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.