ATM #22 Urban Poverty and Health in Asia

Bulletin 22 ISSN 2010-1198

URBAN POVERTY

and HEALTH in

ASIA

Nursing students in training, Yogyakarta, Indonesia

The Asian Trends Monitoring Bulletin is a project

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the analysis of pro-poor projects and innovative

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approaches that will contribute to alleviate poverty.

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The emphasis is put on identifying major trends

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for the poor in rural and urban areas, highlighting

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sustainable and scalable concepts, and analysing

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how these could impact the future of Asia’s well-

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Frequency The Asian Trends Monitoring Bulletin will be produced eight times a year and can be downloaded for free at http://www.asiantrendsmonitoring.com/downloads Principal Investigators Phua Kai Hong T S Gopi Rethinaraj Research Associates Johannes Loh Marie Nodzenski Guest Writers Nicola Pocock Taufik Indrakesuma Bianca Ayasha Production Johannes Loh, Production & Research Dissemination Michael Agung Pradhana, Layout & Design

- Thermometer (p.19)

- Nurses in Indonesia (p.18)

copyrighted by the Lee Kuan Yew School of Public Policy. Please follow the suggested citation: When citing individual articles Phua, K. H. & Nodzenski, M. (2013). Prospects for the Future: Towards Better Regional Governance in Health. In Asian Trends Monitoring (2013), Bulletin 22: Urban Poverty & Health in Asia (pp.17-19). Lee Kuan Yew School of Public Policy, Singapore.

When citing the entire bulletin Asian Trends Monitoring (2013), Bulletin 22: Urban Poverty & Health in Asia. Lee Kuan Yew School of Public Policy, Singapore.

When citing our survey data Asian Trends Monitoring (2012). A dataset on urban poverty and service provision. Lee Kuan Yew School of Public Policy, National University of Singapore.

Please acknowledge the source and email a copy of the book, periodical or electronic document in which the material appears to chris.k@nus.edu.sg or send to Chris Koh Lee Kuan Yew School of Public Policy 469C Bukit Timah Toad Singapore 259772

Contents 4 s Urban Poverty and Health in Asia

by Phua Kai Hong

6 s Protecting the Health of Asia’s Urban Poor

by Nicola Pocock

9 s Healthcare-seeking Behaviour in Slums

by Nicola Pocock

12 s The Unhealthy Impacts of Poor Water and Sanitation

by Nicola Pocock and Taufik Indrakesuma

14 s Unregistered and Excluded: the Government Healthcare Problem

by Taufik Indrakesuma and Johannes Loh

17 s Prospects for the Future: Towards Better Regional Governance in Health

by Phua Kai Hong and Marie Nodzenski

3

Urban Poverty and Health in Asia Public health in urban areas has been and will continue to be affected

faced by officials in these four cities in the field of public health. We pres-

by global population trends. More than 50% of Southeast Asia’s total pop-

ent the findings of the Urban Poverty Survey as supporting evidence of

ulation is projected to be living in urban areas by 2025, which will exert

the realities in the field. Finally, we will discuss the future of regional health

additional pressure on urban health systems. Traditionally, cities offered a

governance and the potential impact of further integration in ASEAN on

health premium over rural areas, especially as they advanced their infra-

health systems and cities.

structure. At the onset of the 20th century, improvements in water, san-

We invite you to share the ATM Bulletin with colleagues interested in

itation and sewage systems, roads, and green spaces meant that cities

pro-poor issues in Southeast Asia. The Bulletin is also available for down-

became healthier places to live. In addition, the growth of cities provided

load at www.asiantrendsmonitoring.com/download, where you can sub-

a range of indirect benefits to health, including the expansion of food mar-

scribe to future issues. We encourage you to regularly visit our website

kets with a steady and diverse supply, public services, transportation sys-

for more updates and recent video uploads in our blog. Thank you again

tems and a critical mass of educated people necessary to drive innovation

for supporting the ATM Bulletin, and as always, we gladly welcome your

and commerce (Dye 2008). Public resources can be concentrated at lower

feedback.

cost in cities, which is effective in public health interventions through basic

Phua Kai Hong Johannes Loh Marie Nodzenski

primary health care like immunization, clean water and waste disposal.

However, as this bulletin will demonstrate, these improvements in public health are not equitably accessible to all parts of society. Even major cities in the region such as Jakarta and Manila have large slums that are deprived of healthy living conditions. Not only are health centres difficult

Guest Writers

to access, the most basic amenities such as sanitation and piped water are

Nicola Pocock Taufik Indrakesuma Bianca Ayasha

also scarce. As such, major interventions are necessary to close these gaps and improve the health of poor communities in Southeast Asia.

In this bulletin, we focus on the trends in urban health in Asia, highlighting the deficiencies in health and healthcare for the urban poor. We then discuss the specific types of public services that need to be improved in order to maximize impact. Throughout the bulletin, we will also include

Suggested citation

case studies of micro-interventions that we found throughout Southeast Asia, and point out opportunities to replicate their successes in cities. The

When citing individual articles

data and case studies that are used in this bulletin are the result of primary

• Phua, K. H. & Nodzenski, M. (2013). Prospects for the

data collection and field research. The team’s research on urban poverty

Future: Towards Better Regional Governance in Health. In

entailed travelling to four of Southeast Asia’s major cities: Jakarta, Manila,

Asian Trends Monitoring (2013), Bulletin 22: Urban Poverty

Hanoi, and Vientiane. The team conducted an extensive Urban Poverty

& Health in Asia (pp.17-19). Lee Kuan Yew School of Public

Survey of 1,400 respondents as well as in-depth interviews with stakehold-

Policy, Singapore.

ers in all four cities. In this issue, we also compare the major challenges

When citing the entire bulletin • Asian Trends Monitoring Bulletin (2013), Bulletin 22: Urban Poverty and Health in Asia. Lee Kuan Yew School of Public Policy, Singapore.

When citing our survey data • Asian Trends Monitoring (2012). A dataset on urban poverty and service provision. Lee Kuan Yew School of Public Policy, National University of Singapore.

4

Local health staff provides vaccination in Laos

Urban Poverty and Health in Asia

by Phua Kai Hong

Urbanization has been directly correlated

problems that have arisen because of poverty

such slum and squatter settlements makes up

with economic growth in developed as well

and inadequate housing among urban popu-

a third or so of the urban population.

as rapidly developing countries. The level of

lations. Adequate housing provision to meet

The pace of population migration, urbaniza-

urbanization defined simply as the proportion

the needs of the urban poor and low-income

tion and globalization represents current and

of a country’s population living in cities has

is crucial because it enables households to link

projected challenges for the health of urban

been higher, the higher the country’s per capita

homes to infrastructure for potable water sup-

populations. As a broad array of influences

GDP. Yet burgeoning growth of cities through-

ply, solid waste removal and modern sanita-

impacts on the health of populations in cities,

out the developing world appears to be posing

tion. City governments in developing countries

public policy and organization are necessary to

the most critical challenge to the future of these

around Asia are struggling with the prolifera-

promote effective planning and evaluation of

cities and their societies to date. In facing such

tion of slums that include squatter settlements.

policies and programs. While the historic role

a challenge, the cities that have linked urban

Many of these are considered illegal because of

of public health emphasized addressing the

growth to economic development and housing

a lack of land tenure rights. Spiraling land costs

rudiments of physical environment such as san-

appear to have been most successful in address-

in fast growing cities mean that the most conve-

itation, much of health care has come to focus

ing the issues posed by slums and the provision

nient locations in and around the city centre to

on individual level of health and addressing

of homes for the urban poor.

stay for low-income earners are often unafford-

individual risk factors. However, the influence

The effort to relate urban growth to hous-

able. Slums and squatter settlements are the

of living conditions on health in cities should

ing development has been crucial in pre-empt-

housing solutions of the poor. In many cities in

include the physical and social environment as

ing many of the environmental and health

developing countries, the population living in

well as health services. At the broadest level, the

5

physical environment involves quality of water,

people in low-income informal settlements or

"Towards healthy urban governance,

food, air and noise levels but more recently, the

slums. Currently, it is estimated that 60% of the

principles of good governance need to

perspective of how the built environment can

world’s informal settlers and slum dwellers are

be continuously applied to the fullest

affect health is gaining momentum.

in Asian cities. In South Asia, slums and squatter

promotion and protection of health.

Similarly, a livable environment brings up

settlements constitute 58% of the total urban

There is no single solution, and actors

concerns of size, density, diversity and complex-

population, compared to 36.4% in East Asia and

will need to continuously navigate a

ity that are hallmarks of global cities, but the role

28% in Southeast Asia. In absolute figures this

fast-changing environment in order

of social networks and support as well as social

translates to more than 550 million people.

to achieve results. Change is best facilitated through nodes of power

capital, is currently emphasized. Such physical

A platform for the notion of healthy urban

and social environment issues have implications

governance seeking to improve the social,

and influence among the urban poor,

for public policy and public health practice in

political, physical and economic environment

local governments and the public

terms of planning, implementation and impact

in cities is crucial to improving the health of the

health sector that are establishing

evaluation. Increasingly, consideration of other

urban poor and may be considered as a strate-

cross-linkages beyond geopolitical

influences including interfaces of municipal,

gic pathway for healthy urbanization.“Healthy

regions. National decision-makers can

regional and national government, business

urbanization”, as defined by the WHO Centre

create more supportive and enabling

and civic organizations is critical and likewise,

for Health Development, refers to the process

environments for achieving fairer

the broader trends of migration, urbanization

of enabling cities to achieve health and equity

opportunities for all by rendering

and globalization will impact living conditions

through eight key principles, the “8 Es”:- envi-

visibility to the health vulnerabilities

that affect the health of urban populations.

ronmental sustainability, empowerment of

of the urban poor through the skilful

Underlying these are the fundamental political,

communities, engagement of all sectors, energy

framing of public policy. "

economic and social/cultural factors serving as

efficiency, elimination of extreme urban pov-

the foundation for any perspective on human

erty, enforcement of security and safety, equity-

future: Acting on social determinants for health

development and well-being in Asia. Rapid and

based health systems and expression of cultural

equity in urban settings. WHO Centre for Health

unplanned urbanization in Asia has profound

diversity. ATM

implications for population health. With globalization, governance failures at the domestic and international levels have resulted in inequities that translate into severe health impacts for the urban poor. Urban poverty and growth of slums, informal settlements and squatter areas thus pose obvious hazards and risks to health.

Asia is home to more than half of the world’s population and in the near future, estimates are that more than 60% of the increase in the global urban population will also be in Asia. In a rapidly urbanizing environment, different groups of people may be exposed to a wide range of risks from communicable and non-communicable diseases as well as violence and injuries.

Different groups exhibit varying degrees of vulnerability or exposure despite the fact that they live in the same city. These varying vulnerabilities are translated into unequal physical and mental health outcomes. The most extreme end of the health inequity gradient in cities includes

(WHO, 2008. Our cities, our health, our

Development, Kobe, Japan.)

6

Protecting the Health of Asia's Urban Poor

by Nicola Pocock

Unhealthy environments

constituting around 12% of the population in

poor sanitation. Detrimental effects on health

ASEAN.

include increased prevalence of communicable

In many Asian cities, planning for healthy cit-

As Dye (2008) notes, health in urban areas is

diseases, elevated risk of dying from prevent-

ies has not kept pace with city expansion and

typically better than in rural areas, when mea-

able conditions such as diarrhea and leptospiro-

inflows of urban migrants. Rapid rates of migra-

sured by lower fertility and infant mortality

sis, as well as less obvious health risks. For exam-

tion have caused demand for public services

rates as well as higher access to sanitation and

ple, poor structural quality of housing can mag-

to outgrow capacity in several cities. For exam-

nutrition. However, the growth of slums could

nify the adverse effects of disasters (Unger and

ple, sewerage system infrastructure is poor in

offset these health gains. This is confirmed by

Riley 2007), typified by a survey respondent in

developing Southeast Asian cities. Only 1% of

responses to the Urban Poverty Survey that

Manila who described the need to place old car

Jakarta’s population is connected to a sewerage

indicate the urban poor’s difficulty in accessing

tires on the roof of her house during typhoons

system, followed by 7% in Manila, 12% in Ho Chi

health services (see Figure 2).

(Loh et al 2012).

Minh City and 41% in Phnom Penh (BAPPENAS 2007).

As shown in the data, a large number of

Overall, the impact of slum environments on

respondents still feel that health services are

the health of their residents is overwhelmingly

The most apparent outcome of this failed

expensive and a large strain on their house-

negative. In figure 3, Unger and Riley (2007)

urban planning is the prevalence of slums.

hold budgets. When asked about the prices of

outline the adverse health outcomes that arise

Southeast Asia has seen the growth in slums in

medicine in particular, responses were more

from the physical condition and legal circum-

Cambodia, Laos PDR, Myanmar and Thailand

positive, but only slightly. In following sections,

stances of tenure. This is also supported by

(see Figure 1). In aggregate, the slum population

the repercussions of unaffordable formal health

data collected in the Urban Poverty Survey on

as a percentage of urban population has seen

care services are discussed.

the self-assessed health of respondents. Figure

a minor decrease in Southeast Asia, from 50.7%

Health outcomes are worse in slums com-

4 shows, for example, that only 21% of respon-

in 1990 to 48.7% in 2005 (UNSD), but absolute

pared to rural and other urban areas (Unger

dents believe their health to be in “very good”

numbers of people remain high. In 2005, 67.8

and Riley 2007). Slum residents face a greater

or “excellent” condition. Given the multitude of

million were living in slum areas in all coun-

number of health risks related to their physi-

health risks faced on a daily basis, this is hardly

tries except Brunei, Singapore and Malaysia,

cal environment, such as overcrowding and

surprising.

7

8

Life for Jakarta's Elderly In Depok, Jakarta’s southern suburb, the team interviewed an old man named Agus who could only approximate his age to be over 80.

Agus lives in a small house with his son’s family, numbering a total of nine people, including several small children, in the house.

Agus used to work as a construction worker, but was forced to retire when his body could no longer handle the work. Now he relies on the support of his children to sustain himself, and has no savings or pensions that he can draw from. When asked about whether he

elderly, as deteriorating immune systems make self-medication and

smokes (an all too common affliction amongst Indonesia’s poor), he

bed-rest much less effective.

could only smirk as he answered that he “used to smoke a bit too

The recent health care reforms in Jakarta (discussed in detail in a

much, but now has the discipline to restrict himself to one cigarette

following section) have the potential to dramatically improve access

per day”.

to health care for people in Agus’ position. However, the reforms

Given his limited financial resources, it was unsurprising to hear

unfortunately do not reach poor families that have been forced out-

that Agus does not make a habit of going for routine health check-

side of the city limits. Agus and his family had to move to their cur-

ups to the nearby health clinic. He reports that clinic visits are usu-

rent residence in Depok because slum crackdowns and rising costs of

ally reserved for serious ailments that he or his family could not self-

living in the 1980s became unbearable. Depok, however, is not part

medicate, and that the occasional cough, flu, or fever does not war-

of the Jakarta Capital Region, and thus does not enjoy the benefits

rant any special medical attention. Though this is a common stance

of its health care reforms. Therefore, regular check-ups and proper

towards medicine amongst the poor, it is especially risky for the

medical attention remain out of reach for Agus and his neighbors.

In order to improve health outcomes in

(Indrakesuma et al 2012b). As an environmen-

slums in the short term, Riley and Unger (2007)

tal determinant of health, housing quality has a

stress the need to gather data on slum disease

huge impact. A study in Thailand showed that

burdens and intra-urban health disparities. The

improvements in housing design and materials,

disease burden in slums may be very different

including in sanitation, equipment, ventilation

from national and even other urban disease pri-

and fuel for indoor cooking and heating, has

orities. The Urban Poverty Survey was able to

played a role in health gains. Mosquito-proofing

gather information on the types of illnesses that

houses (e.g. installing windows) and reducing

respondents suffered within the past month

pools of open water has also been beneficial in

before the survey (see Figure 5).

reducing mosquito-borne diseases (Friel et al

Riley and Unger (2007) also emphasize the

2004).

need to identify and target modifiable con-

Effective health interventions in slums will

ditions of slum life. Immediate interventions

require engagement with community groups

could include reducing sewage run off, educat-

and, notably, private pharmacies that are often

ing residents on hand-washing and hygiene,

the first point of contact for health services in

and installing proper waste disposal systems

slum areas, as has been found in Indonesia

and toilets (ibid). In a slum built atop a trash

(Simanjuntak et al 2004) and Bangladesh (Khan

heap in Bekasi, Jakarta’s eastern suburb, the

et al 2012). The reasons for this, as well as other

building of new toilets in the vicinity of a school

behavioral aspects of providing healthcare

as well as extensive hygiene education has

for the poor, are discussed in the next section.

decreased open defecation in the community

ATM

9

Healthcare-seeking Behaviour in Slums

by Nicola Pocock

In face of numerous health risks, slum resi-

Urban Poverty Survey reported high levels of

clinic or hospital, whereas adults tended to self-

dents face significant barriers to access health-

difficulty in accessing formal health services, as

treat. The poorest individuals were more likely

care. Private (and often unlicensed) pharmacies

shown in Figure 6.

to use a public health centre compared to those

and traditional healers may be located within

When facing illness, the urban poor tend

with higher income, corroborating earlier find-

slums, but it is uncommon for formal health care

to self-treat with cheap medicine from private

ings on use of Posyandus (Indonesia’s public

providers to be based nearby. The monetary

pharmacies, or access the nearest available and

health centres) by income (ibid, Kaye and Novell

and opportunity costs of traveling to a health

affordable alternative. A study on healthcare-

1994a). The visualization of the ATM team’s sur-

centre may further deter slum residents from

seeking behaviour of 160,261 residents in a

vey results in Figure 7 shows that the current dis-

accessing services. Even in cases where cheap

North Jakarta slum found that when faced with

tribution of treatment preferences in Southeast

or free government health services are available,

diarrhea in the past month, 25% treated them-

Asian cities is mostly skewed towards govern-

slum dwellers are usually ineligible for such ser-

selves, 23% visited a public health centre, 18%

ment hospitals and health centres, though self-

vices, as they are typically not formally regis-

visited a private provider, 16% went to hospital,

medication and traditional medicine are still the

tered as residents. Consequently, slum dwellers

9% bought drugs from a drug vendor and 9%

first choice for many poor families.

often encounter the formal health sector in late

used other healthcare providers, i.e. traditional

One worrying sign, however, is that there is

stages of often preventable chronic diseases

healers (Simanjuntak et al 2004). Children were

still a propensity to ignore their illnesses and let

(Riley et al 2007). Respondents in the ATM’s

often brought to a public health centre, private

them go untreated. One in four respondents in

10

the Urban Poverty Survey claimed that if they

regular Posyandu users were more likely to be

being poor, dirty, and unhealthy”. However,

fell sick, they would rather continue working

immunized than non-users (Kaye and Novell

survey responses seem to indicate that a slight

than seek treatment. Although the logic behind

1994a). Crucially, this demonstrates that publicly

majority of respondents in all four cities (nearly

it is clear – the cost of treatment and opportu-

funded and accessible health centres can posi-

65%) are satisfied with the quality of services

nity cost of lost income are large in the short run

tively influence health behaviours.

provided by their local health centre.

– the long-term consequences of deteriorating

However, the urban poor may use private

The poorest in slums often face multiple

health services for other reasons. In a slum

deprivations and may not be reached by offi-

Indonesia’s Posyandu system of publicly

settlement in Delhi, India, nearly 90% of study

cial health programs. In one urban slum in

funded primary health care centres is a model

respondents used private providers for basic

Indonesia, evaluation of a national vitamin A

of excellence among the countries visited by the

primary care, often unlicensed and unregis-

supplementation program found that 63% of

team. In several poor areas of Jakarta, Posyandus

tered. Reasons given for not using public health

children in slums had not received the supple-

were easily identifiable and found in different

centres included long distance from home, lon-

ment. They were more likely to be malnour-

corners of the slum, allowing local residents

ger time to get treated, rude behaviour and in

ished, shorter, anemic, or to have had diarrhea

easy access close to their homes. In Jakarta, 56%

some cases, bribes that had to be paid to hospi-

in the past week compared to children who had

of slum dwellers primarily used the Posyandu,

tal staff to receive treatment (Barua and Pandav

received the supplement. They were also more

while public health centres in Manila, Hanoi, and

2011). Anecdotal evidence from interviewees

likely to come from families with a history of

Vientiane were the first choice for 37%, 3% and

in Manila and Hanoi support this claim: one

infant or child death. The authors highlight that

14% respectively. Past research corroborates the

NGO in Manila reported that their beneficiaries

children who were not reached by the vitamin

positive effect of having access to free primary

were reluctant to visit the local free health clinic

A program were also unlikely to be reached by

healthcare in urban slums; one study found that

because they were afraid of being “scolded for

other programs, such as immunization (Berger

health are often much greater.

11

et al 2008).

Often, it is not a physical barrier of reaching the poorest of the poor: infrastructure even in the poorest areas of these cities is usually good enough for assistance to reach them. The main barrier then is usually informational or psychosocial, where lack of awareness, shame, and prejudice increase the poor’s inhibitions to seek help. This is a barrier that is often forgotten or unaccounted for when health providers design their programs and interventions. ATM

popular street snacks are variations of deep fried flour. The end result is that although these families appear to be well fed, they remain malnourished.

At a glance, this does seems like a problem of finances. However, one set of interventions from Mercy Corp, an international NGO, proved otherwise. Mercy Corp sought to improve nutrition in Jakarta’s slums by improving the food products sold by street vendors. Thus, they launched a program called KEBAL, short for Kedai Balitaku or “My Child’s Café” in 2009. The logic behind the program was that if some food vendors started to sell healthier food while keeping prices low, people would choose to buy the healthier, slightly more expensive food rather than the cheaper, unhealthy

MERCYCORP's KEBAL Program

food.

Not all problems of health among poor urban communities are mat-

eight neighborhoods in West Jakarta and partner them with nutri-

ters of finance. Some problems are matters of behavior, while oth-

tionists. The nutritionists then created a menu of healthy meals and

ers are caused simply by lack of information. A perfect example can

snacks that would replace the unhealthy products that the vendors

be found in Jakarta’s pushcart vendors. For most poor households

used to sell. Food would be partially prepared in a central cooking

in Jakarta, both parents need to work full time in order to make

center so that ingredients remain fresh and clean, and exposure to

enough money, meaning that they do not have enough time to pre-

the unsanitary outdoor environments (one of the main hazards of

pare meals for the family. Also, proper kitchen equipment is a rarity

selling food from pushcarts) is kept to a minimum.

in slums, with several households barely able to afford a small stove.

Thus, most households rely on pushcart vendors for their meals.

The method used was to engage a number of street vendors in

The program was designed to be self-sustaining, as the food vendors were given ample training not only in cooking the healthy

Pushcart vendors are a viable alternative due to how cheap the

menu and general hygiene, but also in financial literacy and man-

prices are. However, this cheap food comes at a cost. In order to keep

agement. The organization plans to expand the program through

prices low, vendors are often forced to cut corners in food prepara-

micro-franchising, as it hopes the model is appealing enough for

tion. Cheap ingredients, high use of MSG and generally prioritizing

more food vendors, as well as other aspiring micro-entrepreneurs,

flavor over nutrition are common traits, which is perhaps why several

to participate.

12

Open defecation – a common issue in Southeast Asia’s slums

The Unhealthy Impacts of Poor Water and Sanitation

by Nicola Pocock & Taufik Indrakesuma

Many health problems, particularly commu-

toilet with other households.

price of five drums of water (1m3) costs around

nicable diseases, originate from poor quality

Another household member having diarrhea

US$3, whereas the same amount of piped water

or lack of clean water and sanitation systems

in the past month and being less than five years

costs only US$0.20 from a piped connection

for drinking, bathing, cooking and cleaning. A

old were also significant factors (Simanjuntak et

(Padawangi in Indrakesuma et al 2012a).

study in 2004 showed that besides low house-

al 2004).

Purchasing drinking water from vendors has

hold income and illiteracy, factors positively

The lack of public service capacity has led

been associated with higher diarrhea preva-

associated with diarrhea episodes within the

to the expansion of the private sector in water

lence and other negative health outcomes,

last month in a North Jakarta slum were:

provision and sewage systems. For example, the

compared to those who don’t purchase drink-

• use of water from a communal tap,

Urban Poverty Survey found that 46% of slum

ing water. In two Jakarta slums in 1994, 28% of

• poor rubbish disposal, daily consumption

dwellers in Jakarta use private water vendors,

mothers reported that at least one child under

followed by 31% in Manila and 2.5% in Hanoi.

three years old had experienced diarrhea in the

Relying on private water sources comes at sig-

last month, with frequency of reporting high-

nificant cost to the poor, who pay up to fifteen

est among poor mothers and those using water

times the amount of piped water. In Manila, the

from vendors (Kaye and Novell 1994b). Purchase

of food from street vendors, • living in a house that flooded within the year prior, • living in a wood structure and sharing a

13

of cheap drinking water has also been associated

sanitation systems at the household level led

with malnutrition, diarrhea and greater infant

to significant decreases in the incidence of

and child mortality. A 2009 study showed that

water-borne diseases (Butala et al 2010). The

families that purchased cheap drinking water

intervention involved communal infrastruc-

tended to have less educated parents, more

tural improvements, such as paving of internal

crowded households, fathers who smoked, and

roads, street lighting, storm water drainage and

lower socioeconomic levels (Semba et al 2009).

solid waste management. Individual house-

It is clear that structural conditions, i.e. having a

holds benefitted from water connections, toi-

piped water connection, and access to a toilet,

let construction and underground sewage sys-

can affect health.

tems (ibid). The authors draw attention to slum

However, the Urban Poverty Survey does

upgrading at the household level, as opposed

not show these connections conclusively. In

to the neighbourhood level (via shared facili-

the results shown in Figure 9 below, responses

ties). The latter has been shown to not reduce

showed no strong link between sources of water

the transmission of communicable diseases

and frequency of illness as a whole. There does

(Zwane and Kremer 2007, in Butala et al 2010).

appear to be a link between primary source of

It is often overlooked by authorities that slum

drinking water and frequency of contracting

upgrading can have wide-ranging multiplier

diarrhea, as 15% of those who shared a commu-

effects that will lower the burden of public bud-

nal tap also reported contracting the disease in

gets. A healthier and cleaner environment helps

the past month, compared to 4% of those with

to improve educational outcomes, strengthen

a household connection and 6% of those who

families’ economic situation and lowers health

used other sources.

expenditure e.g. for water-borne diseases. While

Both household and community level struc-

it is difficult to precisely measure the cumulative

tural improvements are needed. One quasi-

impact of upgrading in slums, studies as above

experimental study in Ahmedabad, India

have illustrated the positive outcomes. ATM

reported that upgrading in slum water and

14

Unregistered and Excluded: the Government Healthcare Problem

by Taufik Indrakesuma & Johannes Loh

In order to curb expenditures and prevent mis-

services are not being exploited by those who

season. Of the Urban Poverty Survey respon-

use, most government healthcare subsidies are

can afford it.

dents in Jakarta, 12% have only lived in the city

limited by a number of criteria. Eligibility criteria

Unfortunately, these requirements are often

for 5 years or less, which partially explains their

differed between the cities visited, but foremost

a severe impediment for the poor. As one dis-

difficulties in accessing government healthcare.

depended on being a registered “poor resident”

trict head in Jakarta noted, a large number of

In Manila, a similar story emerged – 29% of

of the city. This requires having both residency

slum residents are migrants who do not register

respondents reported a great degree of diffi-

status and household income information in

their residency and are thus ineligible for care. In

culty in accessing health services. PHILHEALTH,

the local government database. This way, local

some cases, the residents are seasonal migrants

the national insurance scheme, is estimated

governments ensure that the free healthcare

who return to their villages during harvesting

to have only 50% coverage (REF). This is also likely due to gaps in official resident databases, causing a great number of households to be excluded from insurance coverage.

In Hanoi, being registered on the “poor list” guarantees access to all government services, including healthcare, but getting onto the list is cumbersome (Indrakesuma and Loh, 2012).

Only the poorest registered residents in each district are put on the “poor list”, so being a registered resident does not automatically guarantee access to healthcare.

As shown in Figure 10 on the left, health insurance cover varied significantly between the cities. Jakarta’s health insurance coverage was the lowest of four cities, with 10% of respondents reporting some form of insurance.

Vientiane followed with 11%, while Manila and Hanoi had much higher coverage rates (31% and 54% respectively). This is further evidence that government healthcare programs still have very limited coverage.

Fortunately, there are efforts in place to improve data collection and coverage of government health insurance programs. The two case studies below, one from Jakarta and one from Manila, demonstrate innovations that directly address the main weaknesses of government healthcare plans, and are good examples for other cities to follow. ATM

15

Health worker conducts a basic health assessment in Indonesia

16

Free Healthcare for Jakarta – What Problems Remain?

full, while the other four hospitals reasoned that their equipment

--- by guest contributor Bianca Ayasha ---

age after being rejected treatment by four hospitals. One hospital

The Jakarta Health Card program was recently launched by Joko

claimed to not have a specialist who was able to treat her and also

Widodo, the new Governor of Jakarta, on November 10th, 2012. The

that it was not part of the Jakarta Health Card program. Three other

program is part of his goal to provide free health care for all residents

hospitals rejected Ana because all of their ICUs were full.

was not advanced enough to treat Dera.

The second case is Ana Mudrika, who died of intestinal block-

of Jakarta, especially the low and middle income groups. The Jakarta

Both Dera and Ana's deaths stirred public uproar in the media

Provincial Government aims to disburse four million Jakarta Health

and social media, such as Twitter and Facebook. These cases have

Cards in total. Cardholders will be eligible for free medical treatment

also shown that there are still issues that the Jakarta Provincial

in 340 public health centres (Puskesmas), 88 regional general hos-

Government needs to address to further improve health care

pitals, as well as some private hospitals that are participating in the

provision.

program.

First, the local clinics and the hospitals have experienced short-

The program is funded by the Provincial Health Insurance bud-

ages, both in manpower and capacity. Several clinics and hospi-

get, so only residents of Jakarta are eligible to receive the program.

tals are suffering from a shortage of doctors, in particular special-

Proof of residency in Jakarta is the one requirement to obtain the

ists. Doctors in some local clinics could attend up to fifty patients

Jakarta Health Card. This is done by showing their Identification

a day. Sometimes, patients are only attended by nurses. There is

Card (Kartu Tanda Penduduk) or Household Information Card (Kartu

also a shortage of beds in most of the regional general hospitals.

Keluarga).

The increases in the number of hospital beds have not been able

Prior to this program, it was neither easy nor cheap for residents

to accommodate the rising number of hospitalized patients. The

of Jakarta to access healthcare services. Some poor people were eli-

Jakarta Health Card program is likely to worsen the discrepancy

gible to receive free healthcare by obtaining Declaration of Poverty

between the number of patients and available beds as well as the

letters from their neighborhood authorities. Without this letter,

number of doctors. Thus, the Jakarta Health Card might be coun-

people either had to pay full price for medical services or be denied

terproductive in terms of the efficiency and quality of the medical

treatment altogether. In this sense, the Jakarta Health Care program

services that each patient receives. Involving more private hospitals

does simplify the process for a large number of Jakarta’s residents to

inside the Jakarta Health Card program might be one solution.

seek medical treatment.

Secondly, there is the issue of moral hazard. As medical services

After five months of implementation, there has been on aver-

are now free, there is now a greater risk of service overuse. This

age a 70% increase of patients across all regional general hospitals.

would exacerbate the service capacity problems. Thus, campaigns of

At a glance, the significant rise of patients shows that the public is

how to live healthy lives should be implemented hand in hand with

responding positively to the Jakarta Health Card. However, some

the Jakarta Health Card program, to build awareness that despite the

cases have shed light on the shortcomings of the Jakarta Health

now affordable health care, prevention is still better than treatment.

Card program.

Finally, the Jakarta Provincial Government must resolve the long-

First, there is Dera Nur Anggraini's case. In February 2013, Dera

running residency issues of migrants. There are residents of Jakarta

Nur Anggraini and Dara Nur Anggraini, twin daughters of Eliyas

that have been staying and working “illegally” in the city for years.

Setya Nugroho and Lisa, were born prematurely. As premature

These people include street sweepers, security guards, bus driver,

babies, they required treatment inside the neonatal intensive care

etc. Despite their “de facto” resident status, they still do not have

unit (NICU). In addition, Dera's pharynx was also imperfectly devel-

official documentation which clearly states that their domicile is, in

oped. The estimated cost of NICU treatment was between one and

fact, in Jakarta. The Jakarta Provincial Government needs to set eas-

two million IDR per day. Under the Jakarta Health Card scheme, all

ier requirements for people to apply for Jakarta residency. By being

of Dera and Dara's hospital expenses would be covered. However,

legally acknowledged as a resident of Jakarta, they will receive iden-

Dera died because she was rejected by eight hospitals before her

tification cards and household information cards, which enable

parents found one that would treat her. Four of the hospitals were

them to apply for Jakarta Medical Cards.

17

Promoting the National Health Insurance Scheme for the Poor --- by Nicola Pocock --The Micro-insurance Innovations Program for Social Security (MIPSS) has been supporting the expansion of the Philippines’ national insurance scheme for the poor, Philhealth, since its launch in 1995.

According to the social health insurance provider, 82% of the population had enrolled in the scheme in 2011. Of them, the poorest members (34%) are fully sponsored by the government and the LGU. Specifically, MIPSS has been involved in promoting the group registration scheme, KaSAPI, in collaboration with a network of MFIs, to increase horizontal coverage since 2005.

The MFIs receive a commission according to the number of people enrolled. However, due to insufficient marketing, poor data exchange between MFIs and Philhealth, and a lack of participation from MFIs in the design process, enrollment has not been as high as anticipated. According to Dr. Antonis Malagardis, MIPSS’ program director, the scheme has not reached the 150,000 enrollment target yet.

The benefits package may be too shallow to incentivize people to enroll - “ 90% of claims are hospital bills, and the scheme only reimburses 30% of the bill. So out-of-pocket payments are 70% for the patient”. The low proportion of claims by the poor (fully sponsored group), in relation to membership proportion, may indicate that the poor are less likely to make claims, compared to private and government employees. To increase the depth of coverage, MIPSS has supported the shift from fee-for-service towards a capitation payment model, whereby the hospital can be reimbursed for treatment

up to a capped amount per person. According to Dr. Malagardis, MIPSS has not yet developed a health microinsurance product, as the Department of Health has prioritized increasing enrollment in Philhealth. Private insurers haven’t been all that interested either – “among those who can provide MI products, they have not yet come up with one that is affordable, accessible and simple to understand”.

Health Maintenance Organizations (HMOs), private entities that provide both insurance and treatment, charge premiums that are five to six times higher than Philhealth. In slums, informal health insurance providers offer some insurance schemes, but the payout is a maximum of just PHP 10,000 per annum for hospital visits. In order to market micro health insurance to the poor, messages need to be targeted. Dr Malagardis already has some ideas to market products to slum dwellers: “microinsurance premiums are as low as the cost of one cigarette or one SMS per day”.

Two key lessons can be taken away from this case study. First, the lack of participatory inclusion of MFIs in the design of benefits package means they have not been as engaged in rolling out the group membership scheme. This shows the importance of engaging all relevant stakeholders, as MFIs are likely to have the greatest reach in marketing financial products to the poor compared to other formal insurance providers and financial institutions.

Secondly, Philhealth and MIPSS are already working to increase the depth of coverage by shifting from fee for service to capitation based payment model for hospital reimbursement. However, informal health insurance providers remain an untapped potential partner in these efforts. Could formalization of already existing informal schemes in slum areas help increase coverage for slum dwellers?

For more information, please see: http://www.microinsurance.ph/ index.php

18

Prospects for the Future: Towards Better Regional Governance in Health

by Phua Kai Hong & Marie Nodzenski

Which regional trends are most likely to have

by 2015. Enhanced integration will most likely

and migration flows will put added pressure on

an impact on health in ASEAN countries?

cause sustained movement of people. Health

urban centers too. How are Southeast Asian cit-

being a key outcome in the migration experi-

ies likely to look like in the near future? Although

It is expected that Southeast Asia’s political

ence and in light of migrants’ contribution to

regional demographic and epidemiological

influence and economic growth will continue

economic development, health and labour

trends can be identified in Southeast Asia, pre-

to expand over the next decades. At the same

productivity are likely to be some of the great-

dicting their impact on different countries is

time, population trends in fertility decline and

est socio-economic and political challenges in

difficult, given the great diversity and dispari-

ageing will continue to be key challenges for

ASEAN’s social integration.

ties between them. Southeast Asia can be con-

growing economies. Rural-urban migration

As recent history has shown, infectious dis-

sidered a microcosm. The region is constituted

flows will intensify both within and between

eases continue to be a leading health challenge

of countries at various stages of development

Southeast Asian countries. The need to reduce

in ASEAN. The 2003 SARS episode has been a

(from first world to third world), of various eth-

unemployment in some countries and to fill

crucial determinant in shaping regional gover-

nicities and religions, of various political systems

labour shortages in others will continue to be a

nance for health. Yet, in light of demographic

and ideologies - it is thus difficult to generalize

key driver of migration in Asia. Migration flows

and epidemiological changes, new health

about the future of Southeast Asian cities in the

in the region will be further intensified as the

issues require intense cooperation between

light of health trends and challenges.

ASEAN integration process moves forward to

Southeast Asian countries. Economic growth

Nevertheless, lessons should be drawn from

become “a single market and production base”

and rapid urbanization, demographic changes

comparing the leading cities as challenges and

19

solutions will be different in megacities such as

environmental pollution control. Other inter-

Jakarta and Manila (with population densities

ventions need to promote and facilitate good

It is recognized that these interventions

reaching 10,000 people per km2) or in Lao and

nutrition and physical activity, as well as create

involve implementing different levels of health-

Cambodian cities which are less densely popu-

safe and healthy places in which to work and

related improvements and that extending the

lated but which may have to deal with larger

play. In addition, many communities require

numbers to the entire population is not a sim-

flows of rural‐urban migration. Political systems

effective action to prevent urban violence and

ple exercise. Nevertheless, in order to scale

and political history are also crucial in determin-

substance abuse. In order to ensure access to

up action that will help the people who live

ing a city’s pace of development and approach

essential health care services, the health system

in slums or informal settlements today, and to

to urbanization. Past socialist models of strong

needs to be designed on an equitable basis.

avoid more people living in such conditions

top‐down control have liberalized towards a

While communicable disease control is still a

in the next 25 years, bold steps are needed to

greater growth of markets and a number of bot-

priority, new interventions concerning injuries,

improve urban governance in ways that achieve

tom‐up movements have been contributing to

non-communicable diseases (NCD) and mental

better housing, water and sanitation, transpor-

change in these countries. Generally, compe-

health are of growing importance. For the poor

tation, education, employment, healthier work-

tition and opposition movements will be the

to acquire access to the necessary services, as

ing conditions and access to health-promoting

leading force in demanding urban changes in

well as improved food, education and transport,

interventions as well as health services (WHO,

the development process.

evidence suggests that effective intervention to

2008).

Southeast Asia is a fast‐growing and fast‐

necessary for sustained economic growth.

invest in health and social programs are indeed

changing region. A mix of rapid demographic changes, a rise in epidemics and bad governance constitutes a possible worst case scenario for the region. Yet, in light of efforts at the regional level to tackle emerging health issues, the probable scenario would be one riddled with episodes such as SARS which can also spark innovative responses, contributing therefore to a more optimistic vision of the future. But it is crucial to reflect on how to create more equitable, inclusive and healthy cities which do not leave vulnerable population groups to the vagaries of development. This rests on the condition that Southeast Asian countries, both individually and as a regional grouping, strive towards better governance for health.

What needs to get done to improve health among ASEAN populations?

Social capital or solidarity is a firm base for urban health equity interventions, and programmes that build stronger communities at local level should be a part of any intervention package. It is clear that for the people in slums and informal settlements, improving the living environment is essential in the cities. Many experts highlight the creation of healthy housing and neighbourhoods as a priority. This includes provision of clean water and sanitation, energy supply and

Temperature check with a mercury free infrared thermometer

20

How can good governance for health in

cooperation in politics and security, economics

arrangements between those stakeholders,

Southeast Asia be achieved?

and the socio-cultural fields. The Socio-Cultural

such as in public‐private partnerships. Health

Community Pillar paves the way for further

governance will further have to be inter‐sec-

social integration and is central to the creation

toral in order to better address the social deter-

of an ASEAN Community by 2020.

minants of health. These are preconditions to

The role of ASEAN in health governance has been stimulated by health crises which have affected Southeast Asian countries across borders and which have required concerted action.

SARS in 2003 is considered a turning point in regional health governance. The economic and health costs of the epidemic have fostered cooperation in ASEAN and have led to the creation of regional mechanisms.

“Rapid urbanization, population movement, and high-density living raise concerns about newly emerging infectious diseases, but these outbreaks have stimulated regional cooperation in information exchange and improvement in disease surveillance systems” (Chongsuvivatwong V, Phua KH, Yap MT et al, Lancet 2011) ASEAN’s potential as a global health actor expanded with the adoption of the ASEAN Charter in November 2007 and with the birth of an ASEAN Health Division. While institutional development in ASEAN has been clearly visible in economic and security fields, the post‐SARS period witnesses the emergence of public health as an important area for regional governance. Effective regional cooperation can increase the capabilities of national health systems which have been heavily taxed by health crises but yet, are under‐resourced. Under the Charter were also established three pillars for

Enhanced cooperation in health has, in part, been supported by the growing awareness that

the design of a holistic and effective approach to health in Southeast Asia.

health and development are closely linked. For

While health issues, such as urban health,

example, the estimated cost of SARS to East

which require taking measures to reduce pov-

and Southeast Asia has been estimated to be

erty or improve infrastructure and sanita-

US$18 billion (Coker et al. 2011). Environmental

tion, seem to belong to the domestic sphere,

health issues such as the haze are also increas-

regional health governance can have a positive

ingly thought to impact on political stability

impact on national developments and health

and economic development in the region. In

improvements. Although it may seem difficult

1997, the total social costs incurred by the haze

to design legislation or to create enforcement

amounted to US$9 billion. Similarly the long‐

mechanisms on such issues at regional level,

term cost of unhealthy population segments

ASEAN has a crucial role to play as a platform for

such as migrants are likely to impact Southeast

knowledge and information exchange, as a plat-

Asia’s development.

form for more developed countries to share best

It is therefore necessary to address, both

practices with less developed countries as well

at national and regional level, issues pertain-

as to improve data tracking. As a regional orga-

ing to the health of vulnerable population

nization, ASEAN will increasingly have to push

groups. Indeed, rapid growth in Southeast Asia

for the harmonization of health standards, and

has led to important health disparities, pos-

especially between the urban cities throughout

ing great public health challenges. Inequity in

the region. ATM

health has been a central theme of this Asian

Regional health governance will also have

“Further growth and integration of the ASEAN region should include as a priority, enhanced regional cooperation in the health sector to share knowledge and rationalize health systems operations, leading to further public health gains for the region’s diverse populations”

to be more inclusive of various stakeholders (in

(Chongsuvivatwong V, Phua KH, Yap MT et al,

Trends Monitoring issue. Closing inequity gaps both within and between ASEAN countries is an imperative. The concept of equity is further central to a reflection on good governance. Achieving good governance in ASEAN will require addressing disparities between its member states.

particular of civil society organizations) and will be most effective through the use of flexible

Lancet 2011)

21

School children in Laos wash their hands during a break

22

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24

Principal Investigators

Research Associates

Phua Kai Hong is a tenured professor at the LKY School

Johannes Loh is working as a Research Associate at

of Public Policy and formerly held a joint appointment as

the Lee Kuan Yew School of Public Policy. He holds

Associate Professor and Head, Health Services Research

a Master’s degree in Public Policy from the Hertie

Unit in the Faculty of Medicine. He is frequently con-

School of Public Policy in Berlin, and a Bachelor of Arts

sulted by governments within the region and interna-

in Integrated Social Science from Jacobs University

tional organisations, including the Red Cross, UNESCAP,

Bremen. His previous research experience includes aid

WHO and World Bank. He has lectured and published

governance, visual political communication and pub-

widely on policy issues of population aging, health-

lic sector reform in developing countries. Prior to join-

care management and comparative health systems in

ing the Lee Kuan Yew School of Public Policy he has also

the emerging economies of Asia. He is the current Chair of the Asia-Pacific Health

worked for the United Nations Environment Programme in Geneva, Transparency

Economics Network (APHEN), founder member of the Asian Health Systems Reform

International Nepal, and the Centre on Asia and Globalisation in Singapore. His email

Network (DRAGONET), Editorial Advisory Board Member of Research in Healthcare

is johannes.loh@nus.edu.sg and you can follow his updates on trends in pro-poor

Financial Management and an Associate Editor of the Singapore Economic Review.

policies in the region on Twitter @AsianTrendsMon.

His email address is spppkh@nus.edu.sg T S Gopi Rethinaraj joined the Lee Kuan Yew School

Taufik Indrakesuma is a research associate at the Lee

of Public Policy as Assistant Professor in July 2005.

Kuan Yew School of Public Policy. He is a recent grad-

He received his PhD in nuclear engineering from the

uate of the Master in Public Policy programme at the

University of Illinois at Urbana-Champaign. Before

Lee Kuan Yew School of Public Policy. He also holds a

coming to Singapore, he was involved in research and

Bachelor in Economics degree from the University of

teaching activities at the Programme in Arms Control,

Indonesia, specialising in environmental economics.

Disarmament and International Security, a multi-disciplin-

Taufik has previously worked as a Programme Manager

ary teaching and research programme at Illinois devoted

at the Association for Critical Thinking, an NGO dedi-

to military and non-military security policy issues. His

cated to proliferating critical thinking and human rights

doctoral dissertation, “Modeling Global and Regional Energy Futures,” explored the

awareness in the Indonesian education system. His research interests include behav-

intersection between energy econometrics, climate policy and nuclear energy futures.

ioural economics, energy policy, climate change mitigation and adaptation as well as

He also worked as a science reporter for the Mumbai edition of The Indian Express

urban development policy.

from 1995 to 1999, and has written on science, technology, and security issues for various Indian and British publications. In 1999, he received a visiting fellowship from the Bulletin of the Atomic Scientists, Chicago, for the investigative reporting on South Asian nuclear security. His current teaching and research interests include energy security, climate policy, energy technology assessment, nuclear fuel cycle policies and international security. He is completing a major research monograph "Historical Energy Statistics: Global, Regional, and National Trends since Industrialisation" to be published in Summer 2012. His email address is spptsgr@nus.edu.sg

25

The Lee Kuan Yew School of Public Policy is an autonomous, professional graduate school of the National University of Singapore.

Its mission is to help educate and train the next generation of Asian policymakers and leaders, with the objective of raising the standards of governance throughout the region, improving the lives of its people and, in so doing, contribute to the transformation of Asia. For more details on the LKY School, please visit www.spp.nus.edu.sg