For New Health Minister Nila Moeloek, a Destiny Deferred

When Nila Djuwita Anfasa Moeloek walked out onto the State Palace lawn last Sunday afternoon as Indonesia's new health minister, it was an introduction that was five years overdue.

In an exclusive interview with the Jakarta Globe at her home immediately following the announcement, she says she was as surprised as many observers were to learn of her selection as health minister. Observers had largely ruled her name out of the running, with attention focused instead on Hasbullah Thabrany, a public health professor and one of the national health insurance scheme's (BPJS) principal architects; Ali Ghufron Mukti, a Health Ministry insider; Fahmi Idris, BPJS' current director; and Akmal Taher, a former director general of health services.

Nila previously served as President Susilo Bambang Yudhoyono's Special Envoy for the Millennium Development Goals, and she succeeds Nafsiah Mboi, who was sworn as health minister on July 14, 2012, after her predecessor, Endang Rahayu Sedyaningsih, unexpectedly succumbed to cancer.

Nila says she first learned on Friday that she had been short-listed when President Joko Widodo sent her a text message asking her to come to the State Palace on Sunday. "He asked me to wear a white shirt," she says.

"The last time I spoke with [President Joko] in person [prior to last Friday's text message], was on August 17," during an Independence Day celebration, Nila says.

Although many observers had hoped Nila would be selected, she had largely been discounted for reasons of history. She was previously short-listed — and according to credible reports, selected — to head up the Health Ministry in 2009, but was unexpectedly bumped just hours prior to announcement. The reason, according to leaks from President Susilo Bambang Yudhoyono's office: Nila had failed a psychometric test, suggesting she would have difficulty performing her duties as minister under pressure.

"That's complete nonsense," Nila says of the allegation. "I'm an ophthalmological surgeon. I use some of the smallest instruments in medicine to operate on people's eyes, healing and restoring their vision. Of course I perform well under pressure. My career provides ample evidence of that."

Many believe the last-minute substitution of Endang for Nila in 2009 was rooted in the fact that Nila's husband is Faried Anfasa Moeloek, a staunch anti-tobacco advocate who previously served as health minister between 1998 and 1999.

Learning curve

Nila is no outsider to the nation's health system — or its challenges. As special envoy for the MDGs, Nila used her position's operating budget to create Pencerah Nusantara, a now-nominally nongovernmental organization (despite its decidedly governmental origins) that deploys interdisciplinary teams of young doctors, nurses, public health practitioners and nutritionists to seven remote districts, where the teams live and work collaboratively with underserved communities.

Pencerah Nusantara's teams are charged with revitalizing Indonesia's ageing system of primary health care centers, or puskesmas. This mission, launched under Nafsiah's tenure, was greeted with suspicion verging on hostility by the then-health minister, who would remind the teams in closed-door meetings that any attempt at "revitalization" was to be conducted under the auspices of her own strategic leadership — and not as counterpoint to it.

Nila faces a steep learning curve during her first weeks in office. She will have to quickly assess unaddressed challenges at the Health Ministry, while simultaneously absorbing and adapting the president's ambitious set of policy priorities to the political reality of administering one of Indonesia's largest and oldest civilian bureaucracies.

Confidential work plan

Prior to the announcement of Nila as health minister at the State Palace on Sunday, the Jakarta Globe obtained a confidential work plan, drafted by a sub-group of Joko's transition team, outlining the administration's policy priorities for the Health Ministry.

During the interview, Nila abided by Joko's injunction for ministers in his incoming cabinet to refrain from commenting on policies and programs — a measure that would appear equally aimed to protect the president's agenda, as well as the reputation of many like Nila, who appeared to have been caught by surprise.

Given her reluctance to discuss programs, the Jakarta Globe could not determine whether Nila had read the transition team's work plan, or was familiar with the points in it. Similarly, the Jakarta Globe was unable to determine whether Nila had previously endorsed the document or offered input on its contents prior to her selection as minister.

The document was produced with the input of one of Nila's close associates, who is involved in Pencerah Nusantara and whose anonymity was requested for this article.

Primary care systems

The transition team's work plan calls for a massive scale-up over the coming years of a model resembling Pencerah Nusantara — which the NGO only began implementing as a pilot in 2013.

Prior to Nila's appearance at the State Palace, an official close to the incoming minister expressed confidence that Pencerah Nusantara would serve as the Health Ministry's implementing partner, rolling out a program of "integrated primary health care and community-based collaboration ... in 101 primary health care centers" across the archipelago.

The transition team plans further call for scaling a model fitting the description of Pencerah Nusantara to Indonesia's remaining 7,000 primary health care centers between 2016 and 2019. Health experts say such a plan could meet resistance from those in the ministry for reasons ranging from cost to evidence-based efficacy.

Asked directly about these plans, Nila equivocates: "We will consider something like [Pencerah Nusantara], but plans are not fixed yet."

"I need to wait and discuss any future programs with the president and his cabinet," she adds.

If a program resembling Pencerah Nusantara were to be scaled nationally, it would likely involve diverting current or future professionals enrolled in the government's PTT program, which provides scholarships for doctors and nurses on condition of their placement and practice in remote areas for three years or more following graduation.

Also unclear is the question of funding such an expensive program on a national scale.

Data monitoring

According to the transition team work plan obtained by the Jakarta Globe, the minister of health will be tasked with developing an integrated system for monitoring location-based performance data of the ministry's initiatives in the field — and reporting them to the president's situation room.

It is not immediately clear what performance metrics the president intends to monitor, or how it intends to mandate their reporting in real-time, given the well-known difficulties that the ministry's monitoring and evaluation mandate involves in the era of decentralization.

Coordination between national and provincial-level authorities within the Health Ministry will likely be a challenge, due to regional autonomy laws enacted after 1998 with the dissolution of the Suharto dictatorship.

Health card scheme

Within the next year, the ministry will pilot a Health Card scheme in seven districts and cities with the goal of enrolling one million new households, according to the transition team work plan. This scheme was initially touted on the campaign trail by Joko, who introduced an identical program while governor of Jakarta. Under the scheme, card holders will be able to access benefits under BPJS, which began its rollout in January of this year.

Critics, however, say the president's Health Card plan sets up yet another parallel system and adds barriers to accessing health care, particularly for Indonesians who are economically disadvantaged or underdocumented, such as migrants.

Asked to defend the president's Health Card plan against these specific criticisms, Nila declined to comment.

Another challenge that Nila confronts as minister will be the question of ensuring health care coverage for Indonesians overseas. The nation's health care law provides a guarantee that all Indonesians — irrespective of where they live — are entitled to access health care, but no provisions currently exist to ensure this entitlement is met.

It is also not immediately clear how the president's plans for health cards and expanded access to the national health insurance scheme will be extended, as promised on the campaign trail, to Indonesians working abroad — as the Philippine government guarantees for its citizens abroad.

HIV and AIDS funding

Indonesia, one of only three countries in the Asia-Pacific region that is seeing a trend of increased HIV infections, faces a $30 million funding gap in its fight against HIV and AIDS — due in part to the imminent and long-planned withdrawal of the Global Fund, and partly due to legislators' lack of commitment to the nation's five-year strategic plan to combat HIV and AIDS.

While the domestic budget for tackling HIV and AIDS has increased from $27 million in 2010 to $37 million this year, the current funding gap is estimated at about $30 million, and it is expected to increase to about $175 million by 2020.

Asked specifically what she plans to do, as minister, to plug the nation's HIV and AIDS funding gap, Nila says: "The Global Fund — I don't know; I think you will have to ask Nafsiah?"

While the transition team work plan obtained by the Jakarta Globe does reference increased efforts to respond to HIV and AIDS as a national priority, it contains no specifics.

Regarding efforts to broaden the resource base for the national response to HIV and AIDS, as well as other diseases, the plan only obliquely references "non-budget funding options," as well as consideration of ways to "tax drugs and medical devices [without] adding to the burden of health care costs."

Family planning

The transition team document appears to be silent regarding the administration's plans for integrating family planning into the national health insurance scheme. It is similarly mute on any plans the administration may have for the National Family Population and Family Planning Board (BKKBN).

Asked whether she will prioritize finding a replacement for Fasli Jalal, who serves as BKKBN's current chief, Nila declines to comment, except to say that she foresees greater "integration" of BKKBN within the Health Ministry — a verb likely to raise eyebrows at BKKBN, which for decades has existed as a standalone agency with a nominal reporting relationship to the health minister.

Nila adds, however, that "population is very important to the vision and mission of the Health Ministry."

Transparency and accountability

There may never have been a more precarious era in which to serve as Health Minister than the present. Nila bears ultimate responsibility for ensuring clear, accurate and timely monitoring of a variety of agencies — among them BKKBN and BPJS — that, by law, have some form of reporting relationship to the minister of health, but whose operations are not under her control.

Nila faces the unenviable task of ensuring, for example, that auditors from the national health insurance scheme's independent oversight board are able to access the data they need to detect fraud and identify supply and demand gaps that BPJS' operational arm must plan to address.

Ensuring transparency and accountability at BPJS may be complicated by the fact that the organization is effectively run as an independent fiefdom by Fahmi Idris, an erstwhile contender for Nila's job who could harbor sour grapes. One of the only levers of power the Health Minister has at her disposal to compel action at BPJS is something of a nuclear option: withholding funding for BPJS' operations entirely.

Nila also faces the challenge of effecting an internal cultural shift at the Health Ministry towards greater transparency and accountability.

Although Nila generally enjoys a reputation among international and domestic partners as a credible and competent actor, many will want to see some sign of good faith demonstrating commitment to transparency and accountability; hopes for the same under her predecessor's tenure were, official avowals aside, slowly deflated.

When Nafsiah Mboi left the National AIDS Commission in 2012 to assume the office of Health Minister, the reputation that followed her — "fearless" seemed to be the universally invoked description — lasted longer than may have been deserved, some observers say.

"She's fearless — except when the data tells a story she doesn't like," one observer, who spoke to the Jakarta Globe on condition of anonymity for fear of retaliation, said.

"Naf tried to suppress the increase in Indonesia's maternal mortality ratio for about a year," another expert familiar with the matter, who also spoke to the Jakarta Globe on condition of anonymity, said.

"She kept rejecting the numbers, saying 'This isn't acceptable', and sending them back to be recalculated with different methods —and often the numbers would come back higher!"

Indonesia's official maternal mortality ratio now stands at 359 dead mothers for every 100,000 live births, far higher than the nation's self-set target of 102 by 2015 and a substantial increase from 223 in 2007.

Nila will also have to rehabilitate the Health Ministry's reputation among civil society organizations as a transparent authority for ensuring accountability. In another now-infamous story related to the Jakarta Globe by witnesses of the event, during a meeting with international partners whom Nafsiah apparently presumed did not speak Bahasa Indonesia, the then-health minister admonished members of an Indonesian NGO not to disclose, in the presence of foreigners, reports that women living with HIV were being forcibly sterilized — for reasons of national pride and standing.

The Jakarta Globe was unable to determine what, if any, action Nafsiah took on the reports of forced sterilizations that she allegedly attempted to suppress.

Discussion is already beginning to circulate among the nation's health professionals about a series of so-called "think tanks" (an apparent misconstruction of "brainstorming sessions") that the new minister plans to hold.

International and domestic partners of the Health Ministry will likely hope to see Nila include the ministry's so-called "echelon one" officials in meetings with civil society organizations, as a signal to both that she expects her ministry to be responsive to its constituents.

However, if the new minister does decide to require her top officials' participation, it may come with resentment as a political cost internally.

Discussions between top officials at the Ministry of Health and civil society have not always gone smoothly.

During the Indonesian Maternal Health Caucus, a side-event of the Women Deliver conference held in Kuala Lumpur in 2013, the ministry's chief officer for maternal health, believing herself to have been singled out as the target of "persecution ... [and] unfair attacks," attempted to literally shout down civil society participants who presumed the forum had been arranged as a rare opportunity to voice constructive input on government policy.

The Jakarta Globe put the question directly to Nila: "What steps will you take as health minister to ensure transparency and accountability in your administration?"

Hearing this, a non-ministry aide interrupted Nila, who had begun to reply, and shut down the interview.

There appeared to be no acknowledgement of irony, given the question left hanging.

Observers may have to watch closely for an answer.

source: http://thejakartaglobe.beritasatu.com