Promoting health, preventing illness

Interview with Budi Gunadi Sadikin, minister of health, Indonesia

How has the Indonesian government reformed its health system?

When I joined the ministry in December 2020, the president gave me two tasks. The first was to save our people from the pandemic and the second was to reform the Indonesian healthcare system. In September 2022, we launched six pillars of healthcare reform: primary care, secondary care, healthcare resiliency, healthcare financing, healthcare human resources and healthcare technology. We also combined 11 antiquated laws into one single healthcare law in 2023, which laid the foundation for the whole reform. 

What results have these reforms had so far?

The biggest killers in Indonesia are stroke, heart attack and cancer. Every year our databases register 300,000 deaths from stroke, 215,000 from heart attacks and 234,000 from cancer. Based on my experience during Covid, the actual number is usually three times higher – so the number of deaths from stroke is closer to 900,000. Three million Indonesians die every year from these non-communicable diseases. 

If you manage stroke within two hours or a heart attack within six hours, the probability for the patient to live is very high. So we should have facilities in all 514 cities by 2037. When I started, only 44 cities had facilities for treating heart attacks. Can you imagine if you have a heart attack in Toronto and you have to go to Vancouver for treatment? Ridiculous! So with the grants and loans we have raised, we’ve increased the number of catheterisation laboratories from 44 in January 2023 to 129. 

But we won’t see significantly increased numbers of lives affected yet because we don’t have enough specialists. So I am sending young doctors and health workers with our fellowship programmes to study cardiac interventions abroad. And we’re reforming the national insurance system to cover the costs completely for patients.

What is the most important political choice
you’ve made?

The average US life expectancy is 76 years, the average health per capita cost is $12,434. Cuba and Panama have about the same life expectancy but spend less than $1,400. Life expectancy in Japan, Korea and Singapore is around 84 years, and they spend under $4,400. They spend more to keep people healthy than to treat sick people. This is a political choice. From the government’s perspective, it’s better to be healthy than to have a modern hospital to treat people who become sick. The biggest political choice I’ve made is to move the budget, law and priorities towards promoting health and preventing illness, because it is a much better strategy for people and for the country.

Why did you and Sri Mulyani Indrawati launch the pandemic fund? 

Having been a banker, I’ve seen many global financial crises. In just weeks, the World Bank and International Monetary Fund can disburse billions. In 2020 came the first global health crisis I’ve ever seen and Indonesia could not get the protective suits, equipment and vaccines that saved millions of lives. In a global financial crisis, money is the medicine. In a global health crisis, you cannot directly transform money into vaccines or medicine, because pharmaceutical and vaccine companies will be paid more by developed countries. So we need equal access to emergency medical countermeasures: vaccines, therapeutics, medicine and diagnostic tools. 

During Indonesia’s G20 presidency in 2022 we proposed two mechanisms: the pandemic fund and the pandemic treaty. A company cannot by law protect its products only to sell them to the highest bidder: this is just not right. There should be a mechanism to reimburse companies fairly for their inventions and capital, but they should offer their products to all 8 billion people in the world fairly. That is the concept of the pandemic fund. 

The pandemic treaty is about access to medical countermeasures, and is finally getting approved. But I am afraid we’ve lost the essential component that during a pandemic, all the needed emergency medical countermeasures should become public goods, with the companies that own the patents reimbursed fairly. 

What challenges remain?

The biggest challenge is the supply of healthcare professionals. Formerly, as a banker, if I gave a loan I checked if the company had a secure supply of raw materials. If not, it would not have enough cash to repay the loan. In the healthcare sector, the most critical resource is doctors. Indonesia can easily get money, but not doctors. No country has an excessive supply of doctors except Cuba. That increases the price significantly. We lack cardiologists and neurologists, and stroke and heart attacks kill more than one million people every year. That is why I want to import doctors, as happens in many industries without resources: we import from the Philippines or Malaysia. But the barrier to entry for physicians is extremely high and that becomes politically extremely sensitive.

As for shrinking international aid, Indonesia has received over $1 billion for the last 14 years for tuberculosis. To be honest, there has been little progress. Every country should have a very clear financial and healthcare pathway: for Indonesia for the first 10 years, live on grants; for the next 10 years, reduce grants to 50% and use concessional or low-interest loans; for the next 10 years live by commercial loans; then, finally, carry on by ourselves. That puts responsibility back onto the countries and their leaders. 

It’s a good signal to become more efficient and commit our own budget. Living forever on grants is not healthy.

What political choices are needed now, in Indonesia and abroad?

We have to spend more on programmes that save people, not more money on the programmes that potentially kill people. 

There are three types of war: war with nature – the biggest was the Yangtze River flood that killed four million. Second is war with people – World War Two cost more than 60 million lives. Third, with the most casualties, is war with pathogens. One billion people have died from infectious diseases in the last 300 years. The number of soldiers killed is much lower than the number of people who’ve died from stroke, cancer, heart disease or even infectious diseases. So why do our political leaders allocate resources to things that kill? We should spend much more on health care to protect our citizens’ lives. That is my plea, to all global leaders. It’s much better for humanity – all eight billion of us.