The global burden of dengue

Dengue, a systemic viral infection transmitted from person to person by the Aedes mosquitoes, presents a persistent and escalating problem in many parts of the world. Globally, the dengue infection has been predicted to reach 100 million cases in more than 110 countries, and the incidence rate, death and disability-adjusted life years (DALYs) lost have all increased during the past two decades (Zeng et al. 2021). Although dengue transmission occurs mainly in tropical regions, it has been highest in Asia (Simmons et al. 2012), where more than 75% of the world’s population infected with dengue live. Eight countries in the Southeast Asian region are classified as hyperendemic areas, including Indonesia (Murray et al. 2013). Recent studies indicate that dengue has the highest DALYs lost in Southeast Asia compared to other neglected tropical diseases such as schistosomiasis, leprosy, trachoma, hookworm and ascariasis (Shepard et al. 2013).

In addition to the morbidity and mortality, evidence shows that dengue significantly impacts the economic burden. A systematic review estimated the global cost of dengue illness was US$8.89 billion annually, consisting of 46% non-fatal cases admitted to hospital, 33.6% non-fatal ambulatory patients, 8.5% non-fatal non-medical cases and 11.9% fatal cases (Shepard et al. 2016). Asian countries experienced productivity losses of US$6.7–$1,445.9 for inpatients and US$3.8–$1,332 for outpatients per dengue episode. The cost of productivity losses associated with fatal dengue episodes in Asia is around US$12,035–$1,453,237 (Hung et al. 2020).

Dengue also affects quality of life, mainly psychological and social functions. From the quality of life perspective, dengue infection causes discomfort and nervousness. During the acute phase of the disease, the physical symptoms of dengue have several effects on personal mobility and social activities that persist into the late-acute stage of the disease. The most common symptoms sometimes last beyond the period of fever. These disorders often worsen, especially in those who do not seek treatment (Elson et al. 2020).

Environmental conditions and community behaviour can also affect the development of dengue, which affects the prevalence of dengue yearlong. All age groups are vulnerable to this disease.

Ensuring timely access to quality health services is a basic human right. All people, regardless of their social location, race, economic circumstances, cultural background, sexual orientation or gender, should have equitable access to essential health services (WHO 2015a). From a government perspective, safeguarding responsive and appropriate access to essential health services is one of the key objectives of health systems (WHO 2000, 2007). In most instances, people interact with health systems as patients who require expert opinion and treatments about their health concerns. People’s access to such services is influenced by at least three key dimensions of access: availability, affordability and acceptability (WHO 2015b). Availability refers to the physical presence and reach of the health facilities, workforce and services, whereas affordability refers to the ability of patients or communities more broadly to pay for the health services (ibid.). Acceptability deals with the sociocultural components of health services to ensure the delivery of quality, appropriate, timely and responsive health services (ibid.).

Inequitable access to health care is a recurring health system challenge in Indonesia, given the country’s demographic, geographic, economic, sociocultural and political characteristics. The emergence of the COVID‑19 pandemic in March 2020 has amplified existing access and health inequities within communities and between different population groups across Indonesia. As observed in other countries, the pandemic has led to disproportionate consequences, both mortality and morbidity, among socially and economically disadvantaged populations (Bambra et al. 2020; Dorn et al. 2020). The inequitable access to health care during the pandemic is exacerbated further by the interconnected systemic risks such as inequities in wealth, lack of social protection, unfair employment structure, food insecurity, and maldistribution of health infrastructure and resources (Bambra et al. 2020). For instance, existing government priorities and decisions embedded in sociopolitical infrastructure and economic forces have allowed the pandemic to discriminate against marginalised groups.

Ensuring access to affordable and comprehensive health services, therefore, requires interventions beyond the individual level to include these interrelated structural and political determinants of health. Designing new institutions and mechanisms to address the structural causes of access inequities requires critical examination of how problems and their solutions are framed.

It is a matter of great pride and frequent comment that Indonesia is the fourth most populous nation and the third most populous democracy in the world. This factoid, much beloved by journalists and schoolchildren, opens the door to bickering among other nations’ politicians, but it lays out two vital issues: Indonesia as a nation and Indonesia as a democracy. Both point to the importance of reliable population estimates for the workings of health, education and electoral systems. Demography provides tools to measure population dynamics. The demos in both demography and democracy refers to people—the citizens of a nation. For Indonesia, the demographic story goes back to the early nineteenth century when Sir Thomas Stamford Raffles’ short-lived British administration of Java included a census count. In the subsequent hundred years a restored Dutch administration, riding the trends of modernisation, industrialisation and enlightenment, adopted many innovations to improve the counts of the rapidly growing population, initially in Java but inexorably spreading through the archipelago.

In the historical effort to understand disease and death, doctors and governments used these census results to measure and analyse human experiences of health challenges. At the core of recording disease and death is the importance of understanding population size, characteristics and trends. Public health was growing as a discipline in European medical schools, and administrators were learning to use rates and ratios to evaluate the impact of their actions. Numerators were counts of the blows to the individuals suffering from infectious diseases, nutritional insults or violent attacks. But they gained rational explication when denominators turned them from simple reports into forms of logical analysis. More often than not these denominators were measures of the population including age and sex structure. In the face of pandemics and hunger, the government fostered ever more demographically informed health data throughout the late nineteenth and twentieth centuries.

In this chapter, the history of censuses and health statistics is followed through to the innovations of the reform-era political leaders of the twenty-first century. Two themes stand out. First, following five decades of progress in building statistical strengths in government, bureaucrats have recently backtracked in important ways.

Canvassing health transition in Indonesia

In 1950, about 189 out of 1,000 babies born alive in Indonesia would not have survived past their first birthday. Such a high infant mortality rate overwhelmingly contributed to the population’s low life expectancy for the newly independent nation at the time. Assuming the prevailing age-specific patterns of deaths, for the same year, life expectancy at birth was estimated to be 39.4 years. By 2022, Indonesia’s infant mortality rate has fallen to 17.7 deaths per 1,000 live births, and life expectancy at birth has risen to 68.25 years.

If we go by these trends in infant mortality rate and life expectancy, the future trajectory for the general health and wellbeing of the average Indonesian is looking rosy. After all, the two indicators are meant to capture the underlying factors and contexts that shape the health of the nation. At the outset, gains in life expectancy—and correspondingly, the reduction in infant mortality rate—reflect a narrative of improvements in income per capita, living conditions, nutritional intake and education, as well as access to and quality of health care in recent decades. But focusing only on these two broad indicators may also obfuscate the complex history of Indonesia’s health transition, where wins are often coupled with setbacks, and where health-related innovations regularly intersect with novel conundrums.

What do we mean by health transition, and why do we often hear that Indonesia’s health transition has been marked by increasing complexity over time? The term health transition is often used interchangeably with epidemiologic transition. The latter was first conceptualised by Abdel Omran in 1971 to refer to the long-term shifts in the mix of diseases as people live longer through the course of economic development and social change. More specifically, Omran coined the term epidemiologic transition to describe ‘the complex change in patterns of health and disease and on the interactions between these patterns and their demographic, economic and sociological determinants and consequences’ (1971: 510). In the first iteration of the epidemiologic transition theory, Omran proposed that there are three distinct stages in the transition: the age of pestilence and famine, the age of receding pandemics, and the age of degenerative and man-made diseases.

The increase in government spending associated with the COVID‑19 pandemic between 2020 and 2021 has reduced the Indonesian government’s fiscal capacity for financing welfare programs, including financing a much-needed health sector transformation, for at least the next four years. In the past two decades, the health sector in Indonesia has been affected by a number of major reforms. These include multisectoral reforms outside the health sector, such as changes in public service organisation following the 1999 decentralisation, to reforms that focus specifically on the health sector, such as the introduction of universal health care in 2014 (Mahendradhata et al. 2017). Following these health system changes, new and remaining challenges such as the financing of universal health care and the changing landscape of disease have been identified, and the need for further reforms acknowledged. These challenges and the gaps in the health system exposed by the pandemic have prompted the national government to commit to a health sector transformation that involves reorienting and restructuring the health system through a series of reforms (Ministry of Health Regulation No. 13/2022 about the Strategic Plan of the Ministry of Health 2020–2024).

Drawing upon the government’s projected fiscal space and data canvassing the health sector conditions before the pandemic, this chapter examines the post-pandemic trajectory of health reforms in the country. I outline lessons learnt during the past two years of the pandemic, and consider pre-existing (i.e. pre-COVID-19) health sector challenges, to assess the financing of the health sector transformation. This chapter demonstrates that the costs associated with financing the reforms are huge, and that the pandemic has negatively affected the government’s capacity to finance such spending. Although the narrowing fiscal space due to COVID-19 has put pressure on public funding, the government is likely to prioritise the development of the health sector through various policies. One likely policy is the use of private financing. Better-off members of society would pay more for their health services through pre-paid schemes, while the limited public funding would be allocated to preventive and promotive public health services. In the future, a health sector funded by both public and private sources should be examined.

The unequal distribution of health care workers between urban and rural areas—and across subnational regions—has been a persistent policy challenge in many low- to middle-income countries, including Indonesia. Previous studies in other country settings have suggested that although the types of diseases and severity of illness experienced by rural residents are becoming increasingly similar to those found in urban populations, the access to and patterns of use of medical specialist services are very different. That is, amid increasing prevalence of non-communicable diseases and chronic illness, a significant share of the rural and regional population in the Global South continues to have limited access to medical specialist care (DeBenedectis et al. 2022; Duke et al. 2021; Lorch et al. 2021; Nguyen-Pham et al. 2014). Studies have shown that patients with chronic diseases such as diabetes, congestive heart failure, cancers and obstructive pulmonary disease who live in rural areas with fewer doctors per capita have fewer consultations and diagnostic tests (Corallo et al. 2014). Further, the lack of access to medical specialist services has a compounding impact on the quality of care for rural patients. For example, prehospital time for rural patients is prolonged compared to that for urban patients (Ashburn et al. 2022). Patients who live in regions with fewer beds will experience fewer hospitalisations and a lower likelihood of being treated in intensive care units (Wennberg 2002).

This chapter addresses the issue of regional disparities in access to and use of medical specialist services in Indonesia. While the unequal distribution of specialist physicians has been a longstanding problem in Indonesia, we argue that the required policy response to address this issue has become more complex because of decentralisation. In the context of increasing complexity in the planning and management of human resources for health following decentralisation, we present our assessment of the two broad strategies that have so far been employed by the government: the attempts to produce more doctors, and strategies to invite the private sector and foreign investment to meet the demand for private hospitals with specialist doctors.

For many of us, the concept of disability is at once familiar and unknown. While it is common when considering disability to think of a woman in a wheelchair or a man who is blind, it is less usual to recall that ‘disability [also] encompasses the child born with a congenital condition such as cerebral palsy … the young soldier who loses his leg to a land mine, … the middle-aged woman with severe arthritis, [and] the older person with dementia, among many others’ (WHO and World Bank 2011: 7). In addition, the diversity of disability extends well beyond the type of health impairment to factors including severity, duration, age, age of onset, gender and income. For disabilities can be mild or severe, temporary or permanent, and can affect all people, whether they are young or old, men or women, rich or poor. Significantly, some factors appear to be more common than others (for example, disability tends to be more prevalent among women, older adults and the poor) but each set of circumstances gives rise to different needs and experiences, which are further influenced by the physical and cultural environment in which a person lives. Notably, around the world, and in developing countries in particular, this wide variation in the experiences and challenges faced by people with disabilities (PwD) and their families, and the policies and programs that could best support them, are still poorly understood, largely as a consequence of a lack of reliable, comparable data.

Indonesia recently passed Law No. 8/2016. This law follows the ratification of the United Nations Convention on the Rights of Persons with Disabilities in 2011 and commits the Indonesian government to the eradication of discrimination against PwD and to actively work to support and provide services to this segment of the population.

The COVID-19 pandemic has been a major unprecedented stress on health systems globally. By 30 September 2021, a total of 233.8 million cases of COVID-19 had been confirmed worldwide (WHO 2021). And with the death toll reaching more than 4.7 million as of September 2021 (ibid.), the pandemic has become the largest outbreak of an infectious disease in recent history. As countries respond to the pandemic, additional burdens of maintaining essential health services have been imposed on their health systems. The escalated demand for COVID-19 testing, contact tracing and isolation of cases, and managing severe cases in hospitals, has overwhelmed health care systems in both high and low- and middle-income countries (LMICs). In effect, the pandemic has redirected the focus and prioritisation of health systems, diverting much of the limited health resources to managing the pandemic.

Indonesia is also facing similar challenges in managing the COVID-19 pandemic while trying to maintain the performance of its health system. While the government has issued various programs and policies to mitigate the COVID-19 pandemic, the number of cases has fluctuated since the first case was confirmed on 1 March 2020. As seen in Figure 8.1, the number of daily new confirmed cases continued to rise from early in the pandemic, with higher caseloads observed following the 2021 new year holiday. While the case numbers declined slightly following the roll-out of the COVID-19 vaccination program in late January 2021 (MoH 2021), Indonesia was severely affected by the Delta variant wave. And in mid-2021, Indonesia became the epicentre of the pandemic with more than 49,000 daily confirmed cases and a 2.6% fatality rate (Wibawa 2021). By the end of September 2021, the cumulative number of confirmed COVID-19 cases in Indonesia exceeded 4.2 million, with 141,000 deaths (WHO 2021).

In Indonesia and other LMICs, pandemic-induced disruptions to routine health care services threaten progress towards equitable health improvement. One health goal is to reduce maternal and child mortality, which is among the most sensitive indicators of development and functioning health systems. Even before the COVID-19 pandemic, Indonesia had a high burden of maternal and child mortality. Indonesia’s current maternal mortality ratio is 177 per 100,000 live births, which is one of the highest in the Southeast Asia region (WHO 2020a).

The economic, political, strategic and cultural dynamism in Southeast Asia has gained added relevance in recent years with the spectacular rise of giant economies in East and South Asia. This has drawn greater attention to the region and to the enhanced role it now plays in international relations and global economics.

The sustained effort made by Southeast Asian nations since 1967 towards a peaceful and gradual integration of their economies has had indubitable success, and perhaps as a consequence of this, most of these countries are undergoing deep political and social changes domestically and are constructing innovative solutions to meet new international challenges. Big Power tensions continue to be played out in the neighbourhood despite the tradition of neutrality exercised by the Association of Southeast Asian Nations (ASEAN).

The Trends in Southeast Asia series acts as a platform for serious analyses by selected authors who are experts in their fields. It is aimed at encouraging policymakers and scholars to contemplate the diversity and dynamism of this exciting region.

• • The Islamic political party Pan-Malaysia Islamic Party (Parti Islam Se-Malaysia, PAS) has governed the state of Kelantan on the northeastern coast of peninsular Malaysia for most of Malaysia’s post-independence history.

• • Until 2020, PAS functioned as an opposition party at the federal level, going against the government led by its long-time nemesis the politically stronger and better resourced United Malays National Organisation (UMNO). The David-versus-Goliath story has made PAS’s longevity and durability in Kelantan all the more impressive for having endured decades of marginalization by the federal government. This has to an extent led to the state’s laggard developmental growth and poor socio-economic indicators.

• • PAS has often been portrayed by the mainstream media as an anachronistic and extremist party ill-equipped to cope with, much less solve, the myriad challenges faced by modern society.

• • Notwithstanding PAS’s shortcomings, this article provides an analysis of the factors that have allowed the party to remain in power in Kelantan for so long. It argues that after winning back Kelantan from UMNO in 1990, PAS transformed itself into a modern, well-oiled political machine, particularly when it comes to socializing its agenda to the people of Kelantan and reaching out to many out-of-state Kelantan voters.