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.

INTRODUCTION

The 2018 general elections saw an unprecedented change in Malaysian politics when the then opposition Coalition of Hope (Pakatan Harapan, PH) took control of the federal government and disrupted the six-decade continuous rule of the National Front (Barisan Nasional, BN) coalition. The so-called political tsunami swept across peninsular Malaysia but stopped short of the east coast states of Kelantan and Terengganu. The Pan-Malaysia Islamic Party (Parti Islam Se-Malaysia, PAS), which contested as a third force, managed to strengthen its hold over Kelantan and wrest Terengganu away from the United Malays National Organisation (UMNO). This article explains why PAS has been dominant in Kelantan, not just stemming the Peninsula-wide wave of change in 2018, but also durably resisting the rule of the UMNO-led BN federal government for decades as an opposition-controlled state.

PAS has long been known as an ideologically driven regional party since its political influence barely extends beyond its strongholds along the northeastern coast and in northern states of peninsular Malaysia such as Kelantan, Terengganu and Kedah. These states provide a fertile ground for PAS to mobilize and gain support as they are overwhelmingly Malay-Muslim and are culturally conservative with deeply rooted Islamic traditions. The population of Kelantan, for example, is ninety-six per cent Muslim. It is also a state renowned for its Islamic learning and for producing Islamic scholars (ulama)—so much so that it is dubbed the Serambi Mekah (Verandah of Mecca). Malay and Islamic identities, therefore, play a central role in politics in Kelantan. Political parties of all stripes contending in Kelantan must employ language and rhetoric imbued with Malay and Islamic overtones—both are often tightly intertwined—in order for them to be taken seriously by voters. But as we shall see later in this article, simply projecting one’s Islamic credibility is not enough to entice voters to one’s side, although PAS is certainly good at doing that. More than simply a strong Islamic image, it is PAS’s long-entrenched position in the communities, its well-organized machinery, and extensive political education and outreach efforts that have helped it govern Kelantan for the most part of Malaysia’s post-independence history.

INTRODUCTION

In Malaysia, Islam is often regarded as the religion of the federation. However, it should be noted that the 1957 Report of the Federation of Malaya Constitutional Commission, also known as the Reid Commission Report 1957, clearly states that:

The White Paper of the report further emphasizes:

Article 3(1) of the Federal Constitution states that “Islam is the religion of the Federation; but other religions may be practised in peace and harmony in any part of the Federation” (Laws of Malaysia Federal Constitution 1957, p. 11).