Decentralization in the health sector?
Decentralization in the health sector?
By Rita A. Widiadana
JAKARTA (JP): Decentralization is a hot topic in the health
sector. It is relieving for many but others welcome it rather
pessimistically.
In the national congress on epidemiology, organized jointly by
the National Epidemiology Network (JEN) and Atmajaya Catholic
University, held here from Nov. 7 through Nov. 9, the topic of
discussion centered on the readiness of people in the health
sector to properly implement the policy which is to be effective
from May next year.
JEN's chairman Dr.Satoto was optimistic, saying it is high
time for health managers and workers in regional and provincial
levels to get up and set up their own programs.
"We've been spoiled by the central government (in this case
the Ministry of Health) for more than 30 years. Everything has
been created and decided by the central government, while
regional officers only act as 'caretakers'," said Satoto, a
professor of epidemiology.
Health policies made by the central government often do not
suit every area. "In this reform era, such a top-down approach is
no longer appropriate.
Dr. Tonny Sadjimin, professor of epidemiology at Gajah Mada
University in Yogyakarta, cited a good example of the failure of
central government in dealing with various epidemic illnesses.
In dealing with disease outbreaks such as malaria, diarrhea or
other infectious diseases, the central government usually resort
to their standardized policies and guidelines.
"In some areas, the standardized guidelines may be appropriate
but in other areas they do not work at all," Dr. Tonny asserted.
Each place has its own territorial characteristic, as well as
a different social, economic and cultural background. The
availability of health facilities and human resources also play
significant roles in the implementation of each program or
policy.
"The management of malaria outbreak in Kalimantan should be
different from that in Java or Sumatra," he said.
Dr. Philip Stokoe, resident advisor at the Asian Development
Bank, shared a similar view. "Decentralization in the health
sector is a must. It is not a fiction or a future. It is a
reality that we have to face, like it or not," commented Stokoe.
He acknowledged that many people at regional levels have
little or no knowledge of how the policy will be implemented next
May.
"During my visit to several provinces and regencies, the
majority of people have not yet read about Law 22 and 25 about
decentralization, especially in the health sector," Stokoe
explained.
Laws 22 and 25 on decentralization includes devolution,
deregulation, delegation, privatization and accountability.
"The question in everybody's mind is the districts' ability,
capacity and commitment to the policy of decentralization," he
said.
He added that the current view is that some of the districts
are ready to implement decentralization, while there are others
that can implement it if given technical assistance, however the
rest would heavily rely on the provinces and the central
government.
Dr. Budi Utomo, a medical professor at the University of
Indonesia's School of Medicine, explained that decentralization
in the health sector will determine whether reformation in the
sector will work.
"Decentralization requires changes in mindsets and mentalities
of those involved in the health sector, especially health
officials in regional levels," said the professor who is also
director of the Population Council.
The roles of community health centers would become very
crucial in the era of decentralization.
Provincial and regional government must be ready and must be
able to accept new responsibilities.
Firstly, they have to be able to identify and prioritize the
health problems in their respective areas.
Secondly, they must plan, implement and monitor each health
program in regional and provincial levels.
The responsibility of the central government would be limited
to only setting health standards, regulations and guidelines, and
controlling and monitoring various national-scale programs.
"Compared to the central government, health workers in
provincial and regional areas are actually more capable of
identifying and managing their specific health problems," said
the professor.
The professor, however, reminded that there must be consensus
between every interest group in the society and it should be
supported by appropriate information and data.
Andi Malarangeng, assistant to the minister of home affairs
and regional autonomy, warned decentralization poses both a
nightmare in implementation and a challenge for the future.
"Successful implementation will depend on true delegation of
managerial decisions to the provinces and districts, the
preparedness of the districts, and the commitment of senior
management staff, health officials and related personnel," Andi
said.
In connection with fund allocation, Andi said the central
government will no longer allocate funds for regional levels.
"It is you, health workers, who should fight for funds from
the regional government," he said.
Not all regional governments pay enough attention to the
development of basic issues like health and education.
"There are some governors and regents who still regard health
a minor issue and a money-consuming program. Therefore, you have
to strongly convince them that health is a long-term and
intangible investment for the nation," Andi said.
He suggested doctors, academicians and health-related
personnel collectively push regional governments to provide
adequate funds for the development of health facilities and to
improve human resources in the health field.
Currently Indonesia spends a meager 1.8 percent of the GNP on
health.
Dr. Satoto concluded the session by saying that
decentralization in the health sector is urgent.
"Compared to other (sectors), our health sector is more well-
prepared. We have thousands of community health centers and other
health services across the country which could be fully
empowered," he maintained.
The private sector and communities have been very active in
various health programs.
The problem is whether the central government would release
its powerful hands in controlling health programs-- which for
many high-ranking officials are profitable mines.