Improving management of decentralized health services

Improving management of decentralized health services

By Dumilah Ayuningtyas

JAKARTA (JP): Some 200,000 civil servants in the health
ministry will on Jan. 1, 2001 become employees of regional
administrations, wherever they are currently posted.

"The ministry will now have to define a new structure for its
remaining 8,000 employees who will be in charge of formulating
health and social service policies," Minister of Health and
Social Welfare Achmad Sujudi said recently.

The 200,000 health ministry employees are part of an even
larger scale transfer involving 1.9 million people--almost half
of the total number of Indonesia's civil servants. Uncertainty
about how they will fare following the transfer, mandated by the
regional autonomy policy, has been voiced time and again.

What's clear is that health affairs will be affected by the
new policy. Community health expert Dr Suprijanto Rijadi,
addressing a leadership course for heads of regional health
services, cited how health programs over the past 30 years had
neglected problems which the region would now have to face.

A very striking problem is the uniformity of the health
organizations and health service management. Usually ignored is
the question whether a particular program suits the popular
demand or the situation in a particular region. Innovation or
adjustment of a program to local problems is usually absent as
well.

In many cases, action plans and regional budgets were simply
discarded and taken over by a set of instructions and list of
projects (Daftar Isian Proyek/DIP) from the central government.
Rather than designing programs that suit the needs of a region,
the health services in regencies and municipalities prioritized
DIP implementation.

It was understandable, given that the bulk of funding for
health services, up to 90 percent, came from the central
government. A regional health service usually only served as a
distributor of a budget, measuring its success by the level of
spending instead of the suitability of the program to the local
basic needs.

Riyadi illustrated how individual officials competed in
drawing up programs merely to use up the fund allocated in the
budget.

Now more or less the same individuals will have to prepare for
the coming autonomy policy.

Benefits

Experts have extolled the benefits of decentralization in
health service. They include:

* Programs which are more suited to local needs. Proximity to
the community will help health NGOs better understand the health
needs of the local people. Budget-setting and action planning
will also benefit from this close contact with the locals.

* Faster responses to problems facing a community. Apart from
the proximity in terms of the distance covered and the time
needed, as a person indigenous to a particular region, a health
officer at a regional health service does not need a period of
adaptation.

* Full authority to manage health service units opens up a
vast opportunity to a regional health service to plan innovative
programs unique to a region without having to obey instructions
from the central government.

* More room for community participation. More commitment from
officer will boost productivity several times over.

Seen from one perspective, the decentralization of health
matters, as mandated by the autonomy policy, opens up an
opportunity for regional health services to optimize their
campaign to achieve the motto, "Health for All."

This, however, will remain a wish unless it is combined with
the regions' preparedness and the central government's
willingness to adjust to the new scenario.

The necessary changes includes the health ministry functioning
as a regulator of the provision of health services instead of a
provider of health services.

The ministry's new organizational structure, which will play
the role of a technical and strategic patron of a regional health
program, is indication of the central government's seriousness in
setting requirements for the decentralization. Without such
seriousness, it is likely the negative impacts of
decentralization will abound.

A briefing for heads of regional health services and heads of
subservices was recently held here to brief the officials about
adverse impacts of the autonomy drive.

These include interregional inequity.

When the central government reduces its subsidies for health
facilities and infrastructure, the resource-poor regions will be
hardest hit. A poorer quality of health service might therefore
result.

The poor regions will also be hard put to pay the salaries of
the newly-transferred civil servants, and provide rooms for them
to develop their career. The resulting gap in salaries between
the poor and rich regions may, of course, lead to a brain drain.

Prices

Supplies of logistics, health diagnostic equipment, medicines
and serums/vaccines will pose a special challenge. Purchases in
limited quantities will cause prices to be jacked up, in view of
the minimum quantities in purchases or because certain types of
vaccines have to be shared. Therefore business competence or a
network is necessary for interregional joint supplies to enhance
purchasing efficiency.

As supplies of medicines and health equipment have always been
the largest source of irregularities, a control mechanism must be
devised to ensure that massive corruption in the central
government will not turn into smaller scale corruption in the
regions.

The implementation of Law No. 22/1999 implies a reduced role
of the provinces while certain health problems such as epidemics,
natural disasters, pollution and vector control are cross-
sectoral problems, the handling of which cannot be confined only
to regencies or municipalities alone.

The role of a health institution as a source of a regional
indigenous income will be very prominent. A strong urge to
generate a high indigenous income will make hospitals and
community health centers spur their therapeutical programs (the
curative aspect) rather than the preventive and health support
programs (the preventive and promotional aspects).

Health as human investment is therefore ignored. Ascobat Gani,
a health economic expert, formerly the dean of the Public Health
School of the University of Indonesia, has also cast this
prediction.

An adverse impact of the unpreparedness of the system and the
management in the enforcement of decentralization is that it will
be difficult to implement national policies and standards.

Each region will have their own health vision and program,
which may not be fully in line with the priorities in the
national program and vision. The "Healthy Indonesia 2010" vision
may well be buried.

It is very important to study the experiences of countries
that enforced health decentralization much earlier.

Orville Solon and Christi Hanson (1999) have given the
valuable lessons learnt from the Philippines and Latin America.
They say that it would take some 8-15 years before the benefit or
success of decentralization can be enjoyed.

During the transitional period, there will be money wasting
(including hidden costs) and hurdles owing to conflicts of
interests and politicking of various parties in the health
service area, resulting in confusion.

All this will be the high price to pay before there is an
intensified participation of the community in health programs,
accountability of health institutions, innovations and suitable
programs, interregional cooperation in the purchase of medicines
and health equipment, increase in productivity, and improvement
in the performance of the health care system.

Empowering

This major work must start right now.

The first step in preparing the health service for
decentralization is empowering the legislative council of a
region.

A region must draw up its own rulings on health affairs,
stipulate comprehensive and detailed health policies for their
entire health system and issue various regulations to control
health practitioners, including the administrative mechanism such
as licensing for the private sector.

The parties in charge, namely regional health services or
health subservices, will be assigned to manage health affairs in
the region. Their jobs will include planning and distribution of
funds as well as the drawing up of long and short-term plans for
the development of a health system.

They will also be responsible for the implementation of
routine activities such as staff arrangement and allocation of
the budget, equipment and auxiliary facilities.

Also within their responsibility will be the management of
health maintenance programs, cross-sectoral cooperation, and
communication with other sectors for joint training programs for
various categories of staffers.

In a systematic approach these endeavors will be accommodated
in the establishment of a regional health system, which will be
aimed at promoting the health level of regional communities. A
regional health system will encompass a health service subsystem,
a community health subsystem, a health financing subsystem and a
regional health management system.

The curative and rehabilitation aspects in health services
include the prevention of communicable diseases; control of drug
distribution, particularly psychotropical drugs; environmental
health and nutritional improvement, which form part of the health
service; and community health subsystems.

The scope of responsibility of the health financing subsystem
will be to ensure that every resident, particularly the poor and
those vulnerable to diseases, will get health services.

Health for all, in which being healthy is a human right, must
be fought for by, among other things, recognizing health services
as a public commodity, where subsidies will be extended to those
who cannot afford these services.

The health management subsystem of a regional health system
exists to ensure that the performance of the regional health
system is of high quality, satisfactory to the community and
conforms to the health service standard already set.

Included in this subsystem is a health information system and
evaluation mechanism.

It is important for those assigned to enforce health
decentralization to contemplate on the words of the Filipino and
Latin American health experts below:

"The implementation of health decentralization will never come
to fruition in the absence of a strong leadership, a bright
vision, and a total reform spirit which will gear this
decentralization toward cross-sectoral productive work involving
the community, non-government organizations, private sectors,
universities and the mass media.

It is not possible to build a ship while sailing. It is too
risky an undertaking and the stakes, the health of the community
and the fate of the nation in the years to come, will be too high
a price to pay."

The writer is a lecturer at the University of Indonesia's
School of Public Health.