Tue, 14 Nov 2000

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.