First published in ITIJ 122, March 2011
Providing assistance over large land mass and across islands is a challenge not to be underestimated. Here, Jason and Anna Hue of Blue Dot Assistance (BDA) give their view of the ways in which the Indonesian archipelago can be successfully negotiated
Indonesia is the world’s largest archipelago, comprising 17,508 islands. If the president of the country had to visit 10 islands a day, it would take him almost five years to complete the round, just as his full term is up. Indonesia spans more than 5,000 km from East to West, further than the distance from New York to San Francisco. With a population of 230 million, it is also the fourth most populous nation in the world. With so many islands, Indonesia boasts of some of the most beautiful beaches one can ever find. Its rainforests are millions of years old and the oceans that surround the islands are full of amazing and unbelievable coral, fish and underwater vegetation, all of which are huge tourism attractions. The World Health Organization reports that Indonesia is generally regarded as having relatively adequate levels of healthcare provision, with one public health centre (or government clinic) for every 30,000 people on average. However, these averages conceal large variations in geographic accessibility, with people in the remote interior or small island locations having particularly poor access.
Under most circumstances, tourists, visitors and white-collar foreign workers would be visiting or working in the large cities or other urban areas and for them, there is good access to healthcare, including emergency medical attention. There are more than 1,200 hospitals in Indonesia, almost half of which are run by the private sector. Most of the hospitals (52 per cent) are situated in the overcrowded island of Java. With a population of 136 million, the island of Java accounts for 56 per cent of the country’s population.
To some extent, market forces have supported the unequal distribution of healthcare services between the country’s rural and urban areas. The growing presence of private hospitals offering specialist services is centred in the capital city of Jakarta, with the city enjoying generally acceptable levels of healthcare.
In October 2010, Indonesia’s Investment Co-ordinating Board (BKPM) reported that foreign ownership of hospitals in Indonesia had increased from 65 per cent previously to 67 per cent. The Bali International Medical Centre (popularly known as BIMC) and the Siloam Lippo Karawaci Hospitals are among the prominent hospitals in Indonesia that have now been acquired by a Singaporean investment company.
averages conceal large variations in geographic accessibility, with people in the remote interior or small island locations having particularly poor access
When tourists require medical treatment, generally, they prefer to visit private medical facilities where medical care is perceived to be of higher standards. With the higher levels of healthcare, there is also a higher hygiene level. Djoko Widodo, chairman of the Indonesian Society for Infection Control, said recently that a survey carried out in Indonesia’s largest state hospital, Cipto Mangunkusumo General Hospital, revealed that only 60 per cent of the nurses washed their hands after contact with patients. This statement may alarm the foreigner, but the locals do not seem to consider it a serious matter.
The local population only pay a nominal sum for treatment at the public hospitals. One of the leading local newspapers, The Jakarta Post, reports that only about half of healthcare spending comes from the government, about one-third is paid directly by the people themselves as out-of-pocket payments, and the rest comes from foreign aid, insurance plans and other sources.
Public vs private
Most expatriate websites and forums are of the opinion that the healthcare sector in Indonesia is not up to Western standards. For the common cough and cold, expatriates do not mind seeking treatment at the local clinic or medical centre; however, most expatriates (and even affluent Indonesians) prefer to travel to neighbouring countries, such as Singapore or Malaysia, for treatment of more serious conditions that require more complex medical procedures. Medical treatment received by expatriates at Indonesian private or public hospitals is considered to be very affordable by western standards. Most expatriates have medical insurance cover and are able to recover their claims fully under their insurance policies anyway.
To date, only three privately-owned hospitals in Indonesia (located in different cities in the island of Java) have received recognition from the US-based Joint Commission International (JCI), as compared to 15 JCI-accredited hospitals in the neighbouring tiny island nation of Singapore. The Siloam Hospital (Lippo Karawaci) achieved its JCI accreditation in 2007 and remained the only hospital to do so for the next few years until two other Indonesian hospitals, the Santosa Hospital (Bandung) and the EKA Hospital (Tangerang) received their recognition in late 2010. The renowned specialist hospital, Mochtar Riady Comprehensive Cancer Centre (MRCCC), is not yet a JCI-accredited hospital. Getting accreditation from an international body, though, is not often considered a critical success factor to most local private hospitals, as all these hospitals are already over-populated with local patients.
Simranjit Singh, associate director of healthcare for Asia Pacific at Frost and Sullivan, one of the leading research institutions, said Indonesians seek medical treatment abroad because the domestic healthcare industry cannot cater to the demands of the middle class searching for better service. "Indonesia has huge potential because it has a huge population and spending power. But since Indonesia cannot meet the demand, they seek it abroad. You need to meet the expectations," he said on the sidelines of Hospital Build Asia seminar, held recently.
Most expatriate websites and forums are of the opinion that the healthcare sector in Indonesia is not up to Western standards
He added that several factors could boost the growth of the healthcare industry in a country. The first is connectivity, because hospitals should be located near main roads, airports and other transportation hubs. "The second is accreditation, of doctors, nurses and hospital. You need to have quality doctors comparatively to the West, as the patients can be from the Middle East, America, [or] East Asia," Singh said.
The growing affluence of the middle class in Indonesia has created new demands on healthcare. Middle-class clients tend to expect shorter waiting times, newer medical technologies, prefer to be treated by a western-trained physician and expect better nursing care at the many world-class hospitals in neighbouring countries. Although Indonesian medical schools produce well-qualified and dedicated local doctors and specialists, and almost all are serving in the local hospitals, affluent middle-class patients prefer to seek treatment abroad because travelling abroad for medical treatment often includes a holiday, a shopping-spree and visits to some tourist spots in the destination country.
Concierge services offered by most hospitals in the neighbouring countries also make it conducive for Indonesians seeking treatment there.
It is estimated that Indonesians spend more than US$1 billion on overseas medical treatment each year, making up more than 70 per cent and 65 per cent of the total medical visitors to Malaysia and Singapore respectively.
With the exception of tourist-designated areas like Bali, where medical treatment charges differ greatly between foreigners and locals, the medical charges in cities in other parts of Indonesia are the same for foreigners or locals alike. Foreigners are free to seek treatment at government clinics or hospitals, but whether they go to them depends on the confidence they have in the local healthcare system.
At times, it is not about where the tourist wants to seek treatment, but rather which medical facility can treat his medical condition. BDA previously handled an emergency case in which a tourist honeymooning in the island of Bali was attacked and bitten by a wild monkey. It was fortunate that he had travel insurance with medical expenses benefit. The problem, however, was the lack of facilities on the island to treat monkey or dog bites. Although appropriate vaccines were easily available, searching for the recommended additional Rabies Immunoglobulin (RIG) injection was an uphill task. Even though rabies spread through dog, monkey and rat bites were rampant throughout the island; only one medical facility in the whole island had available stock of the RIG. As such, this shortage created an artificially high cost for the treatment.
Our medical director felt there was no real need for the RIG injection as the bite had occurred three days earlier and RIG is only useful if given within 24 hours of the bite. In this case, vaccine shots would have sufficed. However, since the cost was covered by the patient’s insurance, he insisted on getting the RIG shot.
While anti-serum administered shortly after a dog bite is effective in preventing rabies, patients who delay treatment until symptoms appear are largely beyond medical help for this fatal disease. Indonesia’s most widely circulated newspaper, Kompas, reported that the rabies virus claimed 108 victims on the island in 2008. The provincial government of Bali is targeting to be able to finally declare Bali 'rabies-free' by 28 October, 2012. To reach this goal, the government will be undertaking mass vaccination programmes on the island's dogs over the coming months. A total of 400,000 shots are being prepared for the coming mass inoculation drive.
Although many doctors do understand basic conversational English, most still prefer to communicate in Bahasa Indonesian or the local dialects
Language also poses a problem to many foreigners seeking treatment in Indonesia. Apart from some of the doctors working for international hospitals or big chains, most Indonesian doctors are not able to speak English, hence making it more difficult for expatriates or tourists – or even their emergency assistance company – to fully understand the diagnosis given by them. From our experience, only a small number of local doctors in Indonesia are fluent in English. Although many doctors do understand basic conversational English, most still prefer to communicate in Bahasa Indonesian or the local dialects. Expatriate patients get frustrated trying to understand Indonesian terminology when the local doctors are explaining medical conditions to them, giving them another reason to opt for treatment abroad.
The healthcare industry in Indonesia is competitive and there are many insurance companies, third party administrators, and healthcare providers offering the public various insured, self-insured and other healthcare membership programmes. This is evident from the common appearance of most hospital admissions and payment counters, which are often overcrowded with the providers’ terminals, stickers and brochures advertising the acceptance of the various healthcare programmes.
Most private employers and all government agencies and bodies provide medical insurance to their employees. This market segment of the local population is mostly found in and around the big towns and cities, however, the majority of the population of the country remains in the rural areas, is self-employed and is still living in poverty. Obviously, this larger group does not have the disposable income to buy medical insurance.
Despite the government’s efforts to market Indonesia as a medical tourism hub, most private hospitals in the country are still not ready to accept insurance policies, healthcare cards or letters-of-guarantee that are not issued by an Indonesian-registered company. Hence, there is an urgent need for overseas assistance companies or overseas insurance companies to work directly with Indonesian assistance companies to help place the guarantee letter on their behalf to ensure that their members enjoy the intended ‘cashless’ facility. Apart from this benefit, local assistance companies are also able to act as the local liaison to monitor the patients' conditions as well as to translate the medical reports of the patient into English.
There are several local assistance companies in Indonesia; the more established ones are BDA, International SOS (ISOS) and Global Emergency (Global). Besides being conversant in the local language and dialects, all of these local assistance companies have English-speaking co-ordinators at the 24/7 operations centres. Speakers of other languages, especially Asian languages, are also often available.
In the past, many international assistance companies used to contact other assistance companies in Southeast Asian countries for emergency assistance services in Indonesia. However, in recent years, many of these international assistance companies have found that by partnering directly with the local assistance companies based in Indonesia, they would still get the same standards of service and often, at more competitive rates.
local assistance companies are also able to act as the local liaison to monitor the patients' conditions as well as to translate the medical reports of the patient into English
Over the past decade, Indonesia has faced more disasters and calamities, caused by both man and nature, than most countries in the world. The last 10 years has seen major earthquakes, volcanic eruptions, tsunamis, floods, political riots, and bombings happening all around the country. Due to all this turbulence, all the major cities and tourist destinations in Indonesia have fully-equipped emergency and trauma units. Most are located in the private hospitals, although there are also some in the key state-owned hospitals. The established local assistance companies have good experience handling and managing assistance services during such disasters and calamities.
During the recent tsunami in October 2010 that affected an island off Sumatra, which also experienced a major volcanic eruption at about the same time, more than 400 people were killed and 100 more reported missing. It was reported that there were no proper warning systems in place. The lack of proper infrastructure is widespread in Indonesia, and in cases such as this, the casualty toll and the number of evacuations that have to be made are much higher than need be.
The government did invest partially in certain devices, such as a tsunami warning system, after the devastating December 2004 tsunami. These devices sit on the water in the middle of the ocean and measure changes in sea level and motion. In co-ordination with tide gauges on land, the information is then transferred to ground stations by satellite. The system is meant to give people enough time to reach high ground before a wave hits.
The government is quick to respond to the international media about their problem. "We don't say they are broken down, but they were vandalised and the equipment is very expensive," according to Ridwan Jamaluddin, of the Indonesian Agency for the Assessment and Application of Technology, told the BBC. “It cost us five billion rupiah each (UK£353,000; US$560,000)." Tiziana Bonapace, a specialist attached to the United Nations, said: “Indonesia's early-warning system was meant to be completed by 2010 but is still a work in progress.”
Deploying assistance services in a timely manner amidst this vast and complex country is a challenge, and a good knowledge of the availability and conditions of local medical facilities is critical. Decisions have to be made swiftly. Effective and efficient collaboration of all third parties involved in the chain of services is the criteria. An experienced operations team must know the local environment thoroughly, have an extensive medical network throughout the region and must be able to maintain a high level of quality in the services rendered.
One of the most adrenalin-pumping challenges we had was in 2005 when BDA was called into action during the second Bali bombing in October of that year. An employer group covered by one of BDA’s clients (an insurance company) had sent more than 30 employees and their family members for a weekend trip to Bali when a suicide bomber blasted the restaurant where this group of people were having their dinner.
The resulting evacuation was the largest single medical assistance incident ever performed in Indonesia by an assistance company for one client. The entire operation involved more than 30 evacuations and repatriations combined and were done despite the government jamming the telecommunications network for fear that the terrorists may be planning to trigger other bombs in the island remotely via their cellular phones. Amidst the chaos, panic and confusion, BDA pulled through and successfully carried out the evacuations and repatriations of the victims.
Due to the remote and isolated nature of many of the tourist destinations in Indonesia and the varied religious, social, political and physical environments, it is often far better and more cost effective for the overseas assistance company and insurance company to deal directly with the local assistance company when an emergency happens in Indonesia.
When evacuations and repatriations have to be done over vast distances in Indonesia, the local assistance company would look at the most cost-effective and efficient ways to handle the transportation. Whilst the assistance company would try to save costs for the insurers by using commercial carriers, however, some airlines do not carry stretcher patients over some routes. The local assistance company would turn to private air ambulances under those circumstances.
There are several small air ambulance (private jet) operators in the country and they provide access to the interior. At the same time, many helicopter operators are available in the resource-rich islands, such as Sumatra and Kalimantan, where mining and oil companies have their bases. Such helicopters are also used for emergency transportation when the need arises.
A few Asian regional air ambulance companies even station one of their aircraft in the more heavily tourist frequented spots such as Bali
Indonesian laws require a minimum local ownership of 35 per cent for companies categorised under the air ambulance industry banner when such companies are incorporated in Indonesia. There is no state-funded air ambulance provider that covers the whole country. Numerous 100 per cent foreigner-owned air ambulance operators based in the neighbouring countries of Singapore, Malaysia and Australia also offer emergency transportation to the Indonesian islands. Also, many islands do not have airports or airstrips, meaning that helicopters would then have to be used. The selection of which airline, air ambulance or helicopter charter company to use is dependent on flight availability, aircraft specifications, the airport and landing facilities. A few Asian regional air ambulance companies even station one of their aircraft in the more heavily tourist frequented spots such as Bali, so there is no lack of transportation for emergencies when the need arises.
Many of the islands are not able to provide advanced medical care. Corrupt officials, cultural sensitivities, logistical obstacles and inadequate western standard medical facilities are the challenges that are faced by the local assistance company, making collaboration with a trusted and dependable network of local providers of paramount importance.
The ISOS assistance company is the only assistance company that is of 'international' origin with an operation inside Indonesia. BDA and Global are both local home-grown assistance companies. Other international or foreign assistance companies prefer to work through one of the local assistance companies for all dealings with the local providers, thus eliminating problems of language barriers, bureaucracy and having to negotiate the 'usual and customary' dos and don’ts of the healthcare industry.
We would like to conclude by briefly recounting the following two case histories from our files to illustrate the manner in which BDA staff with different specialist skills and expertise render emergency assistance to people in critical conditions even in the most challenging and inaccessible locations. Each case history has almost all the elements of an adrenalin-pumping rescue and adventure TV series!