Improving management of decentralized health services<\/p>\n
By Dumilah Ayuningtyas<\/p>\n
JAKARTA (JP): Some 200,000 civil servants in the health
\nministry will on Jan. 1, 2001 become employees of regional
\nadministrations, wherever they are currently posted.<\/p>\n
"The ministry will now have to define a new structure for its
\nremaining 8,000 employees who will be in charge of formulating
\nhealth and social service policies," Minister of Health and
\nSocial Welfare Achmad Sujudi said recently.<\/p>\n
The 200,000 health ministry employees are part of an even
\nlarger scale transfer involving 1.9 million people--almost half
\nof the total number of Indonesia's civil servants. Uncertainty
\nabout how they will fare following the transfer, mandated by the
\nregional autonomy policy, has been voiced time and again.<\/p>\n
What's clear is that health affairs will be affected by the
\nnew policy. Community health expert Dr Suprijanto Rijadi,
\naddressing a leadership course for heads of regional health
\nservices, cited how health programs over the past 30 years had
\nneglected problems which the region would now have to face.<\/p>\n
A very striking problem is the uniformity of the health
\norganizations and health service management. Usually ignored is
\nthe question whether a particular program suits the popular
\ndemand or the situation in a particular region. Innovation or
\nadjustment of a program to local problems is usually absent as
\nwell.<\/p>\n
In many cases, action plans and regional budgets were simply
\ndiscarded and taken over by a set of instructions and list of
\nprojects (Daftar Isian Proyek\/DIP) from the central government.
\nRather than designing programs that suit the needs of a region,
\nthe health services in regencies and municipalities prioritized
\nDIP implementation.<\/p>\n
It was understandable, given that the bulk of funding for
\nhealth services, up to 90 percent, came from the central
\ngovernment. A regional health service usually only served as a
\ndistributor of a budget, measuring its success by the level of
\nspending instead of the suitability of the program to the local
\nbasic needs.<\/p>\n
Riyadi illustrated how individual officials competed in
\ndrawing up programs merely to use up the fund allocated in the
\nbudget.<\/p>\n
Now more or less the same individuals will have to prepare for
\nthe coming autonomy policy.<\/p>\n
Benefits<\/p>\n
Experts have extolled the benefits of decentralization in
\nhealth service. They include:<\/p>\n
* Programs which are more suited to local needs. Proximity to
\nthe community will help health NGOs better understand the health
\nneeds of the local people. Budget-setting and action planning
\nwill also benefit from this close contact with the locals.<\/p>\n
* Faster responses to problems facing a community. Apart from
\nthe proximity in terms of the distance covered and the time
\nneeded, as a person indigenous to a particular region, a health
\nofficer at a regional health service does not need a period of
\nadaptation.<\/p>\n
* Full authority to manage health service units opens up a
\nvast opportunity to a regional health service to plan innovative
\nprograms unique to a region without having to obey instructions
\nfrom the central government.<\/p>\n
* More room for community participation. More commitment from
\nofficer will boost productivity several times over.<\/p>\n
Seen from one perspective, the decentralization of health
\nmatters, as mandated by the autonomy policy, opens up an
\nopportunity for regional health services to optimize their
\ncampaign to achieve the motto, "Health for All."<\/p>\n
This, however, will remain a wish unless it is combined with
\nthe regions' preparedness and the central government's
\nwillingness to adjust to the new scenario.<\/p>\n
The necessary changes includes the health ministry functioning
\nas a regulator of the provision of health services instead of a
\nprovider of health services.<\/p>\n
The ministry's new organizational structure, which will play
\nthe role of a technical and strategic patron of a regional health
\nprogram, is indication of the central government's seriousness in
\nsetting requirements for the decentralization. Without such
\nseriousness, it is likely the negative impacts of
\ndecentralization will abound.<\/p>\n
A briefing for heads of regional health services and heads of
\nsubservices was recently held here to brief the officials about
\nadverse impacts of the autonomy drive.<\/p>\n
These include interregional inequity.<\/p>\n
When the central government reduces its subsidies for health
\nfacilities and infrastructure, the resource-poor regions will be
\nhardest hit. A poorer quality of health service might therefore
\nresult.<\/p>\n
The poor regions will also be hard put to pay the salaries of
\nthe newly-transferred civil servants, and provide rooms for them
\nto develop their career. The resulting gap in salaries between
\nthe poor and rich regions may, of course, lead to a brain drain.<\/p>\n
Prices<\/p>\n
Supplies of logistics, health diagnostic equipment, medicines
\nand serums\/vaccines will pose a special challenge. Purchases in
\nlimited quantities will cause prices to be jacked up, in view of
\nthe minimum quantities in purchases or because certain types of
\nvaccines have to be shared. Therefore business competence or a
\nnetwork is necessary for interregional joint supplies to enhance
\npurchasing efficiency.<\/p>\n
As supplies of medicines and health equipment have always been
\nthe largest source of irregularities, a control mechanism must be
\ndevised to ensure that massive corruption in the central
\ngovernment will not turn into smaller scale corruption in the
\nregions.<\/p>\n
The implementation of Law No. 22\/1999 implies a reduced role
\nof the provinces while certain health problems such as epidemics,
\nnatural disasters, pollution and vector control are cross-
\nsectoral problems, the handling of which cannot be confined only
\nto regencies or municipalities alone.<\/p>\n
The role of a health institution as a source of a regional
\nindigenous income will be very prominent. A strong urge to
\ngenerate a high indigenous income will make hospitals and
\ncommunity health centers spur their therapeutical programs (the
\ncurative aspect) rather than the preventive and health support
\nprograms (the preventive and promotional aspects).<\/p>\n
Health as human investment is therefore ignored. Ascobat Gani,
\na health economic expert, formerly the dean of the Public Health
\nSchool of the University of Indonesia, has also cast this
\nprediction.<\/p>\n
An adverse impact of the unpreparedness of the system and the
\nmanagement in the enforcement of decentralization is that it will
\nbe difficult to implement national policies and standards.<\/p>\n
Each region will have their own health vision and program,
\nwhich may not be fully in line with the priorities in the
\nnational program and vision. The "Healthy Indonesia 2010" vision
\nmay well be buried.<\/p>\n
It is very important to study the experiences of countries
\nthat enforced health decentralization much earlier.<\/p>\n
Orville Solon and Christi Hanson (1999) have given the
\nvaluable lessons learnt from the Philippines and Latin America.
\nThey say that it would take some 8-15 years before the benefit or
\nsuccess of decentralization can be enjoyed.<\/p>\n
During the transitional period, there will be money wasting
\n(including hidden costs) and hurdles owing to conflicts of
\ninterests and politicking of various parties in the health
\nservice area, resulting in confusion.<\/p>\n
All this will be the high price to pay before there is an
\nintensified participation of the community in health programs,
\naccountability of health institutions, innovations and suitable
\nprograms, interregional cooperation in the purchase of medicines
\nand health equipment, increase in productivity, and improvement
\nin the performance of the health care system.<\/p>\n
Empowering<\/p>\n
This major work must start right now.<\/p>\n
The first step in preparing the health service for
\ndecentralization is empowering the legislative council of a
\nregion.<\/p>\n
A region must draw up its own rulings on health affairs,
\nstipulate comprehensive and detailed health policies for their
\nentire health system and issue various regulations to control
\nhealth practitioners, including the administrative mechanism such
\nas licensing for the private sector.<\/p>\n
The parties in charge, namely regional health services or
\nhealth subservices, will be assigned to manage health affairs in
\nthe region. Their jobs will include planning and distribution of
\nfunds as well as the drawing up of long and short-term plans for
\nthe development of a health system.<\/p>\n
They will also be responsible for the implementation of
\nroutine activities such as staff arrangement and allocation of
\nthe budget, equipment and auxiliary facilities.<\/p>\n
Also within their responsibility will be the management of
\nhealth maintenance programs, cross-sectoral cooperation, and
\ncommunication with other sectors for joint training programs for
\nvarious categories of staffers.<\/p>\n
In a systematic approach these endeavors will be accommodated
\nin the establishment of a regional health system, which will be
\naimed at promoting the health level of regional communities. A
\nregional health system will encompass a health service subsystem,
\na community health subsystem, a health financing subsystem and a
\nregional health management system.<\/p>\n
The curative and rehabilitation aspects in health services
\ninclude the prevention of communicable diseases; control of drug
\ndistribution, particularly psychotropical drugs; environmental
\nhealth and nutritional improvement, which form part of the health
\nservice; and community health subsystems.<\/p>\n
The scope of responsibility of the health financing subsystem
\nwill be to ensure that every resident, particularly the poor and
\nthose vulnerable to diseases, will get health services.<\/p>\n
Health for all, in which being healthy is a human right, must
\nbe fought for by, among other things, recognizing health services
\nas a public commodity, where subsidies will be extended to those
\nwho cannot afford these services.<\/p>\n
The health management subsystem of a regional health system
\nexists to ensure that the performance of the regional health
\nsystem is of high quality, satisfactory to the community and
\nconforms to the health service standard already set.<\/p>\n
Included in this subsystem is a health information system and
\nevaluation mechanism.<\/p>\n
It is important for those assigned to enforce health
\ndecentralization to contemplate on the words of the Filipino and
\nLatin American health experts below:<\/p>\n
"The implementation of health decentralization will never come
\nto fruition in the absence of a strong leadership, a bright
\nvision, and a total reform spirit which will gear this
\ndecentralization toward cross-sectoral productive work involving
\nthe community, non-government organizations, private sectors,
\nuniversities and the mass media.<\/p>\n
It is not possible to build a ship while sailing. It is too
\nrisky an undertaking and the stakes, the health of the community
\nand the fate of the nation in the years to come, will be too high
\na price to pay."<\/p>\n
The writer is a lecturer at the University of Indonesia's
\nSchool of Public Health.<\/p>",
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