social protection for the poor, anti-discrimination laws and campaigns, and violence prevention programmes. Laws, policies and services need to be in place to enable children, women and other vulnerable sectors of the population to live and thrive in an environment free from violence and coercion. This is the best possible investment in mental health.

Indonesia has taken important steps regarding mental healthcare, including in law and practice, but these steps need to be strengthened and supported as priorities by authorities at all levels and mainstreamed in general health and social services. Primary health services (puskesmas) should reinforce the essential elements of mental health services that are available at the community level. Health practitioners should focus on mental health in the same way as on physical health effectively providing a combination of psychosocial interventions and psychotropic medications which should be available if needed.

I was pleased to learn from various stakeholders in different parts of the country that shackling (pasung) is not accepted and that there are clear policies, guidelines and efforts to end this form of violent and degrading treatment. The “Free shackling campaign” should be commended but must be scaled up, oriented towards alternative community services, and supported by substantial budget allocations, adequate training of the workforce, and the empowerment of persons with psycho-social disabilities. An integrated approach is required to prevent the risk of shackling being replaced by other forms of restrains and confinement  which violate human rights and are not in line with the Convention on the Rights of Persons with Disabilities.

Law No 8/2016 marks a significant advancement towards recognizing the rights of persons with disabilities and challenges the approach that people with disabilities are passive recipients of care and protection. However, this law is not in full conformity with the CRPD as, for example, it fails to recognize the legal capacity of persons with disabilities. Similarly, the Mental Health Act (2014) has strengths and weaknesses. It mandates every province to have its own mental hospital and every district and municipality to build or support the establishment of at least one “non-health care, community-based facility”.  This is the direction that mental health policy should take. However, at the same time the Mental health act is problematic in its definition and application of the principle of informed consent. This issue will be elaborated further in my report.

The BPJS system should seriously address the issue of coverage of psychosocial interventions which need to be provided at the community level by the health and social services. These interventions can be very effective if properly applied, and they can reduce the need to hospitalize and institutionalize people. Mental health conditions, including depression, child mental health problems, and psychosocial disabilities, need to be addressed in a modern proactive and rights compliant way, and this package of investments should be one of the priorities in reaching universal health coverage and attaining the SDGs.

People living with HIV/AIDS

The country has a relatively low prevalence of HIV/AIDS and there has been serious commitment over the past 15 years to fight the disease and provide access to testing and treatment of those living with HIV/AIDS. HIV transmission seems to have been stabilized and has overall started to decline. However, th

e prevalence of HIV/AIDS remains quite high amongst certain key affected populations, in particular men who have sex with men but also amongst sex workers and their clients, transgendered persons (Waria) and people who use drugs. The profile of the epidemic is changing and most new infections are sexually transmitted. Key populations are exposed to heightened risks and face significant barriers, stigma and discrimination, both in law and in practice, when accessing treatment and services. Consequently, they tend to avoid health services. This is not only a human rights issue but also a serious public health concern which can have grave social and economic consequences.

I am very concerned about the situation in Papua where there is a generalized epidemic and infection rates are the highest at the national level. I visited Jayapura and learnt that, despite commendable attempts from all levels of government and other stakeholders, ethnic Papuans are two times more likely to have HIV/AIDS than the rest of the population, and new infection are increasing amongst this group. They face important challenges when it comes to testing, treatment and health-related services both in terms of access but also effectiveness of the response given adverse historical, socio-economic and cultural factors. The critical situation of HIV/AIDS in Papua deserves special attention and efforts from all stakeholders to build trust amongst service providers and users, but also to scale up investment in the health sector, and enhance access to treatment and services in a culturally-sensitive manner. 

Overall, HIV testing in Indonesia has substantially increased over the past few years, which is to be commended, but numbers are still low,  coverage of anti-retroviral treatment (ART) is among the lowest in Asia, and sustainability remains a challenge especially when more than half of the funding comes from foreign sources. In addition, normative, policy and institutional changes are necessary to remove serious barriers that hinder the effectiveness of the HIV response.  More efforts are needed to effectively reach out to those most at risk and to ensuree access to quality evidence-based services, including by working in close partnership with key affected populations.  

During my visit, I was informed that the National AIDS Commission will cease to exist as of next year and its functions and responsibilities will be absorbed by the Ministry of Health. Given the situation, there is a need to have an independent body monitoring the situation, implementing and coordinating programmes, and engaging with key populations. I therefore urge the authorities to reconsider this decision and reinstate a National AIDS Commission with strong independent mandate and sufficient resources to effectively fight the disease and achieve the goal of eliminating AIDS by 2030. 

Drug policy and the right to health of drug users

Drug use has steadily increased in Indonesia in recent years with more availability of synthetic drugs. The authorities have adopted a punitive approach toward drug use and supply in an attempt to deter use and curb trafficking. Penalties for drug-related offences are quite severe, including death penalty. The registration and reporting of drug use is compulsory leading to practices of forced or coerced treatment.

I have visited health centres with specific programmes and services for drug users. Such structures provide counselling and harm reduction services, including opium substitution therapy, but are not widespread and do not cater for the needs of specific populations, such as adolescents. 

The interaction of health services with people who use drugs in Indonesia is mostly based on law enforcement which does not respect some of the basic elements of the right to health, including informed consent and the right to refuse treatment. Criminalization of drug use only fuels discrimination, violence and exclusion driving people away from the health services they need hence seriously undermining public health efforts.

Drug use should not be criminalized, and the reporting on and rehabilitation for drug use should not be compulsory. Indonesia should invest more in prevention, education, and information programmes about drug use. The health and related sectors need to be more active in promoting evidence-based prevention, services and treatment for people who use drugs respecting their autonomy, dignity and privacy.

Members of the press,
Ladies and gentlemen,

There are real opportunities and genuine commitment to achieve the progressive realisation of the right to health in Indonesia but public authorities need to step up efforts to address structural and systemic issues, both in law and practice, to make sure that they are not tempted by the “lower hanging fruit” and none is left behind.

Indonesia is on the right track to develop an equitable and sustainable healthcare system based on universal health coverage. For this ambitious goal to be reached, gaps and challenges for the enjoyment of the right to health need to be identified and addressed in a comprehensive way.  I will elaborate on these gaps and challenges and the ways to address them in my report with the hope that my observations and recommendations will contribute not only to the realisation of the right to health in the country, but also to the attainment of health-related sustainable development goals, including the goal to reach universal health coverage.

I will conclude now thanking the Government of Indonesia for inviting me to visit the country which has enabled me to have a better understanding of the realisation of the right to health and related rights in the country. The invitation in itself shows that there is a commitment to guarantee and improve the enjoyment of the right to health. 

Thank you.