Decentralization Part Two!

[assalamualaikum & salam sejahtera]

Health system aspect that has impact of decentralization concept.

1. Capacity of local government

Decentralized health services in Indonesia seem to have reached a point of no return. In line with the global trend of democratization and privatization, the role of the central government could be limited to regulatory, supervisory, and partial financing. The capacity of local governments to ensure absorption and creation of private sector environments to cater to appropriate human resources should be thoroughly examined.

When we discuss about region in Indonesia, most of them are not ready to really implement the decentralization concept. First encounter problem is based on financial. More than three quarters of local governments in Indonesia are financially dependent on the general allocation budget (Dana Alokasi Umum), allocated by the central government. When this happen, the budget allocation to the health sector is very limited. Although the budget to certain region is enough but most of the budget used to purchase technology and building the access to health such as hospital, Primary Health Center. Only a little budget goes to improve human resources capacity.

One of the driving force of human resources capacity is economic force. When there is region which has low economic force, it will affect the human resources force in that area. Last time, when there is central government policy that new graduates of health professional will have to undergo mandatory services, this problem is manageable. Where as, under new decentralized government, local government has low capacity to attract the health professional or human resources to work in the region. Of course if they given a choice of working in urban area and remote area, with the same salary, most of the health professional will choose the urban area rather than remote area. There is freedom to choose affect the distribution of the health professional in remote area. In urban area, they have greater opportunity to expand the income by joining the private practice as the Indonesia government allow the doctors and specialist to work in 3 places at one time.

However, the Indonesian government, international donors and external agencies are actually aware of the above. Several projects and programs to improve the capacity of human resources have been initiated through loans or grants from external bilateral agencies and multilateral financial agencies such as the World Bank or the Asian Development Bank.

2. Public Health Law

Law is very important element in health system. Without law, a system cannot be manage well by the government. Indonesia did not have a public health law as such for many decades. The epidemic and health law was enacted in 1992. Even where regulations existed, only a few were properly regulated. Only six of 32 government regulations, required by the Health Act of 1992, are adequately regulated. Regulation for human resources for health is one of them.

Without distinct law between central and local government, there will be problems in order to solve certain problem. or example, in case of bird flu, the bird need to be kill and require budget to eliminate the bird, thus who are responsible for this case. That why, the law is very important to solve this problem especially the finance part.

However, efforts to develop the legal infrastructure are being made. A new government regulation, authorizing a Minister to regulate and to set minimum service standards was issued in January 2006. The local government must ensure delivery of services and to share - whenever and whatever possible - with other local governments in providing certain public and personal health services. This new regulation is an attempt to provide a more solid basic infrastructure of public services.

Without a clear definition of the role, function, and financing responsibility of the central and local governments to ensure horizontal equity across various fiscal capacities of local governments, the policy on human resources and public health measures will heavily depend on the leadership and inclination of elected officials at local levels. Efforts to educate elected officials and to facilitate their understanding and commitment, such as intercity study tours to share experience with excellent public health infrastructure in and out of the country should be strengthened.

3. Production Capacity

As I mention earlier that Indonesia has not enough human resources for health (HRH) in term of number. Thus, Ministry of Health made open education policy for the establishment of undergraduate,graduate, postgraduate institution in order to enhance the production of HRH. Nowadays, the increase in number of public health institution.

The number of institutions offering bachelor’s degree in public health, nursing and allied health tripled, compared to the previous three decades. The growing number of education institutions in health and allied health sciences is partly attributable to decentralized governments where local governments, especially at the provincial level, see that they too should have medical, nursing, or public health schools.

Even if the institutions could produce adequate numbers, their absorption across regions would not be proportionate to the population. Based on the previous experiences and current data, it was observed that the distribution of health professionals was always skewed to the big and rich urban areas. The biggest challenge for Indonesia is how to formulate morale and material incentives for HRH in order to deploy them in the remote and in the less prosperous regions.

Another potential problem is competition among the educational institutions by lowering tuition fees in order to get more students at the expense of quality. If this occurs within the next 5-10 years, Indonesia will have an over-supply of low quality HRH. Thus, in this aspect, decentralization play an important role as centralize accreditation is not function well. Regional or provincial regulation on accreditation is easier to control the quality of health institution.

*References:

1. Hasbullah Thabrany; Human Resources in Decentralized Health Systems in Indonesia: Challenges for Equity; Regional Health Forum – Volume 10, Number 1, 2006

2. WHO Country Office, Nepal; Decentralization of Health System and its management