The UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Mr. Dainius Puras, visited Indonesia from the 22 March to the 3 April 2017. The findings of his Indonesia mission have recently been published and will be presented during the 38th session of the UN Human Rights Council, which will take place from 18 June to 6 July 2018 in Geneva. In his report, the special rapporteur also referred to the condition of health services in West Papua and addressed various issues of particular concern in the context of Indonesia’s easternmost provinces.
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Child and Maternal Mortality
The special rapporteur honored the progress in the provision of health services and the establishment of a health insurance scheme, which was able to ensure the provision of basic health services for poor population segments. Live expectancy in Indonesia had significantly increased among certain population segments over the past decades, while the adoption of various regulations and government programs in the health sector had positive effects on the health service sector. However, he also urged the Indonesian Government to “… effectively address high maternal, infant and under-5 mortality and morbidity rates, inequalities, poverty and significant disparities between urban and rural areas. It is essential in this regard to improve integrated data management, institutional coordination and the availability and quality of health-related data.” (p. 4)
While the under-5 mortality in the country has been halved since the 1990s, the special rapporteur expressed his concerns regarding the maternal mortality rate, which remained among the highest in the region “…at 305 deaths per 100,000 live births in 2015, with maternal health in Papua, Sulawesi, Maluku and Nusa Tengarra Provinces lagging behind other parts of Indonesia. Reports indicate that most maternal deaths are the result of complications during pregnancy, unsafe delivery practices, early pregnancies and poor childbirth and postnatal care, including low levels of competence of birth attendants and poor access to family planning services. Other underlying causes include variations in the availability of and access to good quality referral systems for obstetric care in emergencies, particularly in remote areas.” (p. 12)
Equal Access to Medical Facilities and Quality of Health Services
He noted that according to official government data, there are 9,767 health centers (Puskesmas) which is supposed to be staffed with at least nine medical experts. According to 2016 data only 1,200 Puskesmas met the afore mentioned human resource standards. This affects particular people in remote inland areas or islands in the eastern part of Indonesian, who are facing additional health challenges such as limited access to health facilities and lack of medical equipment and appropriate medication. The Special Rapporteur had visited the eastern part of the country, including the province Papua, where he witnessed the above-mentioned disparities and Government initiatives ensuring access to good-quality health-care services for Papuans living in remote regencies.
However, information from Papuan community leaders and other civil society representatives which the special rapporteur collected in Jayapura, highlighted the major challenges faced by Papuan communities in remote areas. “Most villages in remote regencies in the highlands suffer from a lack of health centres, medical equipment and qualified medical personnel. General vaccination and immunization services are not consistently provided, there are no adequate monitoring mechanisms and public health services are not delivered in an equitable manner. It is reported that military personnel have been deployed in the context of outbreaks of disease. Overall, there is a lack of trust in the health services available and ethnic Papuans experience stigmatization and discrimination in health-care settings.” (p. 8 f)
Despite the efforts to overcome regional disparities, the special rapporteur “… noted with concern that preventable and treatable diseases (respiratory-tract infections, measles, diarrhoea and dysentery) claim a high number of victims and affect the most vulnerable members of communities, particularly children. […] With regard to Papua, the Special Rapporteur was informed that, pursuant to the special autonomy framework (laws No. 21 on special autonomy for Papua Province (2001) and No. 35 amending law No. 21 on special autonomy for Papua Province to include West Papua Province (2008)), Papua and West Papua Provinces receive larger health-budget allocations than any other province. Nonetheless, he expresses regret at the roseola epidemic that affected nine villages in Deiyai Regency between April and July 2017 and the outbreak of pertussis (whooping cough) in Nduga Regency in November 2015.“ (p. 8)
The special rapporteur encouraged authorities to continuously improve “…access to good-quality health care and to build the capacity of health structures in remote regions. Members of Adat (customary) communities, including indigenous Papuans, should have full access to public health facilities, goods and services, as well as to facilities, goods and services relating to the underlying determinants of health, such as safe and potable water and adequate food and sanitation. The collection and use of disaggregated data are crucial to efforts to achieve this goal. Culturally appropriate health-promotion tools and information should be developed and disseminated to prevent communicable and non-communicable diseases, particularly in remote areas. Members of Adat communities, including ethnic Papuans, should be trained as health-care workers, accredited as medical practitioners and integrated into the health-care system at all levels. Health-care curricula should include the training of health-care workers to deliver culturally appropriate services.” (p. 9)
HIV/ AIDS
The prevalence of HIV/AIDS in Indonesia is relatively low. 2016 data suggest that about 0.4 % of the population in the 15-45 age bracket are affected. The prevalence raises up to 28 % among certain risk groups like homosexuals, transgender persons using intravenously injected drugs. Only 35 % of persons living with HIV/AIDS know that they are infected. The special rapporteur noticed that some regions are more affected than other, among them the provinces in West Papua. “An analysis of the epidemic shows that most cases are concentrated in a few provinces, mainly Jakarta, Papua and West Papua Provinces, which are experiencing a generalized epidemic. It is estimated that 2.4 per cent of the general population in Papua Province is living with HIV: the prevalence of HIV is reportedly higher among young persons aged 15–20 years.” (p.17)
The report states that the HIV/AIDS situation in Papua province is of particular concern because the generalized epidemic and infection rates are above the national average. “The Special Rapporteur notes specific HIV/AIDS policies in Papua, where HIV tests are offered to all users of health services, regardless of their symptoms, while in other provinces, they are only offered to members of high-risk populations. Despite these and other commendable attempts, ethnic Papuans are currently twice as likely to have HIV/AIDS than the rest of the population, and rates of infection are on the rise in this part of the country. The situation in Wamena, Timika and Nabire Regencies shows that the epidemic is moving from coastal areas to the highlands, where most ethnic Papuans live, often in remote areas. Ethnic Papuans face important challenges when it comes to awareness, testing, treatment and health-related services, both in terms of access but also of effectiveness of the response, given adverse historical, socioeconomic and cultural factors. Women are at particular risk in this context, where new infections are mostly sexually transmitted. This critical situation deserves special attention and efforts from all stakeholders to build trust among service providers and users, but also to scale up investment in the health sector and to enhance access to treatment and services in a culturally sensitive manner.“ (p.18)
In this regard the Special Rapporteur urged the Government that more effort is required to actively to ensure that preventive measures and medical treatment reach out to risk groups and particularly affected population segments.
Recommendations
The report mentions various recommendations which have particular importance in consideration of the health services situation in West Papua:
“(c) Strengthen the health-care system and guarantee adequate, equitable and sustainable financing by increasing national budget allocations for health, and continue improving the availability and accessibility of health services in remote regions, with particular focus on primary care, the role of general practitioners, and the situation of Adat communities, including ethnic Papuans;” (p. 20 f)
“(d) Ensure that a solid health information system is in place to generate quality national data and statistics for the analysis of gaps in and for the design, implementation, monitoring and review of health-related policies and services;” (p. 21)
“(e) Address maternal and under-5 mortality, including by referring to the WHO Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) and the technical guidance on the application of a human rights-based approach to the implementation of policies and programmes to reduce and eliminate preventable maternal and under-5 mortality and morbidity (A/HRC/21/22 and Corrs. 1–2 and A/HRC/27/31);” (p. 21)
“(g) Ensure comprehensive protection for women against all forms of gender-based violence by addressing, without delay, the remaining gaps in legislation and in practice, in order to ensure substantive equality and women’s enjoyment of the right to health and related rights;” (p. 21)
“(I) Remove all legal provisions criminalizing and stigmatizing persons living with HIV/AIDS, including those that criminalize homosexuality, sex work, and HIV/AIDS non-disclosure, exposure and transmission;” (p. 21)
“(j) Guarantee non-discrimination against persons living with HIV/AIDS in the health-care sector by ensuring that health services, materials and information are available, accessible, acceptable and of good quality for all key populations, and that health workers are properly trained and equipped;” (p. 21)
“(k) Address without delay the HIV/AIDS situation in Papua by guaranteeing access to testing, treatment and culturally sensitive health-related services, particularly for young persons and women, and build trust among service providers and users;” (p. 21)
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