kabar Addressing gaps system at all level of government administration. Improving access and quality of for the poor and the

Transcription

1 w w w aiphss. a i p kabar h s s. o r Sixth Edition Addressing gaps in health system at all level of government administration. Health policy strengthening within d e c e n t r a l i z e d government system context; and the implementation of new Minimum Standard of Service. Improving access and quality of health care for the poor and the disadvantaged population. Australian Government Kementerian Kesehatan Republik Indonesia Department of Foreign Affairs and Trade Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) Australian Aid Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) Australian Aid g

2 Download AIPHSS current publications at Kumpulan Nota Kebijakan: Pembiayaan Kesehatan dan Cakupan Kesehatan Semesta Compilation of Policy Notes: Health Financing and Universal Health Coverage

3 List of Contents Policy Support It is undeniable that there are challenges in health service availability and preparedness towards Universal Health Coverage by 2019, which require serious attention. AIPHSS held the 1st Policy Dialogue in Jakarta to find solutions within health system and the intersectoral coordination context. 5 Headlines 1 Responding the growing complexity of health system Australia Indonesia Partnership for Health System Strengthening (AIPHSS) has formulated a health reform agenda, which has also been agreed by the Indonesian Ministry of Health (MoH Indonesia) and the Australian government, represented by the Department of Foreign Affairs and Trade (DFAT). The agreement aims to support Ministry of Health in strengthening National Health System (NHS). Primary Health Care Health service assessment shows that fixing the referral health system in Ngada cannot solely rely on standard procedure and technical mechanism in the regulation. It has to take the local sociocultural context into account. 10 Health Financing East Nusa Tenggara (NTT) Provincial Health Office, supported by AIPHSS, has formulated a grant and social aid in health sector guideline. The draft is a basis for drafting governor regulation (Ranpergub) on grant and social aid in health sector guideline in NTT The AIPHSS Reform Agenda: Strengthening Health System in Facing the Challenges of Health Development and The Implementation of National Medium Term Development Plan (RPJMN) and the Health Strategic Plan 5 Pharmaceutical Policy and National Health Systems Reinforcement in the National Health Insurance (JKN) Era 8 InaHEA 2: Health Financing and Economics of Nutrition 10 Referral Health System in Ngada Why is it not effective? 13 Law no 23 of 2014: Roles of Local and Central Government in Provincial/ District Health Development 15 Grants and Social Aids in Health Sector: The Basis 17 Blueprint of The Enrichment Model of Human Resources for Health Development and Empowerment 19 District Health Account: Supporting health system strengthening with better information on health expenditures 23 Health Workforce Distribution Policy to Improve Access to Health Care 26 Improving Health Efforts through A Better Human Resources for Health (HRH) Management 29 PMK 75 Year 2014 on Revitalization of Puskesmas Through Program Integration 31 Improving Health Governance towards a Healthy, Self-reliant and Equitable Indonesia Health Sector Development Plan for East Nusa Tenggara Province : Challenges, Acceleration Measures and Support through Partnership 38 Minimum Service Standards (MSS) according to Law No. 23 of An Effective Referral Systems in East Java: Ensures People Receive The Best Possible Care Closest to Home 45 AIPHSS support to Revision of Law 32 year 2004 to Law 23 Year 2014 on Regional Governance (Health Sector) Sixth Edition iii

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5 The AIPHSS Reform Agenda: Strengthening Health System in Facing Challenges of Health Development and the Implementation of National Medium Term Development Plan (RPJMN) and the Health Strategic Plan Responding to the challenges in health system and their growing complexity, in early 2014, AIPHSS develop a reform agenda, agreed by the Ministry of Health (MoH) and Australian government, represented by Department of Foreign Affairs and Trade (DFAT). The agenda is then followed by restructuring of the AIPHSS management and establishment of Policy Unit, to assist MoH in health system strengthening. The purpose of the Reform Agenda is to enable AIPHSS activities to be more relevant and focused on the strengthening of health systems, at national level, regional level, primary health care/puskesmas level, and educational institution level (Component-4). Health system strengthening has a systemic or comprehensive impact in contrast to vertical program, which specifically affect the improvement of certain health problems. The main focus of AIPHSS is on the four functions of health system, which are human resource for health, health financing, primary health care and health management, especially those related with decentralization system. In general, the health system The purpose of the Reform Agenda is to enable AIPHSS activities to be more relevant and focused on the strengthening of health systems, at national the national level, regional level, primary health care/puskesmas level, and educational institution level (Component-4) strengthening is preceded by improving weaknesses of the four functions, in two perspectives: 1) whether the functions/ sub-functions are in accordance with the standards, regulations and theory of health system; 2) whether the functions/ sub-functions would be able to face the current challenges in health system The weaknesses of these four functions of health system are reported in 2014 Health Sector Review (HSR), which has also formed as a basis for the reform agenda. The HSR has presented the challenges in health system strengthening. The review conducted by Bappenas is then served as an input in RPJMN development as well as Health Strategic Plan developed by MoH. Inputs and directions from MoH and Australian government, through DFAT, emphasize on the importance of health system strengthening, readiness of health system in facing epidemiologic transition, particularly the increasing of Non-Communicable Disease (NCD), the importance of public health strengthening (health promotiondisease prevention), primary health care revitalization to carry out their four main functions (public health program, clinical service/ individual health, community participation and empowerment, and promoting health in policies development), including their new role as primary health care provider for JKN participants; the improvement of JKN effectiveness, and the unfinished agenda in achieving the MDGs 2015 target. Sixth Edition 1

6 Overall, the conceptual framework of this Reform Agenda is based on the current challenges in health system and the weaknesses of the four functions of health systems, which are human resource for health, health financing, primary health care and health management in decentralized health system. Human Resource for Health (HRH) Reform Agenda The policy direction of RPJMN and Health Strategic Plan is improving the availability, distribution and quality of human resources for health. The HSR has identified several problems as follows: There is no master plan on the number, competencies and production of human resources for health Mal-distribution of the health workforce The quality and productivity of the health workforce are not in accordance with the demands There is no strategy on how to produce primary health care physicians as stated in the Law on Medical Education (UU Pendidikan Kedokteran) Insufficient availability and productivity of public health workers. Other weaknesses identified during AIPHSS program planning and implementation includes: Inadequate information on human resources for health Weakness of HR planning, both institutional and regional The quality of graduates does not meet the requirements especially for midwives Inefficiency and mismatch in the recruitment and placement of HR Uneven distribution and low retention of HR Low quality and productivity of the health workforce There is no career development pattern for the health workforce Low quality of health office personnel, which becomes bottleneck for health administration and management. Based on the above descriptions, it is apparent that the weaknesses of HRH functions cover almost all sub functions of HRH. Therefore the reform agenda should be directed to overcome these weaknesses. There are also some HR strengthening activities addressed by other funding sources, including by the state (APBN) and local (APBD) budgets. Health Financing Reform Agenda The AIPHSS focus in health financing is on the preparation of National Social Security System Sistem Jaminan Sosial Nasional (SJSN) in Health or National Health Security/ Jaminan Kesehatan Nasional (JKN). This includes the development of provider payment system (INA-CBGs and capitation), socialisation of JKN, the integration of Jamkesda (local schemes) into JKN, and training and implementation of DHA in all districts of AIPHSS. The 2014 Health Sector Review has underlined several challenges in health financing, including: The inadequate funding for public health program, which will impact on JKN financial burden in the future JKN memberships to include non-pbi (non-subsidized participants), particularly informal workers Guidelines for benefit package/ clinical pathway and procedure of use Existing cost sharing paid by participants in health service provider Development of cost and quality control system which is one of the basic concepts of SJSN in health sector (JKN) Payment for health service providers (provider payment) Meanwhile, the policy direction of RPJMN stated that the main focus of health financing strengthening includes two main issues as follows: Strengthening the implementation of SJSN in health sector (JKN) Developing and improving the health financing effectiveness. 2 KABAR AIPHSS

7 Other than the above-mentioned issues, there are six issues that are similarly important to be addressed in the reform agenda, supported by AIPHSS. These are: First, deciding the basic package for public health programs (UKM) and clinical service (UKP). In relation to this, AIPHSS has supported the formulation of health functions distribution between centralprovincial-district levels (through ADINKES). This resulted in a comprehensive list of health sector activities and their distribution across central-provincial-districts levels elaborated in the Law 23 of 2014 (UU No. 23 Th, 2014) on Local Government a revision of Law 32 of 2004 (UU No.32 Th.2004) and Decree of Minister of Health 741 on Minimum Standard of Service which regulated the basic needs of health service in accordance to a life cycle approach. Second, cost analysis of health service. So far, cost analysis has been a neglected area though the results is important in health budgeting process, including budget for supporting activity, budget for public health programs (UKM), determination of INA-CBG rate and the amount of capitation payment, premium setting, and premium subsidies for JKN s PBI members. Third, analysis of public health programs funding mechanism, which so far, is entirely depends on health operational budget (BOK), including the allocated amount, funding distribution to district/primary care level, utilisation effectiveness and the supported legislation. Fourth, finding innovative alternative sources of health financing. Health financing so far has been a conventional system: tax based (through state and local budget APBN and APBD) and service tariff, either out of pocket payment or through health insurance/protection. Other sources mobilization has not been optimally explored. For example through the use of tobacco tax revenue sharing fund to province/districts which could be use as a complement of public health program funding; the use of other sectors budget for health, such as village fund allocation (ADD), private enterprise CSR funds mobilization, and others. Fifth, strengthening planning and performance-based budgeting. Health financing needs a realistic planningbudgeting system, which is affordable, evidence-based, performance-based, cost-effective and efficient. The weaknesses in district level in planning and budgeting is on the lack of performance-based system. While at national level, the improvement in planning and budgeting system still need to be strengthened. Sixth, strengthening the capacity of MoH in health financing policy analysis. In many countries, there have been major changes undergoing in health financing in response to the changes in health issues, social determinants of health, people s need and demands, global/regional-national economic turmoil, and the advancing health science and technology. Therefore, there is a need for strong capacities to perform a continuous health financing policy analysis, particularly in the MoH. Primary Health Care Reform Agenda The main role of primary health care is to improve their serviced area s health status through four main activities: 1) conducting public health programs (UKM), 2) providing clinical service (UKP), 3) promoting community participations and empowerment, and 4) encouraging healthy public policy. Since 1 January 2014, primary health care provides clinical as part of its new role as primary health service provider to JKN members. Sixth Edition 3

8 National Medium Term Development Plan Policy Direction 1 Policy direction PHC Reform Agenda 1 Accelerating the access to quality of health service Workforce for MNCH, reproductive health, and older people for MNCH, adolescent and older people health (*) 2Accelerating the improvement of population nutrition status Workforce for nutrition (*) 3 Planning capacity and disease control Strengthening disease control and environmental health and environmental health management (*) 4 Improving access and quality of basic health service Capacity for outreach activities (*) 5 Improving access and quality of referral health service Primary to secondary referral system (*) 6 Improving availability, affordability, distribution Pharmacy management and quality of pharmacy and medical equipment 7 Improving food and drugs control system POM management 8Improving the availability, distribution, and quality of HRH Placement and retention (*) 9Improving health promotion and community empowerment Cost, workforce, health promotion management and UKBM (*) 10 Strengthening the management, research, SP2TP (PHC recording and reporting system) revision (*) development and information system 11 Strengthening the implementation of JKN Service package and capitation management (*) 12 Developing and strengthening the health Planning and budgeting at the central, provincial, district financing effectiveness and Puskesmas (*) Note: (*) = Activities supported by AIPHSS in PHC/Puskesmas revitalisation Photo: AIPHSS BPPSDM 1 Bappenas July KABAR AIPHSS

9 AIPHSS First Policy Dialogue Pharmaceutical Policy and National Health Systems Reinforcement in the National Health Insurance (JKN) Era After more than one year the enactment of the Law No.24 of 2011 on the Social Security Agency (BPJS), Indonesia has been implementing the National Health Insurance ( JKN) to more than million beneficiaries. This exceeds the target set, however, it cannot be denied that there are still many challenges that need to be addressed, especially with regard to the availability and readiness of service approaching the Universal Health Coverage by With the support of the Australian Government through the Australia Indonesia Partnership Program for Health Systems Reinforcement (AIPHSS), the Ministry of Health of the Republic of Indonesia held a policy dialogue to discuss these challenges in order to find internal health sector breakthrough as well as the context of cross-sectoral coordination. The first policy dialogue AIPHSS program took place on May 5, 2015 held SIXTH EDITION 5

10 at Balai Kartini, Jakarta. The dialogue specifically aimed at examining the various challenges that can hamper the access, availability, affordability and safety of drugs, usefulness and quality of medicines and rational use since the Health services cannot be optimally implemented if the drug availability is not maintained and if the quality of product and its usage are not appropriate. On the financing side, the drug in Indonesia takes up 30-40% of the health budget, which is not a small amount. Thus, we need an efficient and effective process in selection, pricing, procurement, distribution, and quality of pharmaceutical products. Ministry of Health Secretary General, Dr Untung Suseno Sutarjo, M.Kes drug is produced, distributed and used in the service. In addition, the Secretary General also added that the infrastructure for quality assurance and drugs policy in Indonesia has played an effective role in ensuring the safety, efficacy, quality and validity of drugs. However, the enforcement of regulations and legislation concerning drug distribution at the market needs to be strengthened through cooperation with the authorities at district level. Efficient and effective drugs management is needed to ensure the availability of access, affordability and quality of medicines, so that drugs are available at any time required. With the remaining barriers between the district and health centre in pharmaceutical supplies scheme, task distributions and clear coordination are needed between central and local authorities to maintain drugs supply and implement pharmaceutical MSS. With regard to the National Health Insurance ( JKN), it is imperative that the public sector drug procurement should use e-catalogue. However, the use of e-catalogue needs to be evaluated systematically. Controlling drug prices as covered in the e-catalogue, which mostly generic drugs, has implications for access and availability of drugs, drug quality and sustainability of the domestic industry. In this case, equality in access to medicine can be improved by promoting of the use of generic drugs, which have quality assurance. Furthermore, this policy dialogue also covered other topics such as experiences and challenges in implementing drug management in JKN era at primary health care (Puskesmas), district health office; regional hospital; vertical hospital as well as the presentation of pharmacy policy, regulatory, quality assurance drug in JKN era of Pharmaceutical Company Combination, Food and Drugs Agency (BPOM), and DG Pharmacy and Medical Device, Ministry of Health. Proposed actions to solve the problem are formulated in the form of agreements and recommendations as a reference to follow-up a synergistic coordination toward improved pharmaceutical management in JKN implementation. Some of the key recommendations include: This dialogue needs to be followed up with meetings focusing on formulating policies and action to solve the problems Some of the topics that need to be followed up, among others: Rational pricing of generic drugs Additional policies for the utilisation of local community To access the presentation material for dialogue activities please visit this website 6 KABAR AIPHSS

11 health centre capitation funds (dana kapitasi puskesmas), in particular for public health programs (in accordance with the purpose of capitation) Policies on drugs/vaccines sampling collection at Puskesmas The possibility of delegating some BPOM administrator authority to the Provincial or District Health Office. Improvement of e-catalogue and its socialisation Revise the NSPK/existing regulations to suit the current conditions, including the division of roles across all sectors and regional centres It is important to establish a working group for the independence of the pharmaceutical industries to use local materials and then compiled a roadmap It is important for the government to have a strong continuous commitment to support program of pharmaceutical industry independence. Pharmaceutical Systems Reinforcement Matrix Agreements Ministry of Health BPOM Agency Health Service Pharmaceutical Industry Hospital/ Health Security Quality Benefit Affordability Availability Rational use Independence SIXTH EDITION 7

12 InaHEA 2: Health Financing and Economics of Nutrition The 2nd Indonesian Health Economics Association (InaHEA) Congress was held in Jakarta on 7 10 April The theme for this year congress is Health Financing and Economics of Nutrition. This event was held to facilitate information and research sharing to improve macro and micro strategic policies in health system at national and regional level. Health Financing and Economics of Nutrition Indonesia continues to have a high prevalence of under-nutrition among children under the age of five. Additionally, Indonesia is also not on track to meet the Millennium Development Goals (MDG) and 2009 national development target. The persistent problem of under-nutrition has a serious impact on human resource quality, particularly in the poorest regions in Indonesia. This situation affects educational outcomes and economic growth, which risks national social development goals and further inequity (Source: 2014 Health Sector Review conducted by Bappenas with AIPHSS-DFAT financial support). Please click here to download all materials presented in 2015 InaHEA Congress 8 KABAR AIPHSS

13 The 2nd InaHEA conference was conducted to facilitate exchange of evidence based information to improve macro and strategic policies in health system reform in Indonesia. This event also promotes the importance of World Health Day, with this year current theme of Food Security. In accordance with the World Health Day theme, the conference discussed Economics of Nutrition, in relation to Food Security. The conference took place in Jakarta and was officially opened by the Minister of Health, Prof Dr dr Nila Djuwita Moeloek F, SpM (K). The Department of Foreign Affairs and Trade (DFAT), as the main sponsor of the event, organized special session on Nutrition, Human Resources for Health, Global experience in public private partnerships, and DFAT health programs in Indonesia. Decision making in the household will affect the family s economic and health condition. For example, smoking behaviour; a father spends in average Rp.50,000 daily to buy 3 packs of cigarettes. Rather than spending that amount of money for cigarettes, shouldn t it better to spend the money for the nutritional needs of the family. Minister of Health, Prof. Dr. dr. Nila Djuwita F. Moeloek, SpM (K) opening speech If we are talking about health economics, I can not think of any more challenging place or time than in Indonesia, right now! James Gilling, head of Australia s development cooperation program in Indonesia Photo: AIPHSS & collection SIXTH EDITION 9

14 Referral Health System in Ngada Why is it not effective? Referral health system analysis from a socio-cultural perspective in Ngada It is found that the effort in improving referral health system in Ngada does not fully depend on the current policies, guidelines, and technical mechanism. The implementation of referral health system is also influenced by local socio-cultural context as an important supporting factor. Government s commitment to provide an accessible health service for the whole population has now been demonstrated with the implementation of National Health Security (JKN) since 1 January The promising environment has given a new hope for people living in remote areas, including in Ngada, where people had difficulty in accessing referral health care. Additionally, Ngada District Health Office (DHO) is now challenged to improve referral health system as regulated in the current policies. This leads to a question: Has the current policy system been adequate to meet people s hope as well as encourage DHO 10 KABAR AIPHSS

15 to improve referral health system effectiveness? In attempt to answer the question, Ngada DHO, supported by Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS), has conducted an assessment on the socio-cultural influence to the effectiveness of referral health system in this district. It is found that the effort in improving referral health system in Ngada does not fully depend on the current policies, guidelines, and technical mechanism. The implementation of referral health system is also influenced by local socio-cultural context as an important supporting factor. Referral system as regulated in Decree of MoH No.1/2012 What is the current referral system and how does the socio-cultural perspective affect the implementation of referral care? Referral system is a system of referring authority or responsibility in disease or case management in health care. The responsibilities are transferred from the unit at the lowest level or with lacking competence to a more competence unit. Referral health system can include patient transfer, specimen, supporting diagnostic examination, and information on a specific case or disease. Referral health system is implemented so a patient can receive the best quality of health care at the closest health service providers with affordable (low) cost. This will create an effective and efficient health service. Five socio-cultural dimensions affects Ngada referral health system The assessment conducted by Ngada DHO with AIPHSS s support has analysed five socio-cultural dimensions that could affect referral health system. These are sociocultural, geographic, referral criteria, model and cost of transport and referral capacity. Community leaders, SIXTH EDITION 11

16 health cadre, PHC funding supports (dewan penyantun puskesmas), socio-cultural staff at sub-district office were involved in the discussion to elicit the current conditions and challenges in the implementation. The findings from the Focus Group Discussion (FGD) underline that the success and failure in socialisation of a system is not merely depending on the procedure and management system, but also on the users and the objective of the system itself. Target and benefit has become the main decisive factors in the implementation of a referral system. Individual referral system can be promoted as part of people s behaviour in Ngada. If people are continuing the practice of referral care system to Puskesmas for seeking help, it will then become a culture in health seeking behaviour. In doing so, facilities and health service behaviour are the main agents in this social construction process. Photo: Next Steps Ngada s local government has an important role in developing policy innovation such as Bupati Order (peraturan bupati). The following recommendations can be considered in the policy: Implementing programs to improve the continuity of basic health care provision including intersectoral coordination and integration Ensuring the optimal number of HRH at the primary health care (Puskesmas) as well as the their quality and performance Assigning an adequate numbers of trained HRH at the referral health care Organizational and referral system change based on geographical condition, location of health service and local cultures and norms Developing interfacilities coordination in referral system based on the classification of health facilities, and districts location. Coordination should involve all technical units, both vertical and horizontal structures. Socializing the criteria of health service provided at each level of care (polindes, pustu, puskesmas, RSUD) to the public Promoting intersectoral collaboration in improving public transportation facilities, and road access to health facilities Complementing the health infrastructure development with socio-cultural strategies to improve health development analysis model. 12 KABAR AIPHSS

17 Law no 23 of 2014: Roles of Local and Central Government in Provincial/District Health Development Regional health development performance must be improved in local-central government structured partnerships. Law No 23 of 3014 has clearly defined the roles of local and central government in this issue. In relation to this matter, Ministry of Health, East Nusa Tenggara (NTT) Provincial Health Office (PHO) through Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) program have conducted a workshop on Strengthening District Health System in Relation with the Implementation of Law No 23 and National Health Security ( JKN). The specific objective of the 2-day workshop held in Kupang, 30 June to 1 July 2015 is to socialize Law no 23 of 2014 on local government, particularly on the authority distribution in health sector. This includes Minimum Standard of Service (MSS) and its implication to the local authorities. Additionally, strategic issues related with the implication of Law no 23 of 2014 and MSS on local health system (SKD) formulation and PHO/ DHO organization structures and working management (STOK) were also discussed in the workshop. In his opening speech, the NTT Governor emphasized the three identified strategic issues that required urgent actions. These are: Synchronization and alignment between central and local policies (RPJMN and MoH strategic planning with RPJMD and PHO/DHO strategic planning at the local level); The need of capacity improvement at the local level to implement health MSS in the context of decentralization health system; and The need of understanding and agreement between actors at central and local level on the operational of holistic and integrated health system at the local level. SIXTH EDITION 13

18 It has been realized that within the second year of its implementation, the JKN dynamic still remained as a popular public issue, which attract many discussants and commentators. Therefore, it is expected that central and local government could identify strategic issues related with JKN implementation at the local level, particularly in expanding coverage, improving access and quality of health care, affordable cost for JKN, a wellsustained and integrated system. Likewise, the establishment of quality and financing control system, and control and monitoring on JKN implementation at the local level, are also important. The effectiveness of JKN implementation is clearly determined by the performance and functionality of actors involved in JKN implementation, both at central and local level, in addressing the main issues mentioned above. Actors involved at the central level includes but not limited to Ministry of Health (Health financing unit (PPJK), Directorate of Primary Health Care (BUKD), Directorate of Referral Health Care (BUKR), Centre for Human Resource for Health Development (PPSDM)), Ministry of Social Affairs, Ministry of Home Affairs, Bappenas, BPJS Health Sector, Quality and Financing Control Team (Tim Kendali Mutu dan Biaya TKMKB), and Clinical Advisory Board. At the local level, the actors involved include Head of District (Bupati), Bappeda, District Office for Social Affair, District Health Office, Provincial/ District Employment Unit (Badan Kepegawaian Daerah), hospitals, Puskesmas, BPJS Health Sector and TKMKB. It is expected that recommendations resulted from this workshop will act as a comprehensive and holistic model for provincial/ district health system strengthening and could accelerate the implementation of JKN in other districts. In particular for 4 AIPHSS targeted districts, which are Ngada, Flores Timur, Timur Tengah Utara (TTU), and Sumba Barat Daya, the findings can be a concrete strategy for district health system strengthening and support the effectiveness of JKN implementation, which can be evaluated in As many as 103 government officials from central and local level attended this workshop. Some of the officials representing local governments were those from East Nusa Tenggara (NTT) Province, Ngada, Sumba Barat Daya, Timur Tengah Utara (TTU), Flores Timur, Papua Province, and West Papua Province. The keynote speakers were experts in their areas, including the head of team revising Law no 32 of 2004 to Law no 23 of 2014, who is also the Commissioner of National Civil Apparatus (Komisioner Aparatur Sipil Negara KASN), Head of MoH Planning Bureau, Head of MoH Health Financing Unit (PPJK), Head of BPJS-Health Sector Research and Development Group, Head of Quality and Financing Control Team (TKMKB), AIPHSS Technical Program Specialist, Head of Centre for Human Resource for Health Development (PPSDM), Head of Medical Care in Public Hospital Sub-directorate, and Head of Standardisation of Primary Care Section, MoH. Furthermore, the workshop was also attended by the Ministry of Health Secretary General and Advisory panel for East Nusa Tenggara/ Head of Human Resource for Health Development, Echelon II to IV at the MoH, and Director for Health Programs at the Australian Embassy (DFAT). 14 KABAR AIPHSS

19 Grants and Social Aids in Health Sector: The Basis East Nusa Tenggara provincial government has regulated grants and social aids for people in East Nusa Tenggara through Governor Regulation No 27 of 2012 on Technical Guidelines on Grant, Profit Sharing, Social Aids and Unexpected Expenses Management for East Nusa Tenggara (NTT) Province. This regulation is enacted in response to People Order (Perda) No 1 of 2014 on East Nusa Tenggara Medium Term Development Plan (RPJMD). In RPJMD, it is decided that NTT local government must allocate budget for grants and social aids until A general rules on grants and social aids for all SKPD within the NTT local government has been regulated in the above mentioned governor regulation. However, it is unfortunate that those general rules have not accommodated grants and social aids in health sector yet. This situation could lead to a potential misinterpretation and legal issues for the health sector s grants and social aids managers. Addressing the issue, with a support provided by Australian government through Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) programs, the Provincial Health Office (PHO) has formulated a guideline on grant and social aids in health sector for East Nusa Tenggara. This guideline will then be a basis for revising the draft of governor regulation (Ranpergub) on grant and social aids in health sector guideline for East Nusa Tenggara. Bellows are some excerpts of the guideline: Grants Aims, Targets, Forms and Mechanism Grants in the health sector are aimed to support East Nusa Tenggara in achieving health programs and developments targets, targeting 1) Central government, 2) Local government, 3) Local enterprises, 4) Public and/ or 5) Civil Society. Grants can be given in the forms of monetary, materials, and services grants. Monetary grants are managed by Provincial Financial Bureau (Biro Keuangan Provinsi) and transferred by direct payment mechanism by Provincial Financial Management Officer (PPKD) to the grantees. Meanwhile, materials and service grants are managed by the Provincial Health Office (PHO). PPKD and PHO are then responsible to record and report the grants that they are managed. SIXTH EDITION 15

20 Grants management mechanism include: a socialization, b selection, determination of candidates and feedback for candidates, c procedures for grants, d grants recording, e grants reporting, and f grants accountability. Socialization to the grantee candidate is important so that health sector grants management can be targeted at the right aim, transparent, and accountable. Governor has the authority to decide the list of grantees and amount and forms of grants (monetary, materials, or service). Grantees are obligated to submit a report to provincial government through provincial PPKD. The report must include all conducted activities with evidence of liability related with the activities attached in the report. The report should be submitted within one (1) month after the activities are completed. Next, PPKD then is obligated to develop a report on grant realization, integrated with report on grants expenses realization. It is also mandatory for PHO to develop materials/service grants realization reports as grants expenses realization at least one month after the activities were completed. Aims, Targets, Forms and Mechanism of Social Aids (Bansos) Management Provincial government can provide social aids (bansos) in health sector in accordance to their financial capacity with priority given to budget allocation to fulfil the mandatory expenses. Social aids (bansos) can include planned and unplanned aids. 16 KABAR AIPHSS Planned social aids in health sector refer to monetary aids given by the provincial government to individual, family/community, in which identities (name and address) of the receiver as well as the amount have been clearly defined during the APBD formulation. Meanwhile, the unplanned social aids are monetary aids given to individual, family, group/ community, which have not been predicted during the APBD formulation. Social aids in health sector are given to improve individual, family, group/ community s health which have been affected by health crisis due to social crisis, economic crisis, political crisis, natural phenomena, and natural disaster, and the health of individual, family, group/ community will be worsened if the social aids were not given. Social aids receiver are categorized in two groups: 1) individual, family, group/ community in East Nusa Tenggara which are suffered from health problems due to social, economic, political crisis, natural disaster and phenomena, 2) Non-government organization that provide protection for individual, family, group and/ or community and social risk. Social aids can be given in the form of monetary aids and materials aids. Monetary aid is managed, recorded, and reported by provincial PPKD, while materials aid is managed, recorded and reported by PHO. The mechanism of planned social aids management includes: a socialization, b candidate selection, and determination, and feedback for planned social aids receiver candidates, c procedures for social aids transfer mechanism, and d e f accountability of planned social aids. The same procedure mechanism is applied for unplanned social aids. Provincial PPKD determines the receiver of unplanned monetary aids not through Governor Decision. The decision is made based on the consideration of the available budget for unplanned social aids listed in DPA PPKD not later than 2 weeks after receiving PHO s recommendation or suggestion. Grants and Social Aids Monitoring and Evaluation Activities funded by grants or social aids in health sectors must meet the requirements of good governance and good government program managements. These should comply the following principles: comply with the current laws and regulations; no indication of corruption, collusion, and nepotism (KKN); uphold the principle of transparency and accountability and financial management. The monitoring and evaluation of monetary grants and social aids is performed by provincial PPKD. Meanwhile, for materials and services grants and social aids, is performed by PHO. Provincial Inspectorate and the public perform supervision on grants and social aids management. Therefore, it is important for the related information to be disseminated to the public.

21 Blueprint of The Enrichment Model of Human Resources for Health Development and Empowerment Human resource is the most essential element in any program and activity, including in health sector. Therefore, the Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) and the MoH s Agency for Human Resource for Health Development and Empowerment (BPPSDMK) issued a blueprint of the 2014 Enrichment of Human Resources for Health Information System. This HRH Information System is a part of the National Health Information System (NHIS), which includes: 1. Health Efforts Information System (SI-UK) 2. Health Research and Development Information System (SI-Litbangkes) 3. Health Financing Information System (SI-PK) 4. Human Resources for Health Information System (SI-SDMK) 5. Pharmaceutical, Medical Device and Food Supply Information System (SI-FAM) 6. Health Management and Regulation Information System (SI-MRK) 7. Community Development Information System (SI-PM) Minimum information required in the HRH Information System includes: 1. Information on HRH: types, number, competence and distribution 2. Information on HRH development and empowerment: planning, development, utilization, guidance, and quality control. Problems Currently, HRH data management is conducted using limited and not well organized computing facilities. This raises several issues, among others: 1. Difficulty in obtaining individual HRH data: a. HRH data are widely spread across various programs both at national and sub-national levels b. Changes in HRH data are not well-coordinated c. The only data available are aggregate data of which the validity has not been tested. 2. Difficulty in obtaining the number of HRH by type based on the actual data: a. Double counting of HRH number may occur due to the unavailability of individual HRH data based on NIK (single identity number) b. There has been no agreement on standard calculation mechanism of HRH number. 3. Difficulty in tracking unique data for individual HRH: The unique code identifier that can be generally applied, such as NIK, is not available. Difficulties in identifying individual HRH performing his/her function as health personnel in any health facility: a. Data on HRH possessing STR (registration identity), SIP (practice permit) and working at in health facilities are not properly managed. b. Poor or even unavailable coordination among sectors issuing STR and SIP. c. The absence of regulations supporting the obligations of private hospitals/health facilities and local public hospital (RSUD) to report to related health office. 4. Difficulties in obtaining data on HRH as training participants: A well-managed database on training participants is unavailable. 5. Difficulties in accessing HRH data due to the unavailability of application system or limited infrastructure of data communication: There is no integration and agreement on data sharing across programs and sectors. 6. Difficulties in identifying factual conditions of HRH at an administrative region HRH data are not linked with the health facilities spatial data 7. Difficulties in determining the number of HRH required for HRH planning: a. Data on prospective students and graduates of institutions producing HRH are not integrated. b. Data on ASN-HRH participating in Tubel (learning task)/ppds / PPDGS (education programs for SIXTH EDITION 17

22 specialist doctors/ dentists) are not optimally utilized. c. Data on training participants are not well managed and utilized. Targets The expected targets of this HRH Information system development are as follows: 1. Integrated HRH management within the MoH, so the maintenance of system and data and in the standardization will be simpler 2. The availability of a single source of data, i.e. integrated HRH data within the MoH for structural and administrative officers, lecturers, health workforce and supporting personnel. 3. The availability of more comprehensive HRH information through data integration. 4. More rational and measureable process of HRH planning, procurement and utilization. 5. Improved accountability of management process, integrity and quality of HRH data, along with a well maintained update. 6. Ease in implementing HRH process through direct access to the system via web. 7. Security and simplicity in access setting to a function-oriented system, which is not depending on the institution s structure. Expected Outputs The expected outputs from the blueprint are: 1. HRH data set is available 2. Blueprint of HRH Information System model is available. This includes: a. Information system concept The conceptual aspect of HRH Information System includes components of cross programs and sectors. The cross programs component consists of HRH data and information related with the organizational function of BPPSDMK, which can be obtained and used internally. Meanwhile, the cross sector component is for external purpose. The information managed in the HRH Information System contains individual and aggregate data of HRH and supporting personnel. The HRH data consists of biographical data and historical data related to HR development (profession, position, education, and training). In order to support HRH distribution mapping development in the Information System, each health worker should be linked with the location where he/she is registered. The location is defined as health care facility. The integration of Geographical Information System (GIS)-based spatial data will encourage the availability of HRH distribution and profile at each health facility throughout Indonesia. b. Architecture of the information system The term system architecture refers to the design of a system and how the system communicates. c. Database design Health facilities are the main facts and data source in HRH assessment. Based on the Government Regulation No. 46 of 2014, health data and information in the implementation of Health Information System can be obtained from three groups of sources: health facilities owned by the central, local governments and private sector; society both individuals and groups; central and local government agencies. d. Procedures of cross program and cross sector data sharing in district, provincial and national levels are based on geographical information system. Data sharing system is web service based system, which is designed to provide data for users. Users can make request based on available options, and the system will process and respond directly to the requests. The HRH Information System (SI-MDK) requires data sharing mechanism to interact or integrate with other systems or modules. Management of the HRH Information System is at least related with external systems and other institutions, as follows: Using the concept of network services with the protocol of HTTP Request/Response to communicate with each other. Mediated by dummy database that is developed the same as or close to the original database. Interface concept for shared use. References AIPHSS Cetak Biru Pengayaan Model Sistem Informasi Sumber Daya Manusia Kesehatan 18 KABAR AIPHSS

23 District Health Account Supporting health system strengthening with better information on health expenditures What is District Health Account? Health Account (HA) is a systematic, comprehensive and consistent way of measuring total (which includes government/public, private and donors/ developing partners) health expenditures at any given level of government. In Indonesia, the National Health Account (NHA) has a humble beginning of a systematic data collection on health expenditures in The activity suffered a long vacuum before recommenced in As the country transformed from a highly centralized system into a highly decentralized one in early 2000s, the complexity of flow of fund is exacerbated, making a health account even more a necessity. Following the NHA, some provinces and districts are developing their Provincial Health Account (PHA) and District Health Account (DHA), most are donor-driven projects and are not sustainable. Meanwhile it is widely accepted that a well-targeted health financing and effective allocation is an important part of a well-functioning health system. In this regard, the benefit of having a health account is the ability to develop strategies for effective health financing and raising additional funds for health, when and where needed. District Health Account (DHA) provides information about the source of fund and how much it is spent on different health care activities, at different providers, for any population groups, in a specific district. In order to develop a DHA, the district systematically and consistently compiles and disaggregates data according to financing sources, financing agents, providers, financing functions, beneficiaries (demographic, socio economics, health status) as well as the resource cost. DHA aims to provide information about who is financing the health services in the district, how much they spend, on what types of services, and who benefits from health expenditures. The objective is to provide a basis for evidence-based decision making and planning. Why is District Health Account important to health system strengthening? The importance of having a health account is even greater as Indonesia implements the National Social Security System (SJSN) in 2014 and in progress to meet health-related Millennium Development Goals (MDGs) target. Moreover, in the decentralized health system, the DHA constitute an evidence-based health planning and financing, which in turn could also contribute to improving local governance and accountability. As mentioned above, the extent of the decentralization structure in Indonesia and the complexity of health financing patterns of the public sector, have increased the importance of compiling a reliable and comprehensive data on health expenditures. From the legal perspectives, the Health Act Law no. 36 year 2009 states that 10 percent of district budget should be allocated to health. DHA can be used to evaluate whether the target percentage has been met. If the target percentage has been at A GLANCE The DHA activities are conducted for a period of time between in four districts in East Java Province and four districts in East Nusa Tenggara Province. The selected districts for East Java are Bangkalan, Bondowoso, Sampang, and Situbondo. The selected districts in East Nusa Tenggara are East Flores, Ngada, Southwest Sumba, and North Central Timor. In each of these districts, data for DHA are collected and analyzed by local DHA team consisting of multi-sector members (Health office, Statistic office, Hospital, Development Planning office /Bappeda, etc). In conducting the activities, AIPHSS is collaborating with the Center for Healthcare Financing (Pusat Pembiayaan dan Jaminan Kesehatan) at the Ministry of Health with regards to socialize DHA to local stakeholders, facilitate the training for data collection and analysis, provide technical assistance in developing DHA, and disseminate DHA results. AIPHSS is funded by DFAT (Department of Foreign Affairs and Trade) as a partnership program between the Government of Australia and the Government of Indonesia to improve access to and quality of basic health services. DFAT provides the necessary structures and contractual arrangements to ensure coordination and joint working between AIPHSS and other DFAT programs in Indonesia. SIXTH EDITION 19

24 met, DHA can be used to show whether the fund is allocated according to the district s health need and priorities. On the other hand, if the target percentage has not been met, DHA can be used to show where the gaps are and how big the gap is. From the equity perspectives, DHA can also be used to show who benefits most from health expenditures and whether health financing has met its intended target, i.e. whether adequate funding is allocated to protect the poor. Further, DHA can also show who pays more for health in the respective district, whether it is public or private. All of these information resulting from DHA can be used to advocate for additional health funding - when and where needed - and/or better allocation of health funding, which in turn will contribute to strengthening the health system in the district according to their specific needs. Is the benefit of DHA real? There are stories from the field that shows that DHA is beneficial in practice to rethink their fiscal space. DHA results are used to identify problems, serve as a catalyst for change by presenting data that convey the magnitude of a problem, and act as an advocacy instrument to stimulate action. In Ngada district, DHA result serves as an impetus to strengthen the local government policy to increase health funding using tobacco tax, in particular to fund the provision of essential and sustainable health services for the most vulnerable groups of people. In other districts, DHA has also been used to acknowledge the need to strengthen the commitment to meet the 10% budget for health as mandated by law. There are plenty anecdotal reports of lack of health funding, and/or mismatch of allocation for priority programs, but DHA provides a hard evidence based on real data. In Southwest Sumba, for example, DHA result shows not only that the target percentage has not been met but that some program priorities are underfunded and allocation is heavily skewed to indirect cost. Information from DHA result identifies the need to increase investment in priority program such as maternal and child health, nutrition, malaria prevention, and TB. DHA result suggests the need to refocus investment in community health, prevention and health promotion measures. DHA result also puts forward the unexplored potential of private funding for health. Similar results are shown in Bangkalan, Sampang, Situbondo, Bondowoso, East Flores, and North Central Timor. Even when the district is lack of additional source of funding, they are able to rethink the use of their existing source of fund. Upon dissemination of DHA result, the local government renew their commitment to better use of Operational Grant (Bantuan Operasional Khusus). These examples suggest that DHA is a relevant and effective tool of advocacy in these districts. What does it take to sustain DHA? To be fully beneficial, DHA should collect data annually. It is a part of annual evidence-based health planning, financing and evaluation process, as government cannot manage what they cannot measure. Information from DHA can be used to make financial projections of health system requirements and compare their own experiences with the past, or with those of other districts; and, more importantly, make the necessary adjustment. The district government expects that DHA can be implemented every year in the district so that we can have a systematic and comprehensive recording of health fund flow every year. (Vice Bupati of North Central Timor district) The key to sustain DHA is long-term commitment of multi sector policymakers. Their support should be manifested politically, such as in advocacy for the adoption of DHA in the district. More importantly, their commitment should be manifested concretely in the form of sustained allocations of personnel and financial resources for DHA, and in the creation of a legal environment that enables DHA. In other words, DHA team in each of these district should be institutionalised by a legal document. A decree or a local regulation has to mandate tasks for data collection and analysis to a multi sectoral team, give them the authority to access data from various agencies (public and private) at the district level on annual basis, and provide them with adequate and continuous funding from the local budget. In addition, sustainability will be more affirmed if DHA is included in the health system. When health account is part of the district health system, provincial health system and the national health system, there would be a necessary legal and institutional arrangement in place to sustain health account activities at all level. Each district and provincial government would set up a health account team in their respective institution as part of the health system and core activities. While at the central level, the Ministry of Health (MOH) could distribute the task between the Center for Healthcare Financing, and the National Health Institute for Research and Development; the latter could take the role of data collection and analysis, while the former could take the role as coordinator and agent of advocacy. Sustainability also requires ongoing interaction between the policymakers and the DHA technical team. This interaction enables the team to react to specific policy concerns, for example, through a more in-depth sub-sector analyses depending on their needs. In 20 KABAR AIPHSS

25 this regards, DHA team members should be trained and be able to demonstrate skills in collecting data, defining expenditure boundaries, analyzing data, and interpreting results in a way that is understandable to policymakers and relevant to policy formulation. Moreover, these skills have to be transferable should there be changes of personnel team member. What are the challenges to the implementation of DHA? DHA activity is not without challenges. The first and foremost is data availability. For example, some data of funding from provincial sources are not available, or not completely recorded. Other financial data is recorded as a global budget and requires the use of assumptions. Accessibility of data in the private sector is extremely difficult; consequently DHA result is highly disproportionate towards public expenditure. Another challenge relates to the capacity of the team. Team members are not always able to conduct data analysis and interpretation, let alone develop recommendations based on DHA result. Further, team members who are already trained in DHA could suddenly be reassigned to other office and have to leave the team. There are also logistic and time management challenges. The team is not adequately equipped with their own computers for data entry, data cleaning and data analysis purpose. In addition, as DHA activity is an additional task, team member tends to prioritize their core tasks and responsibilities. AIPHSS through the Center for Healthcare Financing provides technical assistance and retraining whenever the need arise. However, issues such as logistic, managerial responsibility, data transparency and sharing, need political will and firm policy from the government. Collaboration and transparency among various government agencies are crucial. In addition, it is necessary to establish a better cooperation with the private sector. What lies ahead? There are more hopes and expectations for a better-informed decision making and planning in the future. Some of the districts already succeed in securing a decree regarding DHA team and tasks, a promise of DHA continuation. A continuous implementation of DHA could enable local government to evaluate their investment in local specific priority health program such as maternal and child health, malaria prevention, or nutrition, and adjust accordingly. Ultimately, a better understanding of health expenditures potentially helps the local government to strengthen the local health system and accelerate their effort to achieve the minimum service standards (Standar Pelayanan Minimal) in 2015 and health-related MDGs target. In time, when gender-disaggregated data have become routinely available, observable expenditure trends can help make the case for gender-related budgeting. Local government could improve the health status of women and men by recognizing their different health perspectives and needs, while comprehensively and equitably address these differences. DHA activity in these districts have strengthened the collaboration between AIPHSS, central government (MOH) and local government, specifically local DHA technical team, by means of transfer of skills and knowledge. This collaboration needs to evolve into a more empowering relationship to enable the district to take on the leadership role of the process, away from a donor-driven project. Recommendations The first thing that local policymakers need to do is to take the necessary steps to ensure that DHA data collection and analysis is conducted regularly. With some aforementioned challenges in mind, local government needs to build an integrated computer-based district health information system to ensure seamless multi-sectoral data collection for DHA. This requires a strengthened collaboration between various government agencies. When the DHA activity is produced on a regular basis, the next thing to do is using the information from DHA to implement meaningful and effective local health system improvement. DHA result should be made as user-friendly as possible to encourage policymakers to utilize it in the decision making, planning, budgeting and evaluation process. To enhance the capacity of the DHA team, there should be a formal permanent DHA team that are adequately trained and embedded in the government at the local level, for instance in Bappeda. This will reduce the risk of turnover and the need to constantly recruit and retrain new members. Over the years, the DHA data will allow for trend analyses and monitoring the impact of any financial reform interventions. As mentioned earlier, one of the strategies to do this to ensure that health account is included in the health system in every level. This way, all DHAs and PHAs throughout the country will be linked to NHA and the national health system. This might require reevaluating and strengthening the role and function of the Center for Health Financing at MOH. This also requires producing a MOH regulation (Permenkes) to reinforce NHA and DHAs implementation throughout the country. In addition, as NHA and DHA needs a multi sector approach and collaboration between government agencies as well as private sector, a SIXTH EDITION 21

26 joint-decree (Surat Keputusan Bersama) between MOH and Ministry of Home Affairs (MOHA) might be a potent regulatory framework to achieve greater impact and likelihood of sustainability. Policymakers at district, provincial and central government level should also think about the need to develop a transparent and integrated information between national, provincial, and district for public and private sector. They need to think about the availability, accessibility and quality of data that are fed into the system, and how accurate and timely should they be. Considering the importance of what DHA can contribute to the local development planning and resource allocation, the local government should also pay attention to how they can intensify multi sector collaboration in sustaining DHA. Policymakers at all level should also think about engaging the private sector to take part in DHA activity by making DHA information more enticing and serve the private sector interest as well. Lastly, information sharing should be encouraged and nurtured, not only among government agencies but also with private sector and nongovernmental agencies. Case in point, DHA data and result should be accessible to agencies such as universities and research centres, for Lesson learned Early socialization is crucial to help stakeholders recognize the value of tracking health resources and expenditures and take on the leadership role of the process. A multi sector team is the best approach for DHA data collection and analysis. Private sector should also be involved. Central government and developing partners should find a balance between providing technical assistance and empowerment. Local staff should be able to take the ownership of DHA process. Institutionalization of the process means more than enacted legal framework for the DHA team. It should also mean incorporating the task into routine task and responsibility, provide them with the necessary facility and equipment and continuous funding. research and independent monitoring purpose. By allowing external monitoring mechanism, DHA contributes to strengthening governance and accountability. References AIPHSS Report of DHA Analysis in Bangkalan District. AIPHSS Report of DHA Analysis in Bondowoso District. AIPHSS Report of DHA Analysis in East Flores District. AIPHSS Report of DHA Analysis in Ngada District. AIPHSS Report of DHA Analysis in North Central Timor District. AIPHSS Report of DHA Analysis in Sampang District. AIPHSS Report of DHA Analysis in Situbondo District. AIPHSS Report of DHA Analysis in Southwest Sumba District. Ministry of Health, Faculty of Public Health Universitas Indonesia and World Health Organization The Indonesian National Health Account The Center for Health Financing and Health Security, Ministry of Health: Jakarta. OECD, Eurostat, WHO A System of Health Accounts OECD Publishing: Paris. 22 KABAR AIPHSS

27 Health Workforce Distribution Policy to Improve Access to Health Care General Background Access to health care is one of the basic human rights and human resources for health is one of the key elements in improving the health care access and quality. Health workforce is one of the six building blocks of health system identified by World Health Organization (WHO), which are strongly related with other building blocks of health system. While the national ratios have even exceeded the minimum ratio recommended by World Health Organization (WHO) of 1 physician per 1,000 populations, distribution of health workers across the countries remains a longstanding challenge. Consequently, 30 of 33 provinces in Indonesia do not meet the minimum WHO s recommended ratio. Many factors contribute this mal-distribution of health workers, and effective planning is one of the key elements that should be addressed. Situation Analysis Lesson learned from East Java Even though Indonesia has achieved a noticeable increase in the ratio of health workers to the overall population, distribution, quality, and performance of health workers remain a challenge. Hence, Indonesia needs to strengthen health workforce strategic planning capacity, at all level - one of which is health workforce distribution. Currently, planning for health workforce at the provincial, district level is guided by PMK No.81/Menkes/ SK/I/2004. Aiming to analyse the implementation of this policy, a situation analysis was conducted in East Java. The activity was conducted to identify the planning process; problems and challenges, so action can be taken to improve the current situation. In East Java, it was found that under the current policy, local governments (provincial and district level) have a limited authority to plan and manage their health workforce, which resulted in uneven distribution of health workers. In addition, the local governments also have difficulties in finding solution to address the shortage of health workers. Consequently, problems related with planning and management of human resources for health were identified at the local level. Those are: (1) disintegrated planning system and procedure in health workforce distribution; (2) inadequate capacity of planning unit (SDMK) at all level in regards to human resource for health allocation/ distribution; (3) miscommunication, gaps of understanding, information, and knowledge on the health workforce distribution between planning unit and health service provided; (4) inadequate support from the local government; and (5) disintegrated planning across and between levels. The findings indicated that the current policies should be revised and complemented with manuals and tools to guide the planning unit and related stakeholders across all level. Furthermore, in order to ensure the optimal distribution of human resource for health, bottom-up planning should be promoted and implemented. For doing so, provincial and district health office should have a strong capacity in SIXTH EDITION 23

28 human resources for health planning, including estimating the number of health workers and type of health workers needed, and optimum allocation in their supervised health service providers. Improving the Effectiveness of Health Workforce Planning Process through Policies Based on the review of the current policy and lesson learned from East Java, AIPHSS in collaboration with the East Java Provincial Office, Centre for Workforce, Ministry of Health (BPPSDM) and Law and Organization Bureau, Ministry of Health (Hukor) developed policies on human resources for health distribution planning. The policies include draft legislation (Decree of Minister of Health), guidelines, manuals, and tools complementing the decree. The activity was conducted in and aims to improve the effectiveness and efficiency of human resource distribution/ allocation at provincial and district level. The materials covered in the guidelines and modules will assist provincial and district health office in estimating number, categories, and level of health workforce needed. The need assessment will be based on workload, available working time in one year, referring to Indonesia s workforce policy. Both health institution and health workforce will be benefited by this planning mechanism. And at the end, it is expected health workforce distribution at provincial and district levels can be effective and efficient through a bottom-up planning. Next Steps Pilot Test of the Guidelines, Manuals and Tools in Other Provinces Noting the diversity of Indonesia geographic condition, resources, etc. the drafted guidelines, manuals, and tools should be piloted in other provinces, which have different characteristic than East Java. This is important to ensure that the policy could accommodate the needs of all areas across Indonesia. Finalization of the drafted legislation, guidelines, manuals and tools Once pilot test were completed, the guidelines, manuals, and tools should be evaluated and revised as needed. Following this, the draft legislation can be finalized. Socialization and Dissemination Strategies Once the legislation has been finalized and endorsed, strategies should be developed to ensure the optimal socialization and dissemination to related directorates within the MoH, and related stakeholders, including PHO, DHO, health institution, and local government. Strengthen the collaboration with local government In the era of decentralization, provincial and district government plays important role in determining the outcome of health programs. Hence, MoH, PHO and DHO should work in close collaboration with the local government in the planning process for health workforce. Maintain sustainability of the policy implementation The effectiveness and sustainability of the policy implementation will require strong leaderships from Ministry of Health and strong commitments from the government at every level and the related stakeholders, not only from health sector but also the local government. Furthermore, periodical training (or on the job training) should also be considered in maintaining the capacity of planning and management at the provincial and district level. Remaining Challenges While health workforce distribution is an essential part in increasing health access, particularly for the poor and near poor, we should also acknowledge other problems that need to be addressed in increasing access to health care. First, health workforce production should be in synergy with the needs of the community. While it is hard to precisely estimate number of health workforce needed in Indonesia, the country needs to increase the production of health workforce at the primary level. Additionally, it is also important to ensure type and level of health workforce needed in response to key burden of diseases and health challenges in Indonesia. Second, effective distribution of health workforce can not merely assessed by the ratio of health workforce and the population served. Particularly in large geographic areas with low population density, the ratio might not precisely describe the real condition of access to health care. Acknowledging this issue, the goal of distribution of health workforce is not only on meeting the recommended ratio but more importantly, to achieve an effective distribution of health workforce to ensure people get a good access to good quality of health care. Third, across all level, bottom-up planning process should be promoted and strengthened. This is highly related with the diversities across Indonesia hence the indicators of effective distribution of health workforce might vary among provinces/ districts. For provinces and/ or districts covering remote areas, telemedicine is a method than can be considered. However, the community capacities and the infrastructures should be well prepared before implementing telemedicine. 24 KABAR AIPHSS

29 Conclusion and Recommendations Health workforce is an essential part to be addressed in strengthening health system. In order to improve health workforce distribution at local level on of the main problems in health workforce in Indonesia the revision of current policy is needed to provide guidance on developing effective planning for health workforce. Through effective planning, it is expected that mal-distribution of health workforce could be eliminated so access to health care could be improved. However, considering the population dynamic including the health needs planning process should be accompanied and followed by continuous monitoring and evaluation. Lastly, Ministry of Health could not address this problem by itself. Collaboration with local government, Ministry of Workforce, Ministry of High education and education institutions should be strengthened to ensure not only the effective health workforce allocation but also the availability of types of health workforce needed in the field. AIPHSS Contributions The Government of Australia (DFAT) through Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) provides technical supports and project management through series of activities leading to these policies development. AIPHSS has also facilitated and worked in close collaboration with East Java Health Office, Ministry of Health (BPSDM and Hukor), and experts in developing the policies. References systems/who_mbhss_2010_full_ web.pdf publications/documents/hss-designdoc-pd.pdf uploads/2015/02/human-resourcesfor-health.pdf SIXTH EDITION 25

30 Improving Health Efforts through A Better Human Resources for Health (HRH) Management Government holds the primary responsibility to fund and ensure all the essential goods and services under the right to health. It is as outlined in the state constitution of 1945 (UUD 1945), Article 28 I, paragraph 4. Based on the provision in the constitution, provincial and district governments are responsible for health service delivery in their region. This is in accordance with Law No. 23 of 2014 on Regional Governance which states that the implementation of health care is a mandatory governmental affair, both for the central government, provincial and district governments. Health Resource for Health (HRH) is the backbone of health services. Article 16 of Law No. 36 of 2009 on Health, clearly mentions that government is responsible for the availability of health resources in a fair and equitable manner to obtain the highest standard of health for all. HRH should be properly managed to suit the needs, competence and authority and evenly distributed to optimally support health development. In order to understand the problems associated with the quantity, quality, distribution, and declining number of health workers, AIPHSS Program has supported the implementation of Situational Analysis of Health Workforce in East Java Province. The analysis took place in 10 out of 38 districts in East Java. Data collection was conducted through collected through in-depth interviews and focus group discussions (FGD) with various informants, among others were: heads of district health offices (DHO), directors of hospitals, heads of puskesmas, heads of local civil service agency, and puskesmas staff from various educational backgrounds. Meanwhile, secondary data was collected from East Java provincial health office, i.e. from Health Profile of 2013 and workforce data from the department of HRH development. The Situation of Human Resource for Health in East Java and Its Challenges Number, Distribution and Adequacy of Health Workforce The number of HRH in East Java is inadequate. The total number of HRH in 2013 was 72,443. Mosty worked in puskesmas, followed subsequently in private health care Percentage of Adequacy of Various Types of Health Workforce in East Java facilities and public hospitals. The rest of them worked in health offices, educational units and other technical units. The number of HRH will decrease once any health worker retired or died. The figure below shows the percentage of adequacy of various types of HRH per 100,000 population. Overall, the need for various types of health workforce met less than 50 percent, except for nurses. Human Resource for Health is unevenly distributed. HRH remained concentrated at certain areas. This applied to nearly all types of health workforce. While the average number of doctors per puskesmas is expected to be at least two, the study indicated that the average number of doctors per puskesmas was 1.8 and dentists was Calculation of health workforce fulfilment based on indicator ration of Healthy Indonesia 2010 (Kepmenkes no: 1202/Menkes/Kep/VIII/2003). 26 KABAR AIPHSS

31 1.5. The average number of nurses and midwives was higher, especially for non-inpatient care puskesmas (Puskesmas Non-DTP), but for puskesmas with inpatient care facilities (Puskesmas DTP), the average number of nurses and midwives were still low. Nineteen puskemas assessed in the study did not have doctors, and 201 puskesmas did not have dentists. The need for basic and supporting medical specialists is still low. Inequality in the distribution of specialist doctors has been identified, where there were excessive number of specialists in class A hospitals, but less in class B, C and D hospitals. Production and quality of Health Workforce Production of health workforce in East Java is quite large but the absorption is low. There are 222 health education institutions throughout the province. Most of them are nursing and midwifery education institutions, which produce an average of 6,000 health personnel annually. There are 10 medicine schools provide residents/ specialists education. With a large number of graduates every year per type of education, the need for health workforce in the province actually can be fulfilled. The constraint is on the low absorption rate, hence, the utilisation of HRH is very limited. The quality of health workforce is still inadequate. The results of competency tests suggest that the quality of health workforce is not optimal. There are a number of factors contributing to this problem, among others are: the large number of education institutions (especially for midwifery and nursing education) which resulted in limited amount of practice areas to achieve competence, disproportionate ratio of teaching staff and students, and low quality of education institutions. This eventually affects the quality and performance of HRH. It has been reported that there was a decrease in antenatal visits 1 and 4 and delivery services attended by skilled birth attendant. The quality of midwives as the backbone of health program will greatly affect the success of the program in reducing maternal and child mortality, which are still major health problems in East Java province. The graduation rate of competency test at the central/ national has not been optimal. In 2013, the graduation rate for nurses was 72.8%, and midwives, 66.5%. This shows a need for thorough handling of health workforce quality issues. Management of Health Workforce Planning and management of health workforce have yet to optimal both in terms of adopted methods and data accuracy. Routine annual planning has never been fully implemented. Hence, the planning quality and enthusiasm of the planners gradually decreased. Other problem includes inaccurate and non-updated data. Health workforce recruitment and appointments have not been through a rigorous selection in accordance with required competencies. There are a lot of potential employees who were not utilized in accordance with required competencies, and sometimes not through a good selection process. The career pattern of HRH is unclear, not open and not transparent. There were numbers of officials being assigned not in accordance to the Permenkes no. 971/2009 on Standards of Competence for Health Structural Officials. Limited education and training activities and consequently, the updates of knowledge and technology are not optimal HRH capacity building was not optimal and focused more on the disciplinary aspects Performance assessment has not been performed at all levels. To address the various issues and challenges mentioned above, it is important to develop a specific regulation to govern human resources for health in East Java. The results of situational analysis of HRH in East Java serve as an input for preparing academic paper of draft regulation (Ranperda) HRH. East Java Provincial Regulation (Perda) No. 7 of 2014 on Human Resource for Health On 25 July 2014, East Java Provincial Regulation No. 7 of 2014 on Health Workforce was enacted by the East Java Governor. The regulation aims to realize equitable and proportional health workers in terms of quantity and quality in order to achieve sustainable and optimal health development in East Java. The regulation sets provisions concerning HRH, which include need planning, procurement, development and training, and guidance and supervision. The regulation addresses the need for an overarching regulation for various aspects of HRH management, so that it can answer challenges, among others are: In regards to HRH planning and to determine the availability and needs of health personnel, the regulation establishes the need for mapping through data collection, assessments or management information system of HRH. SIXTH EDITION 27

32 In regards to HRH placement, the government is authorized to distribute and redistribute health workforce in government-owned health care facilities. The regulation also stipulates the placement of HRH through a special assignment. The special placement of HRH includes post-internship placement of doctors, post-education for specialists and senior residents. To answer the needs for HRH at the community level, the government has the authority to place medical personnel in Poskesdes (village health posts). Placement of HRH in the poskesdes consists of at least one midwife and one nurse plus other health personnel according to the needs, especially nutritionist and sanitarian. To ensure the quality of HRH, the regulation governs the development and training, as well as guidance and supervision of HRH in performing their duties and functions. Guidance can be either functional or technical education and training, career system, rewards or incentives. Meanwhile, the supervision is done through certification, registration and licensing. The arrangement of administrative penalty for HRH violating regulation is defined in the Perda. The penalty can be written warning, coercion by government, administrative fines, and/or revocation of license. Through the Perda it is expected that health efforts in East Java in the future can be enhanced and supported by adequate number, types and quality as well as fair and equal distribution of human resources for health according to health development needs. Recommendations for Follow-up For the Provincial Government. Perda No. 7 of 2014 comprehensively and clearly governs various aspects of HRH management in East Java, so that the current problems can be solved. Strict and consistent supervision over the implementation of Perda will support better governance of HRH. This will also support the achievement of sustainable health development and the fulfilment of rights and needs of public health services in the province. For the Central Government. The improvement of health system through better governance of health workforce in the pilot areas in East Java has shown positive results. It is necessary that lessons learned from this pilot be expanded to other areas in Indonesia. References The Drafting Team of Perda on Health Workforce in East Java, Naskah Akademik Rancangan Peraturan Daerah Provinsi Jawa Timur Tentang Tenaga Kesehatan. (Academic Paper of draft East Java provincial regulation on Health Workforce) Team of AIPHSS TA Consultants of Health Workforce draft regulation (Raperda), Analisis Situasi Tenaga Kesehatan Provinsi Jawa Timur. (Situational Analysis on Health Workforce in East Java). East Java Provincial regulation on Health Workforce, Support of AIPHSS Program AIPHSS program, in cooperation with East Java provincial health office has provided technical support to prepare Health Workforce Situational Analysis in East Java. The analysis has served as inputs for preparing an academic paper of draft East Java provincial regulation on Health Workforce. On 25 July 2014, the East Java Provincial Regulation (Perda) No. 7 of 2014 on Health Workforce was enacted by the East Java Governor. 28 KABAR AIPHSS

33 PMK 75 Year 2014 on Revitalization of Puskesmas Through Program Integration Background Health Center/Pusat Kesehatan Masyarakat (Puskesmas) plays a big role in the health system in Indonesia. Puskesmas are expected to respond to the people s health needs pre-emptively and adaptively and provide affordable health services in timely manner. Regulation of Health Ministry no. 128 Year 2004 regarding basic policies on Puskesmas describes the function of Puskesmas as 1. Center as driver for development in health 2. Center for community empowerment 3. Center for primary health care. But in reality, Puskesmas have not been functioning effectively as outlined in the regulation. There remain issues such as: Puskesmas have not been able to accommodate complaints from the public in regards to poor health services in implementing the Public Health Efforts/Upaya Kesehatan Masyarakat (UKM) and Individual Health Efforts/Upaya Kesehatan Perorangan (UKP) People still seek treatment (curative) and rehabilitation at Puskesmas, instead of preventive and promotive measures There remains a need to improve the quality of health service providers and the management of human resources at Puskesmas The need to have referral systems in supporting the health services Health services offered in Puskesmas have not met the national standard for services Unclear governance and operation procedure at Puskesmas as primary health center The lack of orderly management of data collection, classification, distribution at Puskesmas Existing funding and financial management issues in relation to limited allocation of health funding The need to improve management and supervision in Puskesmas, especially in the era of health decentralization where Puskesmas has more autonomy in providing primary health services in the regions. Puskesmas also serve as the Gatekeeper for universal health coverage. In addition to providing primary health services as a part of UKP, Puskesmas are expected to effectively coordinate complaints from participants of BPJS Kesehatan as well as participants of private health insurance companies. In October 2014, Regulation of Ministry of Health No. 75 Year 2014 regarding Puskesmas was issued and the regulation replaced Regulation of Health Ministry no. 128 Year 2004 regarding basic policies on Puskesmas. The new regulation was expected to provide clarification and guidance of tasks to support the realization of health districts. AIPHSS Support AIPHSS provided support to Association of District Health Offices in Indonesia/ Asosiasi Dinas Kesehatan Indonesia (ADINKES) 1 in creating eight drafts of priority activities as recommended by Ministry of Health, including the drafting of Regulation of Ministry of Health No. 75 Year The activities conducted by ADINKES with support from AIPHSS focuses on revitalizing the functions of Puskesmas. The objective of revitalization of Puskesmas through program integration is to develop program implementation guidelines to ensure effective and efficient implementation while utilizing the available resources. The guideline is expected to provide direction for regional government in implementing development policies in their respective regions or districts, and in turn will facilitate the reduction of maternal and child mortality rates in areas covered by AIPHSS. The activities are expected to identify key priorities of the program integration with the overall goal to reach the targets set in Minimum 1 ADINKES is a non-profit organization consisting of provincial health departments in 33 provinces, as well as 497 cities/districts, former heads of the provincial health department, city /districts, and individual observers of health development. ADINKES is formed to promote the implementation of local health development at the provincial and district levels. SIXTH EDITION 29

34 Standard For Services/Standard Pelayanan Minimal (SPM) in the districts. This is conducted by assessing the gaps and existing needs of Puskesmas in regards to UKP and UKM. In addition, the activities include formulating guidelines and training sessions to address the identified issues. These efforts are expected to strengthen functions that are weakening, no longer functioning, even more those that have deviated from the basic concepts. In addition, the activities address the needs to integrate programs by providing assessment on availability of resources needed to implement the functions, and providing inputs on how to integrate these resources strategically, with consideration these resources are often limited. Recommendation The recently issued Regulation of Ministry of Health No. 75 Year 2014 has been critized by health practitioners as it focuses on curative aspect and less emphasis on preventive and promotive measures. Key pillars in the health system such as community empowerment or pemberdayaan masyarakat and development in health or pembangunan berwawasan kesehatan seem to be missing in the revised law. Mandatory programs in Puskesmas remain unchanged, excluding Health at School Efforts or Upaya Kesehatan Sekolah (UKS) and Health at Work Efforts or Upaya Kesehatan Kerja (UKK), programs that should be mandatory according to strategic plan of Ministry of Health or Rencana Strategis (Renstra) Kementerian Kesehatan. With support from AIPHSS, further revisions to Regulation of Ministry of Health No. 75 Year 2014 is recommended to include development of technical guide for Puskesmas management to address and further emphasize on the importance of preventive and promotive measures. References (Footnote) article/281-penguatan-puskesmas,- kunci-sukses-jaminan-kesehatansemesta.html TOR for AIPHSS program on Revitalizing Puskesmas Through Program Integration RPMK 75 Year 2014 Naskah 75 Year 2014 PMK 75 Year download/info-publik/renstra pdf 30 KABAR AIPHSS

35 Improving Health Governance towards a Healthy, Self-reliant and Equitable Indonesia Health Sector Challenges in Indonesia Triple burden of disease. In recent decades, Indonesia faces the triple burden of disease. While communicable disease is still a problem for Indonesia (indicated by frequent outbreaks), there are also re-emerging diseases such as yaws, leprosy, filariasis and schistosomiasis. In addition, newemerging diseases such as HIV / AIDS, Avian Influenza, Swine Flu and Nipah virus also sprung up. On the other hand, noncommunicable disease shows an increasing trend over time. Basic Health Survey (Riset Kesehatan Dasar/Riskesdas 2007 and Household Health Survey (Survei Kesehatan Rumah Tangga/SKRT) in 1995 and 2001 shows a shift in the epidemiology where deaths due to noncommunicable diseases is increasing, while the mortality due to communicable diseases is decreasing. Stroke, for example, is the number one killer in Indonesia, replacing Acute Respiratory Infections that declines sharply. Stroke alone causes 15.4% of total deaths (Riskesdas 2007). Lagging behind on achieving the MDGs. Indonesia also has not achieved health-related MDGs targets, typically Goal 4 (reducing child mortality) and Goal 5 (improving maternal health). 1 Indonesia Demography and Health Survey (IDHS) 2012 shows an increasing average of maternal mortality rate (MMR) which is 359 per 100 thousand live births, compared to 228 per 100 thousand live births in This is a setback, as the number of maternal mortality in the period 1990 to 2007 has decreased by 41 percent (BPS, 2013). The infant mortality rate (IMR) shows a slow decline from 34 per 1000 live births (IDHS, 2007) to 32 per 1000 live births (IDHS, 2012) and under five mortality rate (U5MR) drops from 44 (IDHS, 2007) to 40 (IDHS, 2012). Dual challenge of demographic bonus and the aging population. Within the next twenty years, the Indonesian government should put demographic bonus and the aging population issues in the national strategic planning agenda. The increasing number of elderly people causes the rising cost of healthcare to meet the specialised and integrated health services at the primary, secondary and tertiary level as well as home care services. While at the same time, the number of women of childbearing age are expected to double in 2019, from 67.1 million (2015) to million in , adding to the burden of healthcare costs. Access and quality. The National Social Security System (Sistem Jaminan Sosial Nasional/SJSN) and Law No. 24 of 2011 on the Social Security Agency (Badan Pelaksana Jaminan Sosial/BPJS) implies the need for improvement of access and quality of first-level health facilities as well as advanced level of health facilities, including the referral system. In addition to lacking the amount of the required health workforce, there is an issue of poor quality and poor distribution of health workforce. This includes sanitation officer, nutritionist, and health educator. Data shows that the number of health workers does not meet the target per 100,000 population. The number of specialist doctors per 100,000 population is 7.73, missed the minimalist target of 9. The number of general practitioners per 100,000 population is 26.3, missed the minimalist target of 30. The number of nurses per 100,000 population is , while the minimalist target is 158, and the number of midwives per 100,000 population is while the minimalist target is Self-reliance in raw materials for drugs and medical devices. The issue of self-reliance related to access and quality as well as the availability of drugs and medical devices remains a major challenge to Indonesia. At the moment around 90% of raw materials for drugs and medical devices are imported, causing a high price of drugs and medical devices. Indonesia has a huge untapped potential in this field. 1 World Health Organization. Country Cooperation Strategy at a glance. Indonesia. ccsbrief_idn_en.pdf 2 Kementerian Kesehatan Rancangan Teknokratik Rencana Strategis Kementerian Kesehatan Tahun , Jakarta. 3 AIPHSS. Building Block: Human Resources for Health. SIXTH EDITION 31

36 Vaccines from Biofarma, for example, is able to compete on a global level. Improving Health Governance in Indonesia The abovementioned overview of increasingly complex challenges in Indonesia could weaken the ability of the Ministry of Health to perform according to the demands from their key stakeholders. The Ministry of Health strategic plan is considered to be insufficient in elaborating the how-to of achieving its various strategic objectives. 4 The how-to should describe efforts to transform and improve institutional quality and capability building of the ministry. Institutional quality will focus on a series of efforts for organisational transformation in improving the competence of employees, improving human resources management system, improving the performance culture of the organisation, structuring the business processes, improving organisational governance, and so on. The Map of Strategic Health Plan The Ministry of Health has established a strategy map that shows a causal relations between a wide range of strategic directions and focus priorities to improve and prepare themselves to achieve the Ministry of Health vision for : Self-reliant, Equitable and Healthy Community. In this regard, the national health strategic plan will focus on the improvement of the institutional, funding and regulatory framework. 5 Institutional Framework The challenge in strengthening the institutional quality in is the ability to integrate the strategic plan of the organisation, performance control, budgeting and performance management in various layers of the organisation and functions of the Ministry of Health. At present, the work plan of various units in the Ministry of Health is only associated with the budget plan and not yet fully linked to performance management. Some stages of performance control need to be put in place to overcome strategic challenges in the institutional framework. Below is the description of each stage in the performance control: Stage 1: Performance Contract The stage of performance contract between the Ministry of Health and its Echelon I (and beyond) is a stage to spell out and define various strategic objectives and key performance indicator targets, and cascade them to the lower level. Contract for performance demonstrates accountability from every echelon to the Minister as the principal responsible party for the success of achieving the performance targets in the strategic plan Stage 2: Monitoring Monitoring is required to assess whether performance contracts are on track or off track. Previously, monitoring for the progress of activities in the strategic plan has not been fully implemented, and any evaluation of attainment based on monitoring has not been done. One major reason for this is that contract performance at all levels of the organisation was not institutionalized. A systematic evaluation as well as an integrated effort to achieve the performance targets of the strategic plan based on the monitoring results have not yet been done. Stage 3: Performance Dialogue Performance dialogue aims to evaluate the progress status of performance targets achievement. It is a periodic evaluation of performance targets achievement within a particular period, conducted between the leader and various lower ranks in the ministry. The evaluation should be supported by data and integrated information on the progress status related to the performance targets. Stage 4: Performance Management This stage aims to assess the success of individual performance targets achievement at various levels in the Ministry of Health. It is integrated with performance contract in each unit where the employee works. Currently the Ministry of Health has an employee performance system (Sistem Kinerja Karyawan/SKP) mechanism to assess employee performance. However, SKP needs to be integrated with strategic planning so that every employee in the Ministry of Health will have success indicators that measure employee achievement, not only from the perspective of fulfilling the job description and behaviour (process oriented), but also their individual contribution to achieving the overall performance targets (results oriented). Funding Framework Strategic Plan emphasizes two main aspects in terms of funding, namely increasing funding for 4 Yassierli Preliminary Report (Situation Analysis). 5 Draft Strategic Plan of the Ministry of Health. AIPHSS. September KABAR AIPHSS

37 preventive health and promotion, and increasing effectiveness. Increasing funding for preventive and health promotion is expected to be more cost effective than increasing funding for curative care. Increasing funding for preventive and health promotion also avoids the breakdown of government budget for curative care within the National Health Insurance (Jaminan Kesehatan Nasional/JKN) system towards achieving universal health coverage in Increasing the effectiveness of health funding. Each funding should meet the criteria for cost effectiveness (investment yields the most benefit and leverage), efficient and effective to reinforce the link between budgeting and measurable priorities, programs and core activities. Regulatory Framework The focus of this regulatory framework is improving the national health insurance system. In a decentralized system, where the district/municipality has an important role in implementing health policies, the capacity of the district /municipality determines the success of health sector development. By 2015, there are approximately 540 districts/cities throughout Indonesia. With the enactment of Law no.23 Year 2014 revision on Regional Government, a more comprehensive elaboration of the division of responsibilities between the central, provincial and local government as well as their Minimum Service Standards (SPM) has been set. Aiphss Support Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) collaborates with the Bureau of Planning and Budgeting (Biro Perencanaan/Roren) of the Ministry of Health to provide technical support in preparing the strategic plan for the Ministry of Health This support includes the alignment of related policies and situation analysis ranging from developing health programs to preparing the strategic plan document. The early stage of the strategic planning process, namely the drafting of the technocratic strategic plan, began in June 2014; while the second stage, which is a political strategic planning, is still underway. Four technical consultants from AIPHSS conduct situation analysis - based on studies, surveys, and document review of programs that have been and is being implemented - to produce a summary analysis of each program and indicators. The summary is incorporated in the formulation of the strategic plan. The documents that are referred to in preparing the strategic plan include the Health Sector Review, recommendations from national health meeting (Rapat Kerja Kesehatan Nasional/Rakerkesnas), basic health research (Riset Kesehatan Dasar/ Riskesdas), health research facilities (Riset Fasilitas Kesehatan/Rifaskes), mid-term review of strategic plan , the revised related regulations (for instance: the division of authority and responsibility, minimum service standards, competence, organisation, Public Service Agency/ BLUD), conceptual drafts of revision for division of authority and responsibility, conceptual draft of revision for minimum service standards, the design of the organisational structure and working procedures, materials from National Development Planning Agency/ BAPPENAS for the technocratic planning of National Mid-term Development Planning/RPJMN , and other supporting documents. A number of consultations with key stakeholders were conducted during the preparation of the vision, mission and strategy to revise the health sector policy. The key stakeholders include BAPPENAS, the National Family Planning Coordination Board/BKKBN, the Agency for Food and Drug Control (BPOM) Ministry of Health, and professional associations such as the Association of Indonesian Public Health Specialist (IAKMI), the Indonesian Midwives Association (IBI), the Indonesian Doctors Association (IDI), and the Association of Regional Hospital (ARSADA). During the drafting process, the expert consultants work closely with echelon 1, echelon 2 and the whole Roren team. SIXTH EDITION 33

38 Health Sector Development Plan for East Nusa Tenggara Province : Challenges, Acceleration Measures and Support through Partnership Health Sector Challenges in East Nusa Tenggara In 2013 East Nusa Tenggara (Nusa Tenggara Timur/NTT) province earned a Millennium Development Goals (MDGs) award due to accomplishment in reducing maternal mortality rate (MMR) from 306 to 176 per 100,000 live births. This success has been sustained and MMR went down further to 159 cases in Achievement is also suggested by the decrease of infant mortality rate (IMR) and under-five mortality rate (U5MR), although it tends to fluctuate. In 2007, IMR was at 57 per 1,000 live births (IDHS, 2007), while in 2012 it went down to 45 per 1,000 live births (IDHS, 2012). U5MR in 2007 was at 80 per 1,000 live births (IDHS, 2007), while in 2012 it went down to 58 (IDHS, 2012) (See Figure 1 for details of fluctuations). The prevalence of undernutrition has decreased from 20.4% (IDHS 2007) to 13.0% (Riskesdas 2010) while the prevalence of severe acute malnutrition has decreased from 9.0% (IDHS 2007) to 4.9% (Riskesdas 2010). Communicable Diseases. Almost 90% of villages in NTT are a malaria endemic area. This region is characterised by remote villages with poor environmental conditions, lack of transportation and communication, limited access to health care, low education and low socio-economic status, as well as poor healthy living behavior. In 2012, the highest malaria cases was in Lembata district with cases, while the lowest was in Kupang city with 284 cases. In 2012 there was an outbreak of dengue fever with 1542 cases. The highest was in Kupang city with number of cases as many as 890 cases. The highest mortality rate was in Kupang city, which is 8 people (Case Fatality Rate/CFR 0.9%), followed by Belu district (3 people), Ngada district and East Sumba (1 person each). In addition to malaria and dengue fever, Filariasis is also relatively high, especially in the Southwest Sumba (313 cases) and Rote Dao District (94 cases). In 2011 there was 4684 cases of Filariasis, and it went down to 501 cases in Figure 1. Disease prevalence and mortality rate in NTT 9 BKKBN Upaya Menurunkan AKI dan AKB di Nusa Tenggara Timur.http: //ntt.bkkbn.go.id/viewberita.aspx? BeritaID = Renstra Dinas Kesehatan Provinsi NTT KABAR AIPHSS

39 Acceleration Measures and Tackling Health Sector Challenges The NTT health sector strategic plan is a continuation of the previous health sector strategic plan. The previous strategic plan focuses on strengthening the foundation of the health infrastructure such as the quality and distribution of health personnel, the improvement of equipment and health facilities, the adequacy of drugs, the prevention and surveillance of communicable diseases, nutrition, maternal and child health (MCH), evidence based planning, the initial introduction of regional health information system (Sistem Informasi Kesehatan Daerah/SIKDA), and health financing. Whereas the Strategic Plan puts emphasis on: SIKDA implementation by integrating the functions of recording, reporting, tracking and monitoring of integrated evaluation Figure 2: Map of infectious diseases endemic in NTT Source: NTT strategic plan document analysis to support evidence based policy making. In the previous period, SIKDA cannot be fully utilised because it was still in the process of adoption. When SIKDA is fully implemented, the function of monitoring, reporting, follow-up, and health planning can be wellfunctioning. Commitment to reallocate the health budget more proportionally. Focus on capacity building through training and institutionalisation of partnership with sister hospital for the provision of leadership and management training. Policy Recommendations Learning of the lesson of the health center reform and MCH revolution program, supported by the implementation of the Alert Village. Since 2009, the Department of Foreign Affairs and Trade through the Australian Indonesia Partnership for Maternal and Neonatal Health (AIPMNH) and the Australia Indonesia Partnership for Health System Strengthening (AIPHSS) program has been supporting the NTT government to conduct MCH revolution and reform of health centers to reduce the rate of maternal mortality, infant and under-five. This innovative program is conducted through several approaches, including 2H2 3, sister hospital 4 and web-based distance learning (Program Jarak Jauh/PJJ) in 14 districts in NTT. In 2014, the Ministry of Health, through Health Human Resources Empowerment and Development Agency (Badan Pengembangan dan Pemberdayaan Sumber Daya Manusia Kesehatan/ BPPSDMK) has designed 456 educational modules and provided training to 120 tutors who will implement the web-based distance learning initiative for upgrading nurses and midwives qualification to diploma III. 5 Expanding the scope of the MCH revolution and Active Alert Village program. It is very important to involve the community and family member in monitoring treatment, preventing transmission of infectious diseases and improving nutrition. By replicating the MCH revolution model and the Active Alert Village model, the community can support basic health care providers in the villages, improve the function of surveillance for malnutrition, infectious diseases, healthy living behavior, disaster preparedness and obstetric emergencies. For example, in the case of eradicating malaria, family members and the community can be a support group to ensure patient compliance 11 2H2 is a system of reporting, monitoring and referral of pregnant women conducted in particular within the two-day period before the estimated date of delivery and two days after the delivery. A midwife performs monitoring, reporting and validation via SMS to 2H2 Center which is managed by the health centers. The data is compiled and reported to the hospital for referral preparation. In this system, PONED and health centers is further equipped with supporting infrastructure to be able to respond to obstetric emergencies. 12 Sister hospital and web-based distance learning is an effort to improve the quality of health workforce in handling delivery and obstetric emergencies. A well-known hospital is contracted to provide on-the-job training to health workers at partner hospitals and health centers so that they have the ability to provide 24H obstetric emergency services. 13 AIPHSS news. December Empowering Midwives and nurses in rural health centers. 14 Rita Kusriastuti, Asik Surya. New Treatment of Malaria Policy as part of the Malaria Control Program in Indonesia. Acta Media Indonesia SIXTH EDITION 35

40 during the 28 days and rational drug use until the infection is completely cured, and resistance to malaria treatment has not occurred. 6 Similarly, in the case of improving nutrition, awareness about nutrition and misperception about dietary restrictions for pregnant women and infants can be addressed within the framework of the Active Alert Village and MCH revolution. Analysis shows that a mother who is stunted will be more likely to give birth to a stunted baby, causing stunting across generations. This cycle has to be broken with a long-term investment through better nutrition and adolescent health program in school. In order to be successful, these expansions must take into account the following factors: Improvement of budget planning. The MCH revolution was often constrained by limited budget and non-optimal budget planning and allocation. A study of MCH program cost analysis by Dominirsep Dodo, et al (2010) in Sabu Raijua district finds that the budget planning for MCH program is leaning toward physical development and operational budgeting, while support for developing human resources is still minimum. In addition, delays in the disbursement of funds is also discovered, resulting in the disruption of MCH implementation activities. 7 Prepare an exit strategy. As DFAT funding for sister hospital and webbased distance learning is ending, there should be an exit strategy to ensure sustainability of the program. This primarily involves the transition of funding from donors to financing by the government (either through central government funding/apbn or local government funding/apbd), as well as the involvement of the private sector (for example: Community Social Responsibility) and civil society to maintain the sustainability of the program. In addition to the funding issue, the exit strategy needs to provide monitoring and evaluation instrument as well as allowing external audit. There should also be a capacity building program for hospital managers in relation to financing the sister hospital and web-based distance learning in the future. Bridging cultural and communication differences to support Sister Hospital and webbased distance learning. There are some factors that might hinder the success of sister hospital and web-based distance learning program, such as culture clash, differences in discipline and work ethic as well as the hierarchical system between mentors in the partner hospital with doctors and medical workers in NTT. Belton, et al (2014) finds that local doctors often experience culture shock while participating in the on-the-job training due to differences in work ethic with their mentors, resulting in low selfesteem and reduced incentives to internalise and adopt new knowledge that is transferred through sister hospital and web-based distance learning. 8 Build the foundation of health information systems. Participatory study on SIKDA in two districts in NTT finds that health workers have different interpretation of the reference for measurement and recording (e.g. different definitions of age group). In addition, errors in reporting also caused by misdiagnosis, as the village midwives often act beyond their capacity, which is inevitable in a region that is isolated. 9 Midwives, who are the spearhead in reporting process, also feel burdened by the dual function of caring for mother and child while also providing primary health care, and now coupled with the reporting function. Therefore, the adoption of SIKDA requires several improvements including: (1) an integrated training and coaching so that health personnel have a comprehensive knowledge based on official guidelines regarding reporting, (2) training in time management for rural midwives, for example perform administrational duties during the market day in the village when the majority of people do not visit health centers/village clinics, (3) active consultation and system adjustment according to the local context to facilitate complaints and user interests. Partnerships. The problem of health sector in NTT province requires cooperation among different government level (central-provincialdistrict-commune) and cooperation with development partners (civil society and private sector). The existence of aid, for example the Australia Indonesia Partnership for Maternal Neonatal Health (AIPMNH), the Australia Indonesia Partnership Health Support System (AIPHSS), World Health Organization (WHO), United Nations International Child Education Foundation (UNICEF), and the Nutrition Improvement through Community Empowerment (NICE), is an opportunity to accelerate health development efforts in the province. NTT provincial government should increase cooperation with international organisations such as WHO, Novartis Foundation, the Netherlands Leprosy Relief and the Sasakawa Foundation, Eijkman Institute of Molecular Biology, 15 Dominirsep Dodo, Laksono Trisnantoro, Sigit Riyato Analisis Pembiayaan Program Kesehatan Ibu dan Anak bersumber Pemerintah dengan Pendekatan Health Account. Jurnal Kebijakan Kesehatan Indonesia v. 01, p Suzanne Belton, Browyn Myers, Frederika signs Ngana Maternal Deaths in Eastern Indonesia: 20 years and still walking. BMC Pregnancy and Chilbirth, 14: Frederika signs Ngana, Browyn Myers, Suzanne Belton Health reporting system in two sub-districts in eastern Indonesia: Highlights the role of village Midwives. Midwifery journal. 36 KABAR AIPHSS

41 or even companies such as Biofarma, for the treatment of infectious diseases and ensure availability of medicines and vaccination. Partnerships with donors such as USAID, UNICEF and DFAT - who have funds for infectious disease eradication programs, improvement of sanitation and access to clean water as well as alleviation of poverty - also need to be strengthened. AIPHSS Support The Australia Indonesia Partnership Health System Strengthening (AIPHSS) provides technical support during the preparation of the health sector strategic plan of NTT province , especially in the stage of the planning process, and bring in a team of experts for assistance. AIPHSS also gives full support to the Strategic Plan Seminar at NTT Provincial Health Office. In addition to providing support for institutional improvement, AIPHSS is also a part of the web-based distance learning model implementation that has become a national innovation. Webbased distance learning program provides an opportunity for nurses and midwives (who are mostly women) to increase their competence without having to leave their workplace. This program was launched in July 2014 and will last for another four years. SIXTH EDITION 37

42 Minimum Service Standards (MSS) according to Law No. 23 of 2014 What People are served, the government serves. That is the basic formula of governance in Indonesia. As a country mandated to create a public welfare for the entire Indonesian people as stipulated in the constitution, the government (executive body) serves as the spearhead to implement the mandate. Indonesia is a unitary state which has a tiered governance system, namely the Central Government, Provincial and District / City Governments. To achieve a public welfare, the governance system and harmonious relationships between the central and local governments have been set up. Health is a part of concurrent compulsory affairs that the government must perform in providing basic services. (Article 12, Law No. 23 of 2014). Local governments prioritize the implementation of compulsory affairs related to basic services which refer to the minimum service standards (MSS) established by the central government. More clear meaning of the MSS can be seen in the Government Regulation No. 65 of 2005 on Minimum Service Standards. Article 1, paragraph 6 of the regulation states that Minimum Service Standards (MSS) is a provision regarding the type and quality of basic services which becomes compulsory affairs of local government and that every citizen should at least obtain, this is associated with: 1. Protection of constitutional rights (Articles 28H & 34 of the 1945 Constitution) 2. Protection of national interests, which are related to public welfare, peace and order within the framework of national unity. 3. Fulfilment of national commitments related to international treaties and conventions. 4. Gradual implementation and establishment of MSS by the Government. As a follow-up of the regulation, the Minister of Health issued policies on MSS of health for districts and cities as follows: 1. Health Minister Regulation No. 741/ 2008 on Minimum Service Standard (SPM) of Health for Districts/ Cities as an amendment to Health Minister Decree No. 1457/ 2003 regarding Minimum Service Standards. 2. Health Minister Decree No. 828/ 2008 on Technical Guidelines to Implementing the Minimum Service Standards of Health in Districts/ Cities; and 3. Health Minister Decree No. 317/2009 on Financing Guidelines of the Minimum Service Standards of Health for Districts/ Cities. However, based on the evaluation of the Agency of Health Research and Development (Balitbangkes) concerning Minimum Service Standards in 2011, there are still problems on the sides of management and substances in MSS application, that is discrepancy between the already published MSS and the one mandated by the Government Regulation No. 65 Year Mismatches in the substance side are among others: a. Twelve (12) indicators are not relevant with timeframe of achievement targets in b. The operational definition is not clear. c. The operational definition is not consistent with the calculation formula. d. The qualitative aspect of the MSS is too heavy when associated with the achievement target. e. The numerator and denominator are not traceable. f. Six (6) indicators of the MSS use CBR (Crude Birth Rate) as the basis for calculating targets: fourth visit in antenatal, obstetric complications, maternal, postpartum mothers, neonatal complications, and neonatal visits. However, not all districts/cities know CBR. (Year 2009). Meanwhile, from the management side, the problems are: a. The MSS of health has not been socialised to stakeholders in districts and cities, so that almost all health executive officers in district/cities do not understand the MSS which has been established by the Health Minister. b. Not all MSS have been integrated into the planning mechanisms in RPJMD (Regional Medium Term 38 KABAR AIPHSS

43 Development Plan) and budgeting mechanisms in RKPD (Regional Govt. Annual Work Plan) To overcome the MSS problems above, it is necessary, from the substance side to undertake: 1) Revision of Health Minister Regulation No. 741/ 2008 on Minimum Service Standard (SPM) of Health Sector for Districts/ Cities 2) Revision of Health Minister Decree No. 828/ 2008 on Technical Guidelines to Implementing the Minimum Service Standards of Health for Districts/ Cities 3) Revision of Health Minister Decree No. 317/2009 on Financing Guidelines of the Minimum Service Standards of Health for Districts/ Cities 4) Training on MSS (Revised version) for officers 5) Socialisation of the revised MSS to districts/cities. From the management side, it is necessary to immediately conduct socialisation on MSS of Health to all stakeholders in districts / cities. This should be done together with the Ministry of Home Affairs (MoHA), as the Home Affairs Minister is the Chairman of the Board of Trustees of Regional Autonomy as well as general Advisor of the Regional Autonomy Implementation. Currently, the final draft of the Health Minister Regulation on MSS Technical Guidelines including the indicators and financing resulted from previous revision, is still under ratification process in the DPOD (Regional Autonomy Advisory Council) after obtaining approval of the Minister in the discussion with first echelon officials within the MoH. The objective of the Minimum Service Standards (MSS) is provide the people with health services according to the minimal human life cycle: from planning a family to elderly, as follows: Couples of fertility age: health screening and reproductive health care Pregnant mothers: pregnancy care package Maternal mothers: maternity care package Newborn babies : Newborn health care package Under five children: Under five children health care package Students: Health promotion and health examination Adolescents: Health examination and early detection of prioritized health problems Who And How Following are the implementers and their roles in organizing health MSS activities. 1. Health Promotion in Primary Schools Implemented by: a) Coordinator or manager of health promotion in Puskesmas b) Health personnel in Puskesmas c) Team of School Health Units (UKS) d) Manager of health promotion in the district/city 2. Health Promotion in Puskesmas and its network Implemented by: a) Coordinator or manager of health promotion in Puskesmas b) Health personnel in Puskesmas c) Manager of health promotion in the district/city 3. Promotion for Community Empowerment in Health Sector Implemented by: a) Coordinator or manager of health promotion in Puskesmas Adults: Health examination and early detection of prioritized health problems and cancers Elderly: Health examination and early detection of some prioritized health problems. When The activities related to MSS will take place from 2014 to Where The activities will be conducted at provincial and district/city levels. b) Health personnel in Puskesmas c) Manager of health promotion in the district/city d) Health data and information system management personnel in the district/city 4. Pregnancy care package at Puskesmas and its network Implemented by: a) Doctors b) Midwives c) Nurse-midwives d) Trained nurses in antenatal e) Trained health workers in nutrition f) Nutritionists 5. Maternity care package at Puskesmas and its network Implemented by: a) Doctors b) Midwives 6. Newborn health care at Puskesmas and its network Implemented by: a) Doctors b) Midwives c) Nurses SIXTH EDITION 39

44 7. Under five children health care package at Puskesmas and its network Implemented by: a) Doctors b) Midwives c) Nurses d) Nutritionists 8. Health examination for primary school students Implemented by: a) Doctors /dentists b) Nurses c) Dental nurses or trained officers d) Midwives e) Nutritionists 9. Health examination for adolescents (15-18 yo) at Puskesmas and its network Implemented by: a) Doctors b) Midwives c) Nurses d) Nutritionists 10. Health examination and reproductive health care for adults (19-59 yo) at Puskesmas and its network Implemented by: a) Doctors b) Midwives c) Nurses 11. Health examination for elderly (60 yo above) at Puskesmas Implemented by: a) Doctors b) Midwives c) Nurses d) Nutritionists 12. Examination for suspected Tuberculosis (TB) at Puskesmas and district/city hospitals (RSUDs) Implemented by: a) Doctors at Puskesmas who have been trained on TB b) Doctors at RSUDs who have been trained on TB c) Nurses at Puskesmas who have been trained on TB d) Nurses at RSUDs who have been trained on TB e) Nurses at district/city RSUDs who have been trained on TB f) Health laboratories at Puskesmas which have received training on TB microscopic g) Health laboratories at district/ city RSUDs which have received training on TB microscopic h) Midwives at MNCH polyclinic of Puskesmas who have been trained to examine TB symptoms in children i) Midwives at MNCH polyclinic of RSUDs who have been trained to examine TB symptoms in children j) TB program officers at district/ city health offices 13. Examination of suspected HIV AIDS at Puskesmas and RSUDs Implemented by: a) Doctors /dentists b) Trained nurses and midwives c) Puskesmas health workers who have been trained on HIV/AID counselling d) Health laboratories 14. Sanitation inspections at primary schools and traditional markets Implemented by: a) Sanitarian b) Trained nurses 15. Early warning and response within less than 24 hours Implemented by: a) Epidemiologist b) Trained personnel in epidemiology (surveillance officers of DHO and puskesmas) c) Trained personnel joining in the district/city Quick Movement Team 16. Health promotion for students of exceptional schools (SLB) Implemented by: a) Coordinator or manager of health promotions in a province b) Health promotion manager in high schools or equal 17. Health promotions and community empowerment of health at mass media Implemented by: a) Coordinator or manager of health promotions in a province 18. Sanitation inspections at secondary schools and exceptional schools Implemented by: b) Sanitarian c) Trained nurses Budget Funding for the implementation of MSS is sourced from local budget (APBD). In accordance with Article 9, paragraphs (4) and (5) of the Government Regulation No. 65 of 2005 on Minimum Service Standards and Article 26 paragraph (3) of the Government Regulation No. 58 of 2005 on Regional Budget Management, the financing of MSS should be prioritized in the APBD prior to proposing budgets for other activities. 40 KABAR AIPHSS

45 Sources of APBD funding for MSS activities may come from general allocation fund (DAU), share revenue fund (DBH), or locally-derived revenue (PAD). Meanwhile, the specific allocation fund (DAK) can be used to meet the achievement of MSS as long as it is allocated for such purpose. For districts which depend their funding resources on DAU, DBH and limited PAD, the MSS should also be allocated through DAK. Supports of AIPHSS program The Australia Indonesia Partnership for Health System Strengthening (AIPHSS) was officially launched by the then Australian Prime Minister, Julia Gillard and the Indonesian Health Minister, dr. Nafsiah Mboi SpA, MPH, in October Point B of the Attachment to Law No. 23 of 2014 regarding Distribution of Affairs between the Central Government and Provincial, District/ City Governments was a contribution of the Association of Health Offices in Indonesia (ADINKES) funded by DFAT (Department of Foreign Affairs and Trade) through the Australia Indonesia Partnership for Health System Strengthening (AIPHSS). Through the MoH Bureau of Planning and Budgeting ands through AIPHSS funding support, ADINKES was able to develop 5 (five) out of 8 (eight) prioritized activities in accordance with the MoH recommendations, as follows: a. Distribution of affairs between the Central Government and Provincial and District/ City Governments, attached in the Appendix of Law No. 32 of 2004 (not set forth in the MoH recommendations) b. Revision of Government Regulation No. 38 of 2007 on Distribution of Affairs between the Central Government and Provincial and District/City Governments in Health Sector. c. Revision of Government Regulation No. 41 of 2007 on Regional Government s Organisations, that is the additional article concerning the Authority of Ministries/ Non Ministerial Institutions in Technical Arrangements of Regional Government s Organisations [Article 211, paragraph (2)]. d. Revision of Health Minister Regulation No. 741 of 2007 on Indicators of the Minimum Service Standards of Health for District/City Governments. e. Revision of Health Minister Decree No. 922 of 2008 on Technical Guidelines for the Distribution of Health Affairs between the Central Government and Provincial and District/City Governments. f. Revision of Health Minister Decree No. 828/ 2008 on Technical Guidelines to Implementing the Minimum Service Standards of Health for Districts/ Cities. g. Revision of Health Minister Decree No. 317/2009 on Financing Guidelines of the Minimum Service Standards of Health for Districts/ Cities h. Technical competency development for the implementation of health affairs at sub national and lower levels. i. Revision of Health Minister Decree No. 267 of 2008 on Technical Guidelines of Provincial and District/ City Health Office Organisations j. Revision of Health Minister Decree No. 128 of 2004 on Puskesmas Basic Policies k. Bupati /Mayor Regulations on the Establishment of Puskesmas as Healthcare Providers (PPK), BLUD Puskesmas and Standard Services in Puskesmas. There are several things need to be followed up from the results, as the health minister regulations will mean nothing without any follow up. References The Indonesian Health Minister Decree No. 1457/MENKES/SK/X/2003 on Minimum Service Standards of Health in Districts/ Cities. Government Regulation No. 58 of 2005 on Regional Finance Management Government Regulation No. 65 of 2005 on Guidelines to Developing and Implementing Minimum Service Standards Draft Health Minister Regulation on Minimum Service Standards of Health, 2014 Minimum Service Standards of , ADINKES Team, 2014 Law No. 23/2014 on Distribution of Affairs between the Central government and Provincial and District/ City Governments. Law No. 32/2004 on Regional Governance SIXTH EDITION 41

46 An Effective Referral System in East Java: Ensures People Receive The Best Possible Care Closest to Home The Improvement and Development of Health Referral System in East Java Province 2014 The development of health referral system is important to health system strengthening in order to achieve the right to health and to reach both effective and efficient health care services and financing for the population. 1,2 Since 2014, the Indonesian government has implemented the National Health Insurance (JKN) to all provinces including East Java. Thus, a good and sustainable health referral system from primary health care (at puskesmas) to tertiary level (at hospital) is essential to ensure individuals in receiving optimal care at the appropriate level and accessing health facilities in a timely way. The government of East Java has already issued a governor decree No.188/786/ KPTS/013/2013 on the implementation of regionalization of referral system that aimed to improve its referral system efficiency and access for East Java whole population. East Java Referral System Condition The major issue of JKN implementation in East Java is structuring the individual health referral system in order to reach accessible, efficient and effective health care from primary to tertiary levels. The current referral system has not been working effectively and efficiently to reduce the number of neglected patients as part of referral process from puskesmas. At puskesmas level, only 45 percent puskesmas have the ability to handle 144 cases which primary health care should be able to assist these cases. In terms of health personnel, several health personnel who have completed Basic Emergency Neonatal Obstetric Care (PONED) training were placed in non-poned puskesmas. In addition, numbers of puskesmas still have specialized service such as surgery room compared to other Districts Hospital (RSUD). At hospital level, class A and B hospitals in East Java still received a lot of patients (i.e. 85 percent) who had directly referred from puskesmas. Moreover, districts RSUD in which Australia Indonesia Partnership for Health Systems and Strengthening (AIPHSS) program operated (funded by Australia Department of Foreign Affairs and Trade (DFAT), was the only secondary health care level available for few districts. As a result, these districts RSUD experienced over-utilized referral cases that could be managed at primary level. In addition, many neglected referral cases could not be handled due to the lack of specialist doctors and the unavailability of laboratory and imaging equipment at districts RSUD. AIPHSS Pilot Project in East Java A collaboration project between AIPHSS, the Indonesian Ministry of Health and East Java Provincial Health Office (PHO) has been conducted in terms of a series of efforts to improve and develop regionalization of referral system at the district level. The project aims to develop health care referral system guidelines in East Java based on the case study results in selected districts. A pilot study was conducted during the period of May and November 2014 in the districts of Sampang, Bangkalan, Situbondo and Bondowoso. The seven stages of the improvement and development process of East Java referral system: 1. Developing assessment instrument for puskesmas and hospital, includes training of trainer for Focus Group Discussion (FGD) 2. Conducting health facility assessment and FGD, includes health facility mapping and FGDs for for puskesmas, hospital, community and provincial and districts health office and assessment analysis 18 AIPHSS & Kementerian Kesehatan Republik Indonesia Regionalization of Referral System: East Java Province. AIPHSS and Kementerian Kesehatan Republik Indonesia. 19 Backman, G and et al Health systems and the right to health: an assessment of 194 countries. Lancet 372: KABAR AIPHSS

47 3. Disseminating assessment and FGDs results through workshops at provincial and districts level 4. Developing referral system draft model, includes dissemination process and finalization of referral system model at provincial and districts level 5. Disseminating referral system model through workshops at provincial and districts level 6. Conducting referral system testing, includes monitoring and evaluation, draft and review referral system guidelines for provincial and districts level 7. Finalizing the referral system guidelines, includes workshops for referral model implementation results. Pilot Project Results and Outcomes. The results of puskesmas assessment show that many puskesmas in East Java have not complied with the standard requirements to provide high quality care such as Basic Emergency Neonatal Obstetric Care (PONED). If the local government could prioritizing this PHC issues, it would then reduce bypass cases, which PHC could handle referral cases and decrease delay handling cases in districts RSUD. On the other hand, the hospital assessment demonstrates that several regional referral hospitals in East Java have poor performance of their basic specialities health care including its Comprehensive Emergency Obstetric and Neonatal Care (PONEK) than districts RSUD. Specialized hospitals have the capabilities in providing services according to its specificity as well as outside their specialization, and some of these hospitals have prominent service than their specificity. the FDG s results illustrate that there has been lacking of communication and coordination between health facilities level with PHO, DHO and BPJS (Healthcare and Social Security Agency), lacking of dissemination on JKN mechanism to community, and poor performance of PHC level due to its facilities including limited medicine stocks and health personnel unavailability. The findings from monitoring and evaluation of referral model testing and referral system guidelines implementation in regional and provincial hospitals show that the administration referral procedures have not been done properly, the referral form from puskesmas and hospital for general patients is still differ than patients with BPJS, and there is no report form for the referral system in hospitals. Therefore, the main outcome from this project is a technical guideline for East Java regionalization of referral system. The guidelines will be used to improve the quality and sustainability of individual health referral system at primary health care that ensures collaboration between health facilities, communities as the recipients (users) and stakeholders that could also be apply to other provinces in Indonesia. Provincial and districts health offices are responsible for implementing this improved referral system in coordination with BPJS. From this activity, East Java Provincial Health Office (PHO) and AIPHSS have recommended changes of referral hospital category from two provincial referral hospitals and nine regional referral hospitals to be one provincial referral hospital and seven regional hospitals. Four regional referral hospitals for mental cases remained the same. The standardization of human resources and health infrastructure for hospitals that will be appointed as East Java regional referral hospital is highly needed. Challenges issues. The main challenge for the implementation of health referral system in East Java and other provinces is the unavailability of specialist doctors, medical, laboratory and imaging equipment at Districts RSUD and other skilled health personnel at PHC. In addition, the identification of District RSUDs special services should be identified clearly based on their capacity. The need of improving health referral administration has been another issue that requires to be solved by the support from the districts government. Recommendations To improve efficiency of the regionalization of referral system in East Java and other provinces, the policy makers need to consider several important issues as follows: At National Level a. Conducting benchmarking, evaluation and research to identify standard approaches in the implementation of the referral system in Indonesia. Considering a wide range of diversities in Indonesian region, therefore the activity should also include identification of local/regional specific challenges on implementing the referral model. b. Improving quality and increasing number of human resources for health (HRH) at secondary health care, especially for specialists doctors and other health personnel according to their skills. c. Continuing the support from AIPHSS to facilitate East Java Province Referral System as a model that could be adopted at the national level including its standardized referral forms and referral software applications. d. Improving the current referral model that has not considered disaster or force majeure conditions (for specific diseases such as HIV-AIDS, Tuberculosis, leprosy, mental illness, eye diseases and other specific diseases) by formulating specific referral system for those disaster and specific diseases at national, provincial and districts level. SIXTH EDITION 43

48 At Provincial Level a. Improving communication and collaboration at leadership levels between PHO, DHO, BPJS and other health related stakeholders in order to reach efficient and optimal referral system. b. Improving the quality of health care services at primary health care (puskesmas) including poskesdes, polindes and pustu related to its health personnel provision and heterogeneity, adequate medical equipment, health infrastructure and inpatient care in order to serve more cases at primary level. c. Improving the placement of skilled and trained health personnel according to their skills and training experience based on the needs of PHC level. d. In terms of sustainability, both provincial and local government should not only allocate financial assistance to the referral system but also importantly improve health preventive program rather than curative program. e. In terms of cross-border issues between districts, there should be a memorandum of understanding (MoU) between districts and provincial level to facilitate referral access for population living in border regions. Referral system sustainability. Financial support could be the essential key factor to establish referral system and its continuity in the health system. Nevertheless, leadership from both provincial and districts governments is important to contribute to the sustainability of referral system. The local government should be able to identify the local problems of referral system to provide accessible and reliable health services in all areas. Ensuring financial structure and reshaping the model of care to meet East Java demographic and epidemiological changes by both local and national governments could achieve long-term sustainability of this health referral system. 3,4 Cross-cutting issues for gender and innovation. Referral system as part of health services building blocks would contribute to the strengthening of health systems with other cross-cutting issues such as governance, health financing, and health information systems, especially for gender and innovation issues. The referral system should be able to prioritize infants, under-five children, elders population and poor families to minimize gender inequities and inequalities that still exist in the population, especially for women. 5 Implementers of referral system at various administration levels should be encourage to create further innovation by increasing communication with different stakeholders and health service providers, building collaboration and partnership with multi sectoral and responding to the demands of new standards and guidelines. 3 Moreover, policy and program should be consistent with the overall goals of health system through continuous monitoring and evaluation of referral system at all health care levels. The referral system needs to be dynamic in accordance with the local expectations and requirements to produce more innovation in the health system. Strategic partnership. This activity has strengthened strategic partnerships between East Java Province, the Indonesian Ministry of Health and AIPHSS in terms of assisting local government awareness for improving its current health referral system, ensuring strategic policy related referral system, enhancing health personnel skills and knowledge related to referral system, and providing technical support to the local government. This also provides additional funding support for improving current referral system at provincial and districts level. This activity fosters partnership and collaboration in engagement with other government and private sectors. 20 WHO Everybody s Business: Strengthening Health Systems to Improve Health Outcomes: WHO s Framework for Action. World Health Organization, Geneva, Switzerland. 21 WHO Monitoring the Building Blocks of Health Systems. World Health Organization, Geneva, Switzerland. 22 Sen, G & Ostlin, P Unequal, unfair, ineffective and inefficient gender inequity in health: Why it exists and how we can change it. WHO Commission on Social Determinants of Health. Karolinska Institutet. 44 KABAR AIPHSS

49 AIPHSS support to Revision of Law 32 Year 2004 to Law 23 Year 2014 on Regional Governance (Health Sector) What was the main reason for revising the UU 32 to UU 23? The problem is the lack of clear regulation in regional governance and distribution of government affairs between Central, regional government at province and city level resulting in different interpretation of the Norm, Standard, Procedure, and Criteria (NSPK). This condition creates misperceptions in the functional assignments amongst government structures and delayed efforts in reaching key national targets in the health sector. Disintegration of planning and budgeting in the health sector further exacerbates the situation. Law 32 Year 2004 on regional governance provides arrangement for distribution of government affairs based on these criteria: externality, accountability, and efficiency. In order to ensure quality and uniformity in interpreting the arrangements for all regions, central government determines NSPK particularly to allow the central government to provide proper management and supervision of the distribution of affairs. The arrangement is included in the government decree 38 Year 2007 (PP38/2007). Guideline on organization of the regional local government instruments is further explained in the government decree 41 Year 2007 (PP41/2007). But in reality, there remain basic issues in constructing and determining the NSPK as outlined in government decree 38 Year 2007 (PP38/2007), including different perceptions on how the concept of NSPK should be materialized into the regulations. In the past 10 years since the regulations were issued, the implementation of Law 32 Year 2004 as well as government decree 38 Year 2007 (PP38/2007) and government decree 41 Year 2007 (PP41/2007) have not been effective and the regulations have not been seen as sufficient in providing clear guideline on arrangements of authorities and functional assignments amongst the government structures. This results in issues such as: - Unclear function between District/ Municipality, Province and National related decentralization in health even Ministry of Health already launched minister of health decree no 922/2008 as implementation of PP38/2007 but there are unclear function such as Maternal & Child Health never mentioned in the minister decree 922/2008 but appear in the minimum services standard (SPM) which should part of the District/municipality function. - Unclear roles for Dinas Kesehatan including unclear functional relationships between Rumah Sakit Umum Daerah (RSUD) and Dinas Kesehatan - Increased amount of institutions and regional instruments that do not follow the set criteria resulting in increased burdens on regional budgets - Uneven and non-uniformity of institutions of local government instruments managing health affairs at the province, district, city levels - Health centers as primary services in health not mentioned in the PP41/2007 as part of Dinkes therefore in some District/ Municipalities Health center supervise by Sub-District office and not Dinas Kesehatan. Due to the above, implementation issues arise at the regional level including: - Funds intended to be distributed as APBD for health sector remains lacking - Availability of health care providers remains uneven across regions (where providers are more available in bigger cities) - Unorganized health coverage plans at regional level despite Law 38 Year 2007 s assurance of increased roles of local governments to manage health affairs. In 2014, President of Indonesia issued Law 23 Year 2014 to revise Law 32 Year 2004, in order to provide further clarifications on the regional governance. According to Law 23 Year 2014 Chapter IV, division of administrative affairs is divided into absolute, concurent, public. The chapter further explains that health sector is a part of the concurent compulsory affairs providing basic services, and to be managed proportionally by both central and regional government at province, district and city levels. SIXTH EDITION 45

50 What has the UU 32 been revised to UU 23? Considering the issues mentioned above, it was the government decree 38 Year 2007 and government decree 41 Year 2007 were revised to provide further clarifications to Law 23 Year 2014, of the distribution of government affairs at central, regional provincial and city level as well as the organization of local government s legal instruments. These revisions include: Revision of government decree 38 Year 2007 to include clearer arrangement of authorities and guidelines to organizing government affairs between central, province and city levels New formulation that would allow arrangements of distribution of government health affairs per government structures (central, regional levels) to be included into the regulations related to regional governance. The revision includes further definitions on primary, secondary, tertiary health services as well as division of authorities and duties for Policies, Development, Supervision, Facilities, Monitoring, Evaluation, Health Services, Health Research and Development, Health Financing, Human Resources for Health, Pharmaceutical Supplies, Health Equipmentand Food-beverages Management, Information and Health Regulations, for each sub fields and sub fields between central, province, and city levels. Government decree 41 Year 2007 was established to provide technical guidance on organization of local government instruments at regional level at province, district, city levels. Institution of regional government instruments implementing health affairs has a role to provide description of division of tasks, duties of Dinas Kesehatan (Health Office), Rumah Sakit Umum Daerah(Local Hospital) at all regional levels, and Health Centre (Puskesmas). Included in the regulation is the blue print to determine the rightsizing of the proper and functional organizations with the overall goal to achieve good governance. However, government decree 41 Year 2007 is not considered as comprehensive in providing clear direction and guidance for the regional stakeholders in managing the organization of institutions of regional government instruments. In reality, there has been increasing numbers of institutions that are not necesarrily created according to the set criteria (the needs of the region and the capacity of each districts). This creates burdens and inefficiency on the regional budgeting. Therefore, revision of government decree 41 Year 2007 include: Clarification of the functional relationships between Rumah Sakit Umum Daerah (RSUD) and Dinas Kesehatan Clarification the roles of Dinas Kesehatan (as regulator or also operator of health services) Clarification of arrangements of authorities to ensure the same understanding and perceptions at every level in regards to regional government instruments. Revisit criteria for weighting in determining organization size by including percentage of Local Revenue/Pendapatan Asli Daerah (PAD) into the Local budget/apbd, changing the weight, revisit interval class to get the real situation in the field. The aim for the weighting is to obtain proportional organization according to the geographical variable, size of the areas, population, level of education, level of poverty, availability of natural resources, human resources, facilities and infrastructure, and regional financial capacity. Proposed implementation strategy Implementation Strategy Barriers to implementation Strategies for Mitigate Review the regulations and legislation of roles and responsibilities of the key players in the health sector including clarifying who is responsible for meeting the targets at both national and regional level for the RJPMN targets. Develop a performance management system which will allow the MoH to work with the MoHA to monitor performance in the decentralised system. Political level: Ensuring the legitimacy of national, provincial and district governments in the management of the SKN (Sistem Kesehatan Nasional/National Health System), and clarifying the roles of MoH, Provincial and District Health Offices within the SKN. Policy level: How national priorities such as equity, developing the role of primary health care, can be implemented locally, and how service planning can be integrated at all levels in the system, and across all sectors Governance level: How the MoH can manage governance and accountability for the performance of institutions not directly managed by the MoH but have an impact on health. How to undertake health systems strengthening to align health financing, human resources for health, information and supervision/reporting. Structural level: how to clarify the relationships vertically (MoH, PHOs, DHOs) and horizontally (MoH BPJS MoHA, MoE etc). Particularly, there is a lack of clarity about the roles of PHOs and DHOs, and the relationships between provider institutions like the hospitals within the stewardship of different levels of government within the SKN in relationship to each other, where roles are often perceived differently or are undeveloped in the case of new institutions. Capacity level: how to ensure the right capacities are built so that health institutions provide effective leadership and governance at all levels to manage the changing health needs and expectations of the community. Leadership level: How can the MoH exercises its supervisory responsibilities particularly quality of care, standard setting and enforcement. Socialisation of NSPK and facilitation at the sub-nationals Regulate relationships between District Health Ofice (DHO) with hospital and health centre Strengthen relationships between the MoH with PHO/ DHO 46 KABAR AIPHSS

51 Ensure creation of institutions based on workloads considering the loads are varied Anticipation of increasing of institutions due to interventions by central government Ensure Ministry of Home Affairs (Kemendagri) to consult with regional counterparts in regards to management and supervision of regional governance. Strategies To Mitigate Socialization of NSPK and facilitation at the sub-nationals In order to support the development of NSPK in regards to distribution of government affairs between central and regional government for Health unit, AIPHSS proposed the following activities: - Serial meetings for 30 consultants for 20 months - Write up of the draft of Health Ministerial Decree on NSPK for Health unit in regards to distribution of government affairs between central and regional government at province and district level for: (1) planning for health workers; (2) utilization of health workers; (3) maternal health services; (4) mother and children services; (5) HIV-AIDS health services; (6) Tuberculosis health services ; (7) malaria health services; (8) hypertension health services; (9) financing of minimum standard services; (10) community empowerment; (11) legal drafting; (12) Dissemination; (13) Reporting Regulate relationships between District Health Office (DHO)/Dinas Kesehatan (Dinkes) with district hospitals and health centers/rumah Sakit Daerah (RSD) In the era of decentralization, District Health Office (DHO)/Dinas Kesehatan (Dinkes) is responsible for overseeing Community Health Efforts/Upaya Kesehatan Masyarakat (UKM) and Individual Health Efforts/ Upaya Kesehatan Perorangan (UKP). But in reality, district hospitals/ Rumah Sakit Daerah (RSD) often carries the responsibility of overseeing the health services at the district level, creating inefficiency in the health system functioning. In order to address this issue, policy makers including Association of District Hospitals in Indonesia/ Asosiasi Rumah Sakit Daerah Se Indonesia (ARSADA) recommends that DHO/Dinas Kesehatan manages and provides full supervision for all health services facilities including the district hospitals/rumah Sakit Daerah (RSD). In addition, district hospitals/ Rumah Sakit Daerah (RSD) is recommended to increase its role as the operator while District Health Office (DHO)/Dinkes serves as the regulator of the health services. References Law 32 Year 2004 Government Decree 38 Year 2007 Government Decree 41 Year 2007 Law 23 Year 2014 AIPHSS documents on revisions of Government Decree 38 Year 2007 and Government Decree 41 Year content/7/s1/s13 com/2014/12/24/enam-perda- urusan-wajib-pemerintah-daerah html kebijakankesehatanindonesia.net/ v13/images/gambar/vol/policy%20 brief%20no%2015.pdf com/2014/12/24/enam-perda- urusan-wajib-pemerintah-daerah html com/2014/06/20/menata-ulang- upaya-kesehatan-di-indonesia html Perbandingan-UU Dan-UU #scribd com/2014/11/18/tindaklanjut- undang-undang-nomor-23-tahun tentang-pemerintahan-daerah html executive-summary-adinkesaiphss selayang-pandang-adinkes-nov presentation/d/1h0bmobi_6vgi6fh YTmeLY1BG3kqmCvpUZ0bOM6fyK2Y/ edit#slide=id.p28 mod=browse&op=read&id=jkpkbppk- -roberiasit external/default/wdscontentserver/ WDSP/IB/2012/05/18/ _ /Rendered/INDEX/689950E SW0P1200doman0PenyusunanNSPK. txt berita/berita-arsada/404-usulanuntuk-revisi-pp SIXTH EDITION 47