A vast island nation

It is still very early in the morning when Amirul Mukminin kisses his wife goodbye and leaves the house. The newlywed couple moved into their first shared home a few weeks ago. The streets of Banda Aceh are just coming to life. Cars, pickup trucks and the ubiquitous mopeds provide the soundtrack to the city. Carrying a box full of spare parts and a small collection of tools, Amirul looks for the bus that will take him to Blang Pidie in Aceh Barat Daya. This particular morning, the bus is full. Travelers loaded down with baggage are squeezed into the seats. But Amirul is not in a rush. He knows that sitting in the bus in the tropical heat for ten hours or more will be tough. That’s how long the 350-kilometre journey to the hospital in Blang Pidie takes. The evening before, the hospital had called to say there were technical problems with one of the dialysis machines. For Amirul, this meant heading off to work. The technician has sole responsibility for the maintenance of 120 dialysis machines throughout the Aceh region. In total, Amirul covers eight hospitals, some of which are in extremely remote towns.

The journey to Blang Pidie takes Amirul through the tropical landscape of the Indonesian island of Sumatra. He undertakes lengthy journeys like this several times a month. For trips to hospitals closer to home, he uses his motorbike. After the long, arduous journey on the overcrowded minibus, Amirul finally reaches his destination. The hospital staff are waiting for him and give him a warm welcome. The technician does not take time for a break, but gets straight to work. After all, he knows how urgently every machine is needed here.

The care network for dialysis patients in Indonesia is very patchy. Only 25,000 of an estimated 100,000 patients with kidney disease receive adequate treatment. The poor level of care reflects the state of the country’s healthcare system: on average, there are only six hospital beds and one physician for every 10,000 inhabitants. Healthcare spending accounts for around three per cent of the gross domestic product. That is low, even for an emerging country.

Since the turn of the millennium, Indonesia has been trying to improve healthcare provisions for its 240 million inhabitants. In 2014, the country took a huge step forward by introducing a health insurance programme for all Indonesians. Even the 60 to 70 million people who live in poverty and in the most basic circumstances can now afford medical help. In the next few years, the country aims to open up this care to all inhabitants of the island nation – a gigantic project for this multi-ethnic state. This requires expanding the infrastructure, particularly in rural areas. One of the biggest challenges is Indonesia’s geography: the country comprises 17,500 islands, more than 6,000 of which are inhabited. Whereas 60 percent of Indonesians live on the main island of Java with its capital city, Jakarta, many other islands are very sparsely populated – and isolated.

Kundur Island in the Strait of Malacca is one of these remote islands. Two or three times a week, Husin Maidin waits outside his house in the early morning, standing under palm trees by the roadside, just a few metres from the beach. The dialysis patient is on the lookout for his neighbour, who comes to pick him up with his scooter. Their journey to the harbor takes 45 minutes. From here, Husin has to catch the ferry to the neighbouring island of Karimun, where the nearest dialysis clinic is located. In stormy and choppy conditions, the ferry doesn’t run and he has to wait a day or two before he can go to the clinic again. When he gets back home after a long day of treatment, he is tired and exhausted. “I would love to spend more time at home, as my wife needs help since she had a stroke,” says Husin Maidin.

Fresenius Medical Care has been active in Indonesia since 2000 and is now the market leader for dialysis products in the country. The company has installed over a thousand modern haemodialysis systems there to date, as well as dialysers, water treatment systems and accessories. The company supplies around half of all the clinics. In the Greater Jakarta area, Fresenius Medical Care runs a dialysis centre as part of a public-private partnership. Demand for medical technology is expected to rise in general as a result of the new universal health insurance programme. The Indonesian government has decided to significantly increase the capacity of its hospitals and to make it easier to build private clinics. Dialysis patients are also set to benefit from this. In view of this situation, a major task for Fresenius Medical Care is training clinic staff to handle dialysis technology. That’s why Tri is on the dialysis ward at the hospital on the island of Karimun at the same time as Husin Maidin. She is now responsible for teaching employees how to perform dialysis and passing on the practical skills needed to handle the machines.

Tri is a core member of Fresenius Medical Care’s team in Jakarta, where she is mainly based. However, her job also involves regular visits to other clinics, such as Karimun Island, where she is now. She covers almost all of Indonesia. This isn’t always easy for her, as she discovered just the day before, when she set out on her journey to the island. One of the ferries was late, so she missed the last connecting boat. Late in the evening, she managed to organise a private crossing. But Tri has become an old hand at dealing with day-to-day travel problems like this in Indonesia.

In addition to her job, Tri is also very socially committed. When the tsunami struck in 2006, she traveled to the badly affected city of Padang to work as a volunteer. As a member of the Taiwanese aid organisation Tsu Chi International Medical Association, she has also helped out in the aftermath of several severe earthquakes. In 2014, she gained another nursing qualification to enable her to advance her career.
Amirul has similar ambitions for the future. Through his hard work, he has long finished repairing the dialysis machine in Blang Pidie. An electronic component had to be replaced, but that posed no problem for the young technician. With great dedication, he has familiarised himself with the workings of the high-tech machines. “But I still don’t know enough. I want to learn much more about them,” he says, describing his ambition to be involved in developing a better healthcare system – also to give his wife and himself better prospects in life.