Health development plan towards Healthy Indonesia 2010 - [BUKU]

HEALTH DEVELOPMENT PLAN

TOWARDS

HEALTHY INDONESIA 2010

1999

Ministry of Health Republic of Indonesia.

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BY THE BLESSING OF THE ONLY GOD I PROCLAIM

THE DEVELOPMENT MOVEMENT WITH HEALTH CONCERNS as the National Development Strategy in order to materialize

HEALTHY INDONESIA 2010. JAKARTA, 1ST MARCH 1999

PRESIDENT OF THE REPUBLIC OF INDONESIA BACHARUDDIN JUSUF HABIBIE

On the 1st of March 1999, President of the Republic of Indonesia,

Bacharuddin Jusuf Habibie, proclaims THE DEVELOPMENT MOVEMENT WITH HEALTH CONCERNS as the National Development Strategy

in order to materialize HEALTHY INDONESIA 2010.

Healthy Indonesia 2010 is not belonged to Ministry of Health, Healthy Indonesia 2010 is belonged to all the people of Indonesia. Hence a harmonious, effective and efficient cooperation is required in its realization implementation.

With the completion of this Health Development Plan towards Healthy Indonesia 2010, we confer appreciation and thanks to all sides for their attention and helps so far.

This plan is compiled after receiving input from various departments, universities, experts, professional organizations, NGOs and international agencies. Even though all related aspects and factors have been attended in this document, none the less there are still shortcomings. Hence this document still requires revision.

Healthy Indonesia 2010 can only be achieved through the spirit, dedication and hard work from all of us. Without that, Healthy Indonesia 2010 would be just an empty slogan with no meaning. With high dedication, spirit and hard work from all of us, Insya Allah (God willing) civil society that we all wish for, i.e. a social order that is healthy physically, mentally as well as socially, the modern society that is civilized, faithful, devout, can be achieved by us.

May the Only God always give His guide and confer strength to all of us in implementing the health development. Amen.

Jakarta, October 1999

Page 2 of 88 Prof. Dr. F.A. Moeloek

TABLE OF CONTENTS Preface

Analysis of Situation and Trends

Development Problems Opportunities Threats

Strategic Issues

Principles, Vision and Mission of Health Development

Principles of Health Development Vision of Health Development Mission of Health Development

Direction, Objectives, Targets, Regulations and Strategies of Health Development

Direction of Health Development Objectives of Health Development Targets of Health Development Regulations of Health Development Strategies of Health Development

Programs of Health Development

Principle Programs of Health Development Prioritized Health Programs

Requirements for Health Resources

Manpower resource Facility resource Financial resource

Organization and Motivation in Implementation

General affairs Organization

Implementation motivation

Intra and Inter-sectoral Co-operation Cultivation

Supervision, Controlling and Evaluation

Supervision

Model and Mechanism of Supervision Controlling and Evaluation

Indicators of Health Development

Closure

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Preface

The national aims of the nation Indonesia as stated in the Preamble of the 1945 Constitution is to protect all the nation of Indonesia and all the territory of Indonesia and to promote public welfare, to develop the intellectual life of the nation, and to participate in implementing the world order based on independence, eternal peace and social justice. In order to achieve the national aims, a planned, comprehensive, integrated, directed and continuous national development is conducted. The aim of the national development is to achieve a just and prosperous society with evenly distributed materials and spirituality based on Pancasila and the 1945 Constitution which is contained in the Unitary State of the Rep. of Indonesia which is independent, sovereign, unitary, and having people’s sovereignty within the nation’s living situation that is safe, peaceful, in order and dynamic

as well as within the world’s social environment that is independent, friendly, in order and

peaceful.

To achieve the national development’s aims requires among other things human resource of integrity, autonomous and qualified. The data from UNDP of year 1997 states that the human development index in Indonesia is still at the 106 rank out of 176 countries. The level of education, income and health of Indonesian people is indeed still unsatisfactory. Recognizing the achievement of the national development’s aims is the will of all the people of Indonesia, and in order to face the even tighter free competition in the global era, efforts to increase human resource quality must be implemented. In this case the roles of health development’s success is very decisive. The healthy people will not only support the success if the education program, but also push the increase in productivity and income of the people.

To accelerate the success of health development requires health development policies that are more dynamic and proactive by involving all the related sectors, the government, the private, and the society. The success of health development is not only decided by the performance of health sector alone, but also very much influenced by dynamic interaction of various sectors. Attempts to make the national development with health concerns as one of the new missions and strategies must be able to become the commitment of all sides, beside shifting the old health development’s paradigm into the Health Paradigm. The compilation of health development plan towards Healthy Indonesia 2010 is a concrete manifestation of the will to execute the national development with health concerns and the health paradigm.

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Analysis of the Situation and Trends

The existing health development programs so far being implemented has succeeded in increasing health level of the people significantly, though there are still various problems and obstacles that will influence health development implementation. To identify the problems and obstacles requires analysis of the situation and trends in the future. Below are described the development, problems, opportunities, threats and strategic issues of health development Indonesia is facing these days.

A. DEVELOPMENT 1. Health Level

Up to now the infant mortality rate (IMR) has been lowered with a lowering rate of on average 4.1% per annum. While in 1967 the IMR in Indonesia was still ranging 145 per 1000 live births, in 1991 IMR was already 51 per 1000 live births (Supas 1995) (see tables 1 and 4). The under-five-years death rate (UFDR) (0-4 years) has also been lowered significantly. In 1986 it was still 111 per 1000 live births, in 1993 it was lowered to become 81 per 1000 live births. None the less, the differences of IMR and UFDR between provinces still vary wide. Mean while the MMR has also lowered from 540 per 100.000 live births in 1986 to become 390 per 100.000 live births in 1994 (table 3). In line with this development, life expectancy at birth has also been increased from average 45.7 years in 1967 to become 64.4 years in 1991 (Supas 1995) (see table 2).

The prevalence of moderate and severe Protein Energy Malnutrition (PEM) among the under 5 years children has dropped from 18.9% in 1978 to 14.6% in 1995 (Susenas 1995). The total prevalence of (mild, moderate and severe) PEM has dropped from 48.2% in 1978 to 35.0% in 1995 (see table 6). So are the other nutritional problems, such as blindness due to vitamin A deficiency, iron deficiency anemia, and iodine deficiency, have shown decrements. The result of xerophthalmia survey done in 1992 concluded that blindness due to vitamin A deficiency was not a community health problem any more. SKRT (Household Health Survey) discloses the prevalence of pregnant women suffering from iron deficiency has dropped from 63.5% in 1992 to 50.5% in 1995. Among the pre-school age group, it dropped from 55.5% to 40.5%. Prevalence of problems due to iodine deficiency (GAKY) has also shown a declining figure. The total goiter rate (TGR) was 37.2% in 1982 and declined to 27.7% in 1990.

Indonesia has been declared as free from variola by WHO in 1974. Beside that, several other contagious diseases have been decreased in their morbidities, e.g. framboesia, leprosy, poliomyelitis, neonatal tetanus and schistosomiasis. While in 1995 there were still 4 cases of poliomyelitis confirmed laboratorically, in 1997 there was no positive

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cases confirmed laboratorically. Neonatal tetanus has been decreased from 3.77 per 10.000 live births in 1990 to become 1.56 per 10.000 live births in 1995. Schistosomiasis in endemic areas has decreased from 3.48% to become 1.64%. Several contagious diseases being observed were showing increasing trends of morbidity, such as malaria, DHF and HIV/AIDS. Annual parasite incidence (API) of malaria decreased from 0.21 per 1000 residents in 1989 to become 0.09 per 1000 residents in 1996 in Java-Bali, then increased again to 0.20 per 1000 in 1998. Parasite rate (PR) of malaria outside Java-Bali which was formerly 3.97% in 1995 increased to 4.78% in 1997. Incidence rate of DHF which was noted as 23.22 per 100.000 residents in 1996 increased to 35.19 per 100.000 residents in 1998. Lung TB is still an illness requiring attention as though its prevalence has been decreased from 2.9 per 1000 residents in the period 1979-82 to become ca 2.4 per 1000 residents at the end of Pelita VI, though it has not been evenly distributed among all the provinces. In certain regions as West Java, Aceh, and Bali, the prevalences of lung TB were still ranging between 6.5-9.6 per 1000 residents.

At the end of 1999 there were 23 provinces already reporting the existence of HIV, where 14 of them reporting of AIDS. National prevalence of AIDS in Indonesia is 0.11 per 100.000 residents with prominent disparities between provinces. In Jakarta the prevalence of AIDS is 10 folds higher than the national, i.e. as high as 1,0 per 100.000 people. In Irian Jaya the prevalence of AIDS is 40 folds higher than national figure, i.e. 4,4 per 100.000 people.

Degenerative diseases and non-contagious diseases also show rising trend. The results Household Health Survey of 1995 show that 83 per 1.000 people suffering from hypertension, and ischemic heart disease and stroke are suffered by 3 and 2 per 1.000 people respectively. Emotional mental disturbances among people aged 5-14 years old and above 15 years old are respectively 104 and 140 per 1.000 people. Blindness is also rising significantly from 1,2 percent in 1982 to become 1,47 percent in 1995. Traffic accident in Indonesia in 1994 reaches 34.407 victims, it rises to 49,098 victims by 1997. Mortality due to traffic accident rises from 3,2 per 100.000 people in 1994 to become 4,1 per 100.000 people in 1997 (see table 8).

2. Facilities

Health development that have been implemented during the last 30 years has succeeded in preparing health service facilities and infrastructures evenly throughout Indonesia. At the present time to fulfill basic health service there are 7.243 puskesmas available where 1.676 of them have been up graded to become caring-puskesmas that have in-patient beds, 21.115 helper puskesmas and 6.849 mobile puskesmas. Hence there are at least one puskesmas in each sub-district in Indonesia, and more than 40 percents villages have been

served by government’s health service facilities. The ratio of puskesmas to population is

recorded to be 1:27.600 and helper puskesmas to population is 1:9.400.

Beside that, there are also available special Treatment Clinics (Balai Pengobatan) owned by the government, consisting of 21 units Treatment Clinics for Lung Diseases (BP4), 7 Public Eye Health Clinics (BKMM) and 1 Public Sports Health Clinic.

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Beside that there are also various basic health service facilities owned by government’s sectors outside the health sector, such as the correctional institution, state owned enterprises (BUMN of the plantation, mining dept.) and so on.

In the private sector, basic health services are arranged in the form of general practitioners, practicing midwives, private clinics and delivery clinics. The society and private in the remote areas need much basic health services.

To expand the coverage and reach of puskesmas services various facilities of health efforts with community’s resources have been developed. Now it has been recorded 243.783 units of posyandu with active cadets total 1.078.208 persons, 20.880 Polindes (Village Delivery Hut), 15.828 POD (Village Medicine Post) and 1.853 Pos UKK (Occupational Health Efforts Post).

The even distribution of basic health service facilities is also followed by the increase in referral health service facilities. At the present there are 4 units of A Class General Hospital, 54 units of B Class General Hospital, 213 units of C Class General Hospital, 71 units of D Class General Hospital, 335 units Private General Hospital, 77 units of

Government’s Special Hospital, and 139 units of Private Special Hospital. Total beds are

reaching 120.000 units, so the ratio to residents is 1:1.700. The rate of utilization and the capability of services of hospitals are increasing from year to year (see table 9).

In order to support the basic and referral health services have been developed 27 Health Laboratory Offices (BLK), 27 Food and Drugs Supervision Offices (BPOM) and 10 Environmental Health Technique Offices (BTKL). Private laboratory services have also improved very fast. At present there are registered 599 units private clinical laboratories distributed among 27 provinces.

For the purpose of assuring the smoothness in medicines distribution in governmental sectors especially for the puskesmas there have been built 314 units of district/ municipal pharmaceutical warehouses (GFK). While in the private sector there have been operational 5.724 units of dispensaries throughout Indonesia.

3. Health Manpowers

The number and distribution of health manpower have improved significantly enough so that now there are registered about 32 thousands or so of medical manpower (physician, specialist, and dentist) and 7 thousands or so of dentists, including specialists, and 6 thousands or so of pharmacists distributed throughout Indonesia. The number and distribution of nurses and midwives are also improving very fast. There are registered about 160 thousands or so of nurses with various levels of education. While the number of midwives is registered 65 thousands persons or so including 52.042 persons in the villages. Hence it means that nearly all villages in Indonesia have midwives already. In order to support the development with health paradigm there have also been manpower in the field of public health. At present there are registered about 11 thousands or so of public health manpower with various expertise including among them in the nutritional field about 1.500 persons, and in environmental health about 4 thousands so persons.

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The total number of health manpower working in the Ministry of Health and regional government throughout Indonesia in 1998 is registered about 400 thousands so persons, where 302.947 persons out of them are central health personnel. While the rest about 90.000 persons more are staffs of regional government.

4. Health Inventories

At present there are 224 units pharmaceutical industries consisting of 4 BUMN (state owned enterprises), 35 PMA (foreign investments), and 185 domestic private ones. Since the enforcement of CPOB (good medicine manufacturing practices) in 1996, there are 162 pharmaceutical industries that have had the capability to manufacture medicines according to CPOB.

Since early 1997 Indonesia has been able to produce generic drugs which are conducted by 4 BUMN and 60 private owned pharmaceutical plants. The generic drugs have been more and more accepted by the society.

In the attempt to cure and improve health a portion of the society use Indonesian indigenous medicines. Indonesia has the largest biologic varieties in the world with about 30.000 types of plants. About 940 of them have been known to possess medicinal effects and about 180 of them have been used in the native medicinal recipes by Indonesian indigenous medicinal industries.

In 1992 the number of Indonesian indigenous medicinal industries was 449 units consisting of 429 units of small scale traditional medicine industries (IKOT) and 20 units of traditional medicine industries (IOT). In 1998 the number of Indonesian indigenous medicinal industries has increased into 678 consisting of 602 units IKOT and 76 IOT. Unincluded in the above records are manually mixed ‘jamu’ (Indonesian indigenous herbs) businesses and ‘jamu’ vendors (see table 11).

The needs for vaccines in order to prevent diseases, among others the BCG, hepatitis, polio, measles, DPT and tetanus toxoid have been fulfilled from domestic production. Some of the health inventories such as health instruments have been manufactured locally, while those using high technologies are still being imported.

5. Health Financing

In the last 30 years the government’s commitment for health financing has increased. While the health budget in 1987/1988 was 2,32% of total government’s spending, then in 1997/1998 the health budget was 4,55% of total government’s spending.

The funding from private sector primarily the society’s spending is the largest portion of the health funding. The contribution of private sector and society in funding health is about 65 percents.

The majority of the society pay for their health still using the ‘fee for service’ model. Only 14 percents of the society are covered in the health insurance programs. The Public Health Maintenance Assurance Program (JPKM) which has been developed in all districts/ municipalities is hoped to be able to rationalize funding from the public as a

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base for achieving equality and improving health service quality. The details of JPKM development result coverage up to the end of 1999 are as the following: (1) civil

servant’s health maintenance and pension revenue of 17,2 millions members, (2)

maintenance for employees and families of 1,6 millions members, (3) private health maintenance of 600.000 members and (4) health funds of 22 millions members distributed in about 15.000 villages. Besides, up to recently there are 19 executing bodies (Bapel) of JPKM having license, and in the context of implementing the Social Safety Net program in Health Sector there are 326 JPKM executors which are distributed in all districts/ municipalities.

So far the health development has been built not only upon self strength, but it is also supported by foreign helps either in the form of off shore loans or grants. To some extent due to the economic crisis the foreign helps component in the health budget has shown rising tendency.

6. Policies

The health development which had been done in nearly the last 40 years has undergone enormous changes and improvements in policies. In Pelita I the policies were more emphasized on consolidation. The service functions were directed more towards integration and comprehensively being focused more on the governmental sectors. In the years 1980s the service model started to shift towards the private sector. In Pelita II the policies were prioritized on equity such as through Inpres (presidential instruction) on health facilities and manpower. During Pelita III and IV, beside equality, attention is also given to health service quality improvement. The matter is reflected among others on the change in puskesmas function to become caring puskesmas. Next, during Pelita V a policy has been determined to put midwives in the villages.

In terms of hospital services, since Pelita V and specifically in Pelita VI, much attention has been put to improve service quality through standardization of services, development of accreditation instrument and compilation of indicators of hospital instruments’ performance. During this same period decentralization is also implemented, i.e. delegation of a part of functions to the regions, without being followed by changes in resources.

During Pelita V the policy on medicines is directed to the use of generic drugs, where all government’s health facilities are obliged to use generic drugs.

With the issuance of act (UU) number 23 Year 1992 about Health, then a renewal has happened in the written laws about health development. The act offers a legal base, direction and various national policies for health development which formerly was based on the National Health System (SKN). Policies that integrate funding system and health maintenance system are clearly stated in the act number 23.

In order to protect the society from abuse and misuse of drugs, the act number 5 year 1997 about Psychotropics and the act number 22 year 1997 about Narcotics were issued. For the sake of consumer protection, it is also enacted the act number 8 year 1999 concerning the protection against pharmaceutical preparations and foods. One of the aims of the act is to increase the quality of goods and /or services that assure the continual production of health goods and/ or services, comfortability, safety and survival of consumers.

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The development of state governance at the present time shows a very strong wave of decentralization. The implementation of act number 22/ 1999 on Regional Government and the act number 23/ 1999 on Financial Balance between Central and Region will strongly influence the execution of development including the health development. Decentralization of health efforts offer authority to the districts and municipalities to self determine the health development’s priority of the respective regions according to local capabilities, conditions and needs. As a consequence the success in health development in the future will depend very much on the capability of the manpower resources in the regions.

The trends which occur in the world nowadays are the increasing roles of the third party in regulating health funding through the insurance system, either public or private one. This condition will also become more flourished in Indonesia in the future when trades between countries become more free. Hence the policies to be adopted in health development effort through pre-service payment (pre-paid) system will very strongly decide the direction of health service conferral to the public more evenly and with more adequate quality.

B. PROBLEMS 1. Health Level

Morbidities of some contagious diseases being observed which formerly were declining or undetected, but recently have shown increasing trends, such as malaria, DHF and HIV/ AIDS. Besides with the increasing openness of Indonesia toward outside world and the ease in transportation, there is a potential for the occurrence of new contagious diseases which hitherto have not existed in Indonesia. On the other hand, the degenerative diseases, non-contagious diseases, and traffic accidents have also shown increasing trends. The problem of blindness is also rising significantly enough.

The trends in morbidity of contagious diseases, non-contagious diseases, degenerative diseases, injuries due to traffic accidents, and other health problems as well as other diseases are problems that will influence the health level of the public in the future, all that require optimal management steps.

2. Cross-Sectoral Cooperation

Health problems are national problems that can not be disconnected from the various policies of other sectors, hence their solution should involve other sectors as well. The main issue is how to improve cross-sectoral cooperation more effectively?

The health development so far has not produced optimal results due to the lack of cross-sectoral supports. There are cross-sectoral programs which have not or not enough health concerns so that they bring negative impacts to the health of the society. Part of the health problems are caused by several factors, primarily the environment and behavior, related closely to various policies and program implementation in sectors outside the health. For

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the reason, a very nice cross-sectoral approach is required, so that the related sectors can always calculate the impacts of their programs toward the public health.

For the same reasons, increase in attempt and management of health services can not be separated from the roles of other sectors covering funding, regional governance and development, work force, education, trade, and social and cultural affairs.

3. Health Development Policies

Even though the health development policies have been directed to and prioritized on basic health services, emphasizing more on preventive and instructional health efforts, but the public perception tends to remain oriented on disease curative and health rehabilitation. The attempt to increase public awareness to create healthy life style (Healthy Paradigm) is hard to achieve, as it is not supported by the factors of social economic, educational level and public cultures.

The healthy life style that has not been well created as stated above is made even worse by the highly expensive costs spent by patients or their families in order to get cure and rehabilitation at the health service facilities such as the hospitals. Beside that, the loss in productivity is another burden that should be born by the patient’s family. In other words, such model of services is not only inefficient, but also wasting much costs. While in the other side, the fund from government is declining.

Beside that, the Indonesian territory which is geographically very wide with varying tribes, cultures, religions and various communities, has not been given enough consideration in deciding health policies. So far the decision making in health development policies is viewed to be strongly centralized with the consequence that part of the programs are not suitable to the regional or local needs and requirements. As a result the health development being conducted so far is viewed to be not yet fully effective and efficient.

4. Health Development Expenditure System

As a result of the strong roles of the central government in deciding policies, the mode of spending given by the central government is based on budget allocation which has been decided with its detailed activities. The mode of spending like that plus the inadequate wage system of the civil servants have made it very difficult to produce an appropriate incentive system for budget efficiency. The matter is worsen by the many regulations made by the government and applied uniformly, which has abolished the spirit for competition and obstructed the creation of efficient management model.

Subsidy given by the government for health sector in PJP I (1st phase of long term development) is only about 2.5% from Gross Domestic Product (GDP) which is far from the minimum standard recommended by WHO i.e. 5% from GDP. In practice the relatively small budget subsidized by the government mostly is given in the form of subsidy to the service provider as regular spending (including wages), development spending, and operational costs as well as maintenance costs. In other words, the mode of funding practiced so far is not oriented to the needs of the public and is not directly directed to subsidy the poor people.

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The subsidy given by the government is only 30% of the total health costs. While 70% of the health costs are still the responsibility of the public, and it is dominated by individual cash payment system. As a consequence of the above situation is the difficulty in applying cost control policies and it is also burdening the consumers of health services. In fact the health costs are inclined to increase even more and become unaffordable when the mode of payment stated above is still going on.

5. Health Development Implementation

The mode of policy determination and mode of payment already being applied so far have brought strong influence on the implementation of health development. The quality of health service which is good and in line with prevailing standards is hard to find, especially for the poor people and those living in remote areas.

Beside that, health development implementation is still not yet supported by the utilization of progresses in applied science and technology. More over, the executors of health development have not fully applied high level of ethics and morale. As a consequence of that condition is health development implementation in Indonesia has not fully implemented professionally.

6. Quality of Health Facilities

Even though the number and distribution of health facilities have been regarded adequate, but from the aspect of service quality the services are still below standard. Other health facilities such as hospitals even have not met the minimum requirement yet. In such a situation, the quality of health services being offered are still far from expectation.

The conducive climate for increased private participation from either domestics or abroad in offering health services has not been created optimally. Bureaucracy in licensing and regulating which should be followed is in fact like a barrier for private sector participation in health development.

7. Health Manpower

The weakness of health development from the point of view of health manpower is regarding the uneven distribution, yet inadequate educational quality, unbalanced health manpower composition due to over dominance of medical manpower and the low performance and productivity.

Cross-sectoral coordination especially with the Education and Cultural Dept. in terms of increasing the number of graduates of 4 basic medical specialists badly required by district hospitals in order to improve their service quality is still lacking. Beside that, review and re-structuring of other health manpower educational systems are also needed, either those run by the government or the private.

One of the issues in health manpower development is the manpower utilization, where their uneven distribution becomes a principle problem. Beside that, the career development of the manpower becomes a matter that strongly needs to be developed, it

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covers manpower of both the public sector and the private sector. All the aforementioned efforts need the support of comprehensive, integrated and effective manpower information system.

8. Health Inventory

The majority of medicinal raw materials for the pharmaceutical industries and the health instruments using high technology are still dependent on import hence their prices rise due to depreciation of Rupiah against foreign currencies.

Acceptability towards all levels of the society who need them is striven for through the supply of medicines in 2 channels i.e. the services channels of the public sector and the private sector. In the public sector the efficient management of medicines, including the purchasing and integrated planning at districts and direct medicine distribution at GFK, is an absolute matter. In this case, the ability to analyze essential drug requirement using bottom-up planning according to disease pattern is a main matter. Beside that there is a matter of coordination complexity.

Another problem is concerning the maintenance of health inventories, beside standardization and calibration of instruments being used.

C. OPPORTUNITIES

Various opportunities for success of health development in achieving Healthy Indonesia 2010 among other things are:

1. Demography

The number of Indonesian people is still increasing with a decreasing rate. In 1980 the Indonesian population totals 147,49 millions, it increases to 179,38 millions in 1990, and projected to 210,439 millions in year 2000. Indonesian population in 2010 is projected to be ca 235 millions. The growth of population is also signaled by the change in age structure of the population where there is a shift from young population age structure to old population age structure.

The large number of Indonesian population and the productive age structure are potential market and resources for the development of nation-wide health efforts. Beside that, various changes occurring on the demographic characteristics as a result of development success such as education and social economic sectors will open the opportunities for the implementation of health services that are more effective, efficient and qualified.

2. Laws and Politics

Reform in the legal and political sectors as required by the society opens big opportunities for improvement of system and values in various sectors, including health sector. This big opportunities can be utilized optimally to produce clean governance with health concerns for the interest and prosperity of the people.

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The governance system of the Unitary State of the Rep. of Indonesia based on the 1945 Constitution gives freedom to the regions to execute governance autonomically. In facing the domestic as well as international development vis-a-vis the global competition which is in principle a free competition, then the implementation of regional autonomy with wide, real and responsible authorities proportionally is an opportunity which can be used by the regions to prepare themselves as well as possible. With the implementation of the Act No. 22 year 1999 about Regional Governance and Act No. 25 year 1999 about Economic Balance between Central and Regional Governments, it is also an opportunity for the regions to implement development including development in health sector, to accelerate even distribution and justice according to local problems, potentials and

variousity by involving the public’s participation.

3. Globalization

Globalization in economic sector with its main core being free global trading gives opportunity for Indonesia to take part in international trading. In the health sector, the opportunity is mainly the chance for health workers to work abroad.

For that efforts to increase quality of the health workers to equal those from the other countries should be done among other ways through improvement in education system. The entry of foreign capital to Indonesia will expand even more the employment opportunities for health workers, beside it will help accelerate the transfer of technologies that are needed for the improvement of quality and professionalism of health services in Indonesia.

4. Economic Crisis

The economic and credibility crises hitting Indonesia until now is a good opportunity to do various changes in health sector, including to eliminate various bureaucratic obstacles in the effort to increase efficiency and partnership in development implementation. Difficulty in getting health services due to low purchasing power opens bigger chance for development and consolidation of JPKM.

5. Natural Resources

Indonesian soils and oceans are very rich in various sources for medicinal materials or simplicia. Indonesia has the largest biologic varieties in the world with ca 30.000 types of plants, and part of those plants are sources of natural medicinal materials. This is a very big opportunity to produce medicinal materials as well as completed products domestically by ourselves.

6. Progress in Science and Technology

The progress in science and technology in the telecommunication, information and transportation sectors which are becoming better opens opportunity to accelerate the achievement of equality in health services. While progress in science and technology in health and medical sector gives opportunity for the improvement of the quality of health service efforts which should yet be balanced and harmonized with faith, devotion and ethics.

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7. Cooperation and Partnership

In the global era there are many changes that have occurred in national, regional, as well as international levels which bring multidimensional impacts and which possess high intensity of interrelationship between sectors. Hence, cooperation and interconnection are the main pre-requisite to achieve a new era which is better off based on the new paradigm based on the win-win principle.

The phenomenon of partnership that is equal, open and mutually beneficial is a good opportunity especially for the development of private businesses either of national, regional, or international scales for the development of basic and referral health services, prevention of diseases, and promotion of health.

D. THREATS

1. Macro Economic Situation

The macro economic situation which has not recovered from economic crisis is one of the biggest and heaviest threats to national development, especially the health development as the consequence of the even more limited existing resources. This situation becomes more severe with the still high level of dependence upon imported goods for implementation of health services. The macro economic situation recovery is very much influenced by political situation which is not yet stable enough till now. Hence, though at national level there is already a commitment to give larger allocation for health funding up to 5% of GDP, but there is still a real threat from the macro economic situation that the resource may still not yet preparable within 2-3 years time ahead.

2. Demographic Structure

The great number of population, the relatively still high growth rate, the still low level of education and income, as well as uneven distribution among regions can be a threat to development, including the health development. Beside that the age structure that tends to be young together with the increasing number of elderly groups become the double burdens of development.

3. The Economic Condition of Society

The blow of prolonged economic crisis has also shown increase in the number of poor people together with the decline in various health indicators, especially the rise of overt KEP incidence primarily among infants and children. This condition is a threat to the achievement of health development’s target as one of the efforts in increasing the nation’s productivity. The declining economic condition of the society also influences access of the people toward health services, especially for the poor people. Efforts done through

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the JPSBK (social safety net in health sector) have indeed increased the access, but in the long run this program is hard to sustain by the available resources.

The various worriness in economic sector that is easy to be triggered into riots and also conflicts occurring in various regions in Indonesia which have been unsettled so far become threats toward health development and at the same time become obstacles to achieve the healthy Indonesia.

4. Geography

The geographic condition of Indonesia that is an archipelagic country with more than 17.000 islands and the very great area of ocean is a threat in the implementation of health development. An archipelagic state like this in fact needs transportation and communication facilities as well as a high operational cost.

On the other side with the openness of various archipelagoes, Indonesia becomes susceptible to the possible entry of prohibited goods/ drugs illegally. Beside that the geographic condition that consists of active volcanoes chain that can erupt at no time, and the frequent earth quakes can bring natural disasters threatening the social life. While Indonesian location in the tropical region is an accurate reservoir for the reproduction of various vectors and pathogens.

Indonesia being on the cross-road position between big countries in the world, is in the transportation line, this potentially can bring negative impacts toward public health with the possibility of entry of various negative habits toward health and various diseases from outside world.

5. The Low Health Behavior, Morale and Ethics

Healthy life style is very much influenced by education level of the people. The low level of education is one of the causes of low understanding of the people regarding health information and the formation of healthy behaviors.

Abuses of narcotics, psychotropic drugs and additives tend to rise, in fact it has touched the poor people and primary school children with even wider and more complicated escalation of the problem. So are the production and utilization of alcoholic beverages and other addictives including cigarettes inclined to rise steadily with broad negative impacts to the public.

Beside that, various deviations in sexual behavior, lack of discipline in traffic transportation, smoking habit and overt and unbalanced food consumption become threats to the increment of public health level.

The use of prohibited chemical substances as food additives, sanitary problems as well as hygienic processing especially among household industries are also threats to the consumer community’s health.

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Decentralization of health management is a political commitment that should be implemented by the coming national leadership. There are two acts (UU) related to decentralization have been issued, i.e. act number 22/ 1999 and act number 25/1999. Experiences in many countries indicate clearly that when decentralization is done in a hurry with inadequate preparation either in concept or in operation, great difficulty will arise in its implementation. In the era of decentralization, the control from central government on various programs will decline drastically. If this is not supported by the increase in capability at the provinces and districts/ municipalities then success in health development will be strongly in danger.

7. Globalization

Globalization is a phenomenon occurring in the end of the 20th century that is signaled by the occurrence of inter-penetration and inter-dependence among all sectors, either economic, political, or social and cultural. This situation causes the occurrence of transformation of the nation society toward global society so that state boundaries become unconspicuous any more.

Trades liberalization as the main sign of globalization beside the ease in transportation, communication and information contains great threat for developing countries including Indonesia. The policies of GATS (General Agreement of Trade in Services) and TRIPS (Agreement on Trade Related Aspects of Intellectual Property Rights) will influence very much various aspects of public health services implementation in developing countries. Entry of foreign capital and work force in the health service area can result in the even more rising in quality of health services and management. But negative impacts that should be anticipated are the closure of various already existing service facilities especially those so far have given services to the less well to do people. This situation can only be prevented by intensive attempts to improve professionalism and quality management in the existing health facilities. Other implications are regarding the intellectual property rights, including patent for various drugs and biomedical products. This situation can impede the usage of various products that otherwise can be used but being constraint by regulation on intellectual property rights. This matter also brings implication for the rise in prices of medicines and various biomedical products and instruments.

Ease in transportation, communication, and various information dispersion will also influence the dispersion of diseases, narcotics, psychotropic drugs and other addictives, free sexual behavior and other unhealthy life styles. This situation has very great influence upon the health level of society, especially the younger generation of the nation.

8. Environmental Pollution and Global Climate

In the future, the climate and environment will be less beneficial to health. Pollution to the environments, including air, water, soil and food will increase. Air pollution in the big cities in year 2000 is estimated to rise 2 folds from that of 1990 with its main source coming from the emission of motor vehicles and industrial activities. Air pollution in the rooms needs more attention as the still high prevalence of smoking habit in the society. Management of domestic wastes in the urban, either solid or liquid wastes, which has not

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taken into consideration its impacts on public health is a threat to people living in the urban areas and their surroundings.

The limitation of clean water supply is a threat to the health of society. The limitation in public affordability especially in the rural and urban slum areas is also a serious challenge for the creation of healthy environment.

E. STRATEGIC ISSUES

After studying the various strengths, weaknesses, opportunities and threats as mentioned above, then the strategic issues that should be dealt with are as follow.

1. Cross-Sectoral Cooperation

A part of the health problems are national problems that are inseparable from various policies of other sectors so that the solution should strategically involve the related sectors. The main issue is the improvement in sectoral cooperation, as cross-sectoral cooperation in health development so far has been frequently less success.

The change in society’s behavior toward a healthy life and the improvement in

environmental quality which strongly influences society’s health level improvement need close cooperation between various sectors related to the health sector. So is the increase in effort and management of health services inseparable from sectors governing finance, regional governance and development, work force, education, trading, and social cultural affairs.

2. Health Sector’s Human Resource

The quality of health sector’s human resource is strongly determining the success of

health efforts and management qualified human resource in health sector must always follow the progress in science and technology, and strive to master the state of the art science and technology. Beside that, the quality of the human resource is also determined by the moral values being adopted and applied in the task execution. It is realized that the number of Indonesian human resource in health sector who follows the progress of science and technology and apply professional moral and ethical values is still limited. The emergence of competition in the free market era as a result of globalization should be anticipated by improving the quality and professionalism of the human resource in health sector. This is necessary not only to increase the competitive capability of the health sector, but also to help improve the competitive capability of other sectors as well, among others safeguard the export commodities of foodstuffs and finished food products.

In relation to decentralization of the governance execution, an increase in capability and professionalism of the health managers in every level of administration is a very urging need.

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Viewed from physical aspect, the distribution of health services facilities either puskesmas or hospitals and other health facilities including health efforts supporting facilities can be regarded as evenly distributed all over the territory of Indonesia. None the less it should be confessed that the physical distribution has not been fully followed by increase in quality of services and accessibility by all layers of the society.

The quality of health services is very much influenced by the quality of physical facilities, types of work force available, medicines, health instruments and other supportive facilities, services conferring process, and compensation received and the expectation of the consumer society. Hence the increase in physical quality and aforementioned factors are preconditions to be fulfilled. Afterwards, the process of services conferral is to be increased through increase in quality and professionalism of health resources as stated above. While the expectation of the consumer society is being adjusted through improvement in general education, health information, good communication between health providers and the public.

4. Prioritization, Funding Resource and Empowerment of the Society

So far health efforts are still lacking in prioritizing the approach of health maintenance and promotion as well as disease prevention, and they are insufficiently supported by adequate funding resource. It is recognized that financial constraint from the government and the public is a big threat for the continuity of government’s programs and a threat to the achievement of optimal health level.

Hence, more intense effort is required to increase funding resources from the public sector being prioritized for health maintenance and promotion activities as well as for diseases prevention. Funding resources for curative and rehabilitative activities need more exploration from resources in the society and directed to become more rational, and more effective and efficient in order to increase the services quality. Various researches indicate that most of the direct spending of the public are used not as effective and efficient as a result of unequal information between services providers and services receivers (patients or their families). This situation urges the need for strategic steps in creating funding system with prepayment property already known as JPKM.

The availability of limited resources, especially in the public sector requires efforts to increase participation of the private sector especially in the attempt which are curative and rehabilitative. The attempts are done through empowerment of the private sector to become independent, improvement of equal partnership and mutual beneficiality between the public and the private sectors so that available resources can be used optimally.

Other matters that strongly require settlement are empowerment and independence of the public in health efforts that have not been as expected. Equality, openness, and mutually beneficial partnership in health efforts become a sine qua none for the civilization attempt of a clean and healthy life style, application of healthy life norms and health promotion.

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Principles, Vision and Mission

of Health Development

Principles, Vision and Mission of Health Development

The great effort of Indonesia nation in rectifying the national development orientation that has been done in the last 3 decades requires total reform in development policies in all sectors. For health sector, the call for total reform emerges as there are still discrepancies in health development results among the regions and communities, the public health level is still left behind compared to neighboring countries, and due to the lack of autonomy in health development. Beside that, health reform also is needed considering there are 5 main phenomena that have great influences toward the success of health development. First, basic changes in demographic dynamics that urge the birth of demographic and epidemiologic transition. Second, substantial discoveries in medical science and technology that open new horizon in looking at living processes, health, illness and death. Third, global challenges as a consequence of free trading policies, and fast revolution in information, telecommunication and transportation sectors. Fourth, changes in the

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environment that influence the health level and efforts. Fifth, democratization in all sectors calling for empowerment and partnership in health development.

In order to increase the resistance and struggling power of health development as the main asset of national development, re-evaluation of health development policies has become a must. Changes in the understanding of the concept of health and sick and the increasing treasure of science and technology with information about determinants of disease causation which is multi-factorial have aborted health development paradigm which puts priority on curative and rehabilitative health services.

The application of the new health development paradigm i.e. HEALTHY PARADIGM is an attempt to improve the nation’s health that is proactive. The healthy paradigm is a health development model which in the long run can push the society to become autonomous in maintaining their own health through heightened awareness on the importance of health services that are promotive and preventive.

In order to materialize the HEALTHY PARADIGM as the new health development paradigm, a thorough review on principles, vision and mission of health development needs to be done as soon as possible. The principles, vision and mission of health development should not only be able to settle all 5 challenges of therefore mentioned conventional health development, but also should be able to anticipate various changes in the future. To materialize HEALTHY INDONESIA in the future, the new principles, vision and mission of health development should be implemented consistently and continuously.

Principles of Health Development

The ideal principle of the national development is the Pancasila, while the constitutional principle is the 1945 Constitution. Health development is an integral part of the national development. On the Act number 23 year 1992 about health it is stipulated that health is the condition of well being of the body, mind and social life that enables every person to live productively socially and economically. While on the constitution of WHO year 1948 it is agreed among other things that the achievement of the highest level of health level is the fundamental right of every person regardless of his/ her race, religion, political affiliation and social economic position. The principles of health development are basically truth values and basic rules as the foundation for thinking and doing in health development. The principles are the foundation for the compilation of vision, mission and strategies as well as principal directors in the implementation of health development nation-wide which include:

1. Humanity

Every health attempt should be based on humanity which is being spirited, moved and controlled by faith and devotion to The Only God. The health manpower needs to have noble character and hold tight the professional ethics.

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2. Empowerment and Autonomy

Every person and also the society together with the government have a role, vocation and responsibility to maintain and improve the health level of each individual, family, society and his/ her environment. Every health effort should be able to produce and push the participation of the society. Health development is conducted based on trust and self- capability and strength as well as making the personality of the nation as the pivot point.

3. Justice and Equality

In the health development, each person has the same right in getting the highest health level, regardless of differences in ethnicity, grouping, religion, and social economic status.

4. Prioritization and Utilization

The implementation of qualified and following up to date science and technology’s health efforts should put priority on health maintenance, promotion, and disease prevention approaches. Beside that, health efforts should be done professionally, effectively and efficiently by taking into consideration local needs and situation.

The health efforts are directed so that they would give maximal benefit for the improvement of public health level, and they should be executed with full responsibility according to the prevailing rules and regulations.

Vision of Health Development

The picture of Indonesian society in the future that is hoped to be achieved through health development is the society, nation and state characterized by its people living in a healthy environment and with healthy living behaviors, having capability to reach qualified health services justly and evenly, as well as possessing highest level of health in all the territory of Indonesia. The picture of Indonesian society in the future or Vision expect to be reached through the health development is formulated as:

HEALTHY INDONESIA 2010

In the Healthy Indonesia 2010, the expected environment is the conducive one for the realization of healthy condition i.e. environment that is free from pollution, which is equipped with clean water, adequate environmental sanitation, healthy housing and settlement, zone planning with health concerns, and the realization of social life that is helping each other by keeping cultural values of the nation.

The expected social behavior of Healthy Indonesia 2010 is the proactive one to maintain and promote health, prevent risks for diseases, protect one from disease threats and active participate in healthy society movement. Furthermore, the expected capability of the

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society in the future is able to access qualified health services without obstruction, either economic or non-economic one. The qualified health services referred before are those satisfying the users of the services and those being implemented according to standards and ethics of professional services. Hopefully with the materialization of healthy environment and living behavior beside the increase in the society’s capability as stated above, the health level of individuals, families and society can be upgraded optimally.

Mission of Health Development

In order to materialize the vision HEALTHY INDONESIA 2010, four missions of health development have been determined as follow:

1. Activating national development with health concerns

The success in health development can not be merely decided by hard working of the health sector alone, but it is strongly influenced by the results of hard working and positive contribution from various other developmental sectors. In order to optimize the results and positive contribution, the acceptance of health concerns as the principal foundation of national developmental programs should be striven for. In other words, to materialize HEALTHY INDONESIA 2010, the persons in charge of developmental programs should put health considerations into all their developmental policies. The developmental programs that do not contribute positively to health, not to mention those being harmful to health, normally should not be implemented. In order to realize the national development that contributes positively to health as stated before, then all elements of the National Health System should take part as the main activators of the national development with health concerns.

2. Urging society’s autonomy for healthy living

Health is the joint responsibility of all individuals, society, government and private. The roles played by the government, without awareness of individuals and society to maintain their health independently, will only bear little fruit. The healthy behavior and society’s capability to select and acquire qualified health services strongly decide the success of health development. Hence, one of the main health efforts or missions in health sector is to urge the society’s autonomy for healthy living.

3. Maintaining and improving qualified, equal and accessible health services

Maintaining and improving qualified, equal and accessible health services contain the meaning that one of the responsibilities of the health sector is to assure the availability of qualified, equal and accessible health services to the society. The implementation of health services is not merely in the hands of the government, but it also involves maximally the active participation of all members of the society and various private potentials.

Page 23 of 88 4. Maintaining and improving health of the individuals, families and society as well

as their surroundings

Maintaining and improving health of the individuals, families and society as well as their surroundings contain the meaning that the main task of the health sector is to maintain and improve the health of all citizens, i.e. every individual, family and society of Indonesia, without leaving behind the attempts to cure diseases and or to recover health. For the implementation of this task, health efforts implementation should prioritize on promotive and preventive efforts supported by curative and rehabilitative efforts. To maintain and improve the health of individuals, families and society, it is also necessary to create healthy environment, and hence the tasks in environmental sanitation should also be better prioritized.

Direction, Aims, Targets, Policies

and Strategies of Health Development

Direction of Health Development

Direction of health development towards Healthy Indonesia 2010 according to the national development so far consists of:

1. Health development is an integral part of the national development. The concept of national development should have health concerns, i.e. taking into consideration seriously various positive and negative impacts of each activity toward public health. Health development is directed to improve quality of human resources who are healthy, intelligent and productive, as well as capable of maintaining and improving

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public health with high commitment toward humanity and ethics, and it is implemented with the high spirit of empowerment and partnership. Health development is executed with priority given to health promotion and disease prevention efforts beside the curative and health recovery efforts.

2. Health services run by either government or society should be implemented with quality, justice and equality by giving special attention to the poor people, children, and deserted elderlies, either living in urban or rural areas. Priority is also given to remote villages, new settlements, frontier zones and recesses inhabited by poor families.

3. Health development is executed with the national development strategies with health concerns, professionalism, decentralization and JPKM by paying attention to various challenges existing now and in the future, among other things the economic crisis, change in demographic dynamics, change in ecology and environment, progress in science and technology, as well as globalization and democratization.

4. The public health maintenance and promotion efforts are done through healthy living behavior improvement programs, healthy environment programs, public health services that are effective and efficient, being supported by surveillance, information, and management system that are reliable.

Improvement and revision of rules and regulations need to be done in order to support health development and give legal protection to the public and health workers.

5. The supply and improvement of health facilities and infrastructures are to be continued. Health researches and improvement need to be upgraded to support the improvement in quality of health efforts. Supply of medicines and health instruments that are safe and accessible to the society are stepped up through the development of pharmaceutical and health instrument industries that are more advanced and supported by medicinal raw materials industries that are reliable and the development of Indonesian indigenous drugs. Health funding is stepped up, either that coming from the government or the public, it is managed effectively and efficiently as well as responsibly.

6. In order to support all the health development efforts, manpower with national attitude, ethical and professional is required, it should also possess high dedication spirit to the nation and country, being disciplined, creative, educated and skillful, with noble character and able to hold tight professional ethics. Health manpower and supportive manpower should be improved in quality, capability and distribution so that they are evenly distributed and able to support the execution of health development at every level especially in supporting the implementation of autonomy at the districts/ municipalities.

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Aims of Health Development

The aims of health development toward Healthy Indonesia 2010 is to increase the awareness, will and capability for healthy life of every individual in order to materialize public health level that is optimal through the creation of an Indonesian society, nation and country that is characterized by its residents living with healthy behavior and within healthy environment, possessing capability to reach qualified health services justly and evenly, as well as having optimal health level throughout the territory of the Rep. of Indonesia.

Targets of Health Development

The targets of health development in order to materialize Healthy Indonesia 2010 are:

1. Cross-sectoral cooperation

The significant rise in cross-sectoral cooperation in health development, positive contribution from other sectors toward health, efforts to overcome negative impacts of development to health, and improvement in behavior and living environment that are conducive to the achievement of healthy society.

2. Community’s autonomy and private partnership

The significant rise in community’s capability to maintain and improve their health condition, and to reach proper health services according to needs. The significant rise in health efforts originating from private resources and the number of community members utilizing private health efforts.

3. Healthy living behavior

The significant rise in the number of pregnant women examining themselves and delivering attended by health manpower, the number of infants receiving complete immunization, number of infants receiving exclusive breast feeding, number of the under 5 years children having weighed each month, number of reproductive aged couples using contraceptive, number of people taking balanced nutrition, number of those using sanitary toilet, number of people receiving clean water, number of settlements free from vectors and rodents, number of houses fulfilling healthy condition, number of people exercising and resting regularly, number of families with internal and external communication, number of families practicing well their religious teaching, number of people not smoking and not drinking alcoholic beverages/ addictive substances, number of people not having extra marital sex, and number of people becoming members of JPKM.

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The significant rise in the number of healthy regions/ areas, healthy public places, healthy tourism resorts, healthy working places, healthy houses and buildings, sanitary facilities, drinking water facilities, waste disposal facilities, healthy social environment including social inter-courses, and environmental safety, as well as various standards and laws supporting the achievement of healthy environment.

5. Health efforts

The significant rise in number of qualified health facilities, coverage and reach of health services, generic drugs usage in health sector, rational drugs usage, promotive and preventive services utilization, efficiently managed health funds, and availability of health services according to needs.

6. Health development management

The significant rise in health development information system, region’s ability in implementing health development decentralization, health leadership and management as well as laws supporting the health development.

7. Health level

The significant rise in life expectancy, decrease in infant mortality rate and maternal mortality rate, decrease in morbidity rates of several important diseases, decrease in disability rate and dependency rate, increase in public nutritional state, and decrease in fertility rate.

Health Development Policies

In order to achieve health development’s aims and targets toward realization of Healthy Indonesia 2010, the general health development’s policies are:

1. Consolidation of Cross-Sectoral Cooperation

In order to optimize the results of development with health concerns, then consolidation of cross-sectoral cooperation becomes the main concern, hence it needs careful coordination and consolidation. Socialization of health concerns to other sectors needs to be done intensively and periodically. Cross-sectoral cooperation should cover planning, implementation and evaluation steps.

2. Improvement in Behavior, Society Empowerment and Private Partnership

Early started healthy life style in the society should be up-graded through various health information and education activities, so that it can turn into a part of living norms and cultures of the people in the context of increasing the awareness and autonomy of the society for living healthily. The roles of the society in health development, i.e. mainly through application of public health development concept, is to be encouraged and even more improved to assure the fulfillment of health needs and continuity in health efforts.

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Private partnership is developed further by facilitating primarily the construction of referral health service hospitals and other medical services, by attending the efficiency of the overall health service system. Private partnership is also increased in prevention of diseases and improvement of health level.

The roles of professional organizations as part of the society’s organizations are to be stepped up mainly in aspects related to compilation and supervision of professional standards and ethics in health services. Professional organizations are encouraged to participate actively advancing science and technology in health, help government in formulation of policies and management and supervision of health development implementation and function also in providing input to development of health human resources.

3. Improvement of Environmental Health

The environmental health of settlements, working places and public places and tourism resorts is to be improved through the supply and supervision of qualified water especially the plumbing, regulation of rubbish disposal places, preparation of waste disposal facilities and various other environment sanitary facilities. So that the residents can live healthily and productively as well as be prevented from dangerous diseases which are disseminated through or caused by unhealthy environment.

The quality of water, air and soil is to be improved to assure healthy and productive life so that the country is prevented from conditions that can incur health hazards. For that, improvement and revision of various rules and regulations, education on healthy environment since early ages, and standardization of environmental quality are necessary.

Control over agents, vectors and reservoirs of diseases is needed to create a healthy environment for the whole society. Special attention is directed to environmental troubles caused by technology utilization and dangerous substances, overt exploitation of natural resources, and those caused by disasters, either natural or man made ones. The global impacts of climate change should be cautioned especially those related to the occurrence of various health troubles, beside negative impacts of foodstuff scarcity influencing the community’s nutrition.

4. Improvement of Health Efforts

In order to maintain public health status during the economic crisis, health efforts are prioritized to overcome the aftermath of crisis beside to continue keeping health development improvement. In overcoming the aftermath of crisis, special attention is given to high-risk groups from poor families so that their health level do not worsen and they remain productive. Government is in charge of health service fund for the poor community.

After passing the economic critical period, health state of the society is managed to improve through prevention and decrease in morbidity, mortality and disability especially among the infants, under 5 years old children and pregnant, laboring and puerperal women, through the healthy life promotive efforts, prevention and

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eradication of contagious diseases and the cure and rehabilitation of diseases. The main priority is given to eradication of contagious diseases and outbreaks which tend to rise.

Greater attention is given to efforts to realize higher working productivity, through various occupational health service efforts including nutritional improvement and work force’s physical fitness and other health efforts related to health of work environment and settlement areas, especially for people living in the slum areas. Increase in health efforts is implemented through supporting private sector partnership and society’s potentials. Improvement in health efforts of the governmental sector is prioritized on health services having broad impacts to public health. While individual health services of curative and rehabilitative nature are mainly trusted to private. Basic health services that are implemented through puskesmas, helper puskesmas, midwives at villages, and private health service efforts are improved in equality and quality. The same improvement is also applied on referral health services that are implemented by hospitals owned by the government and the private.

Improvement in quality is done through positioning midwives at villages, development of existing puskesmas and construction of helper puskesmas equipped with facilities. Improvement in service quality is done through implementation of quality assurance by puskesmas and hospitals.

5. Improvement of Health Resources

Improvement in health manpower should support all health development efforts and directed to create health manpower that is expert and skilled in line with the progress in science and technology, devout and faithful to the Only God and holding tightly dedication to the nation and country as well as professional ethics. Up grading of health manpower is aimed at improving empowerment or utilization of manpower and preparation of health manpower, either from the public or the government, that can implement health development.

JPKM is developed further to assure implementation of health maintenance that is more equal and qualified with controllable price. JPKM is run as a joint effort between the society, private and government to fulfill the need for health service costs which are rising continuously. Health service tariffs should be adjusted based on the value of goods and service received by the society’s members getting the care. The less well to do people will be helped through the JPKM system subsidized by the government. At the same time, health insurance is also developed as a complement/ companion to JPKM. The development of health insurance is under the cultivation of the government and insurance association. Beside that gradually the state owned puskesmas and hospitals will be managed by self-financing system.

In the effort to increase health inventories, the purchase and production of medical raw materials which have economic yield will be stepped up. Supply, production and distribution of finished drugs will be increased in efficiency and quality so that the society will be able to get qualified drugs with affordable prices. Rational use of drugs, especially with generic drugs is encouraged through promotion and

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No. Health Manpower Total

1 2 3 4 5 6 7 8 9 10

Doctors (including specialists) about Dentists about

Pharmacists about

Nurses with various level of education, about

Midwives (including 52,040 persons of rural midwives) Public health manpower (with various expertise)

Nutritionists (among the public health manpower) Total health manpower working in the Health Dept. and regional governments throughout Indonesia by 1998, about Health servants in central among the other health manpower

Regional government’s health servants (the remaining), about

13,633 persons 6,972 persons 7,646 persons 150,419 persons 61,003 persons 15,557 persons 8,975 persons 400,000 persons 302,947 persons 90,000 persons Source: Planning bureau of the Health Dept. (Processed from data of CHS/ Dept. of education & culture, Health manpower education center (Pusdiknakes), Personnel bureau and Health Profile 1998)

TABLE 11

MEDICINES AND HEALTH INVENTORY (1997)

No. Health Inventories Total

1

2

3

4

Total pharmaceutical industries consisting of 4 state owned corporates, 35 foreign investments and 185 national private In 1996 there are recorded pharmaceutical industries that are already able to produce finished products according to GMP

(‘CPOB’)

Generic drug production is done by: - state owned corporates

- private pharmaceutical industries Indigenous drug industries:

- small scaled industries of indigenous drugs (IKOA), 602 units - indigenous drug industries (IOA), 76 units

224 units 162 units

4 units 60 units 678 units

Page 83 of 88 TABLE 12

HEALTH FUNDING

No. Health funding Total

1 2 3 4 5 6 7

Health budget of 1987/88 from total governmental expenses Health budget of 1997/98 from total expenses

Contribution of private sector and the public in health funding, about

The peoples that become members of health insurance Until the end of 1998:

- Askes (health insurance) of civil servants and pensioners covers - Askes for health manpower and families covers

- Private Askes covers

- Health fund in ca 15,000 villages covers Executing body (Bapel) of JPKM with license

In order to implement JPSBK program there are (dispersed in all districts/ municipalities) 2.32% 4.55% 65% 14% 17.2 millions 1.6 millions 600 thousands 22 millions 19 units 326 Bapel Source: Planning bureau of Health Dept.

TABLE 13.

MANPOWER REQUIREMENT –

ACCORDING TO THE KIND OF AND PRINCIPLE PROGRAM

No KIND OF MANPOWER Program Principle Program Principle Program Principle Program Principle Program Principle Program Principle Program Principle Total 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Specialist doctor General doctor Practitioner Nurse (S1/ scholar) Nurse (D3/ 3 years diploma)

Assistant nurse (SPK) Midwife (D3) Midwife (D1) Dentist

Dental nurse (D3) Dental nurse

Dental technician (D3) Public health scholar (S1/S2) Sanitarian (D3) Assistant sanitarian (D1) Nutritionist (S1) Nutritionist (D3) Assistant nutritionist (D1) Pharmacist Assistant pharmacist Analyst Others TOTAL

Page 84 of 88 (Modified from the proposal of manpower requirement to support health program toward Healthy Indonesia 2010)

TABLE 14

MANPOWER REQUIREMENT –

ACCORDING TO KIND AND PLACE OF DUTY

NO. KIND OF MANPOWER CENTRAL PROV. DISTRICT/ MUNICIPAL

PUSK TOTAL

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

Specialist doctor General practitioner Nurse (S1/ scholar) Nurse (D3/ 3 yrs diploma) Assistant nurse (SPK) Midwife (D3) Midwife (D1) Dentist

Dental nurse (D3) Dental nurse

Dental technician (D3) Public health scholar (S1/S2) Sanitarian (D3)

Assistant sanitarian (D1) Nutritionist (S1) Nutritionist (D3)

Assistant nutritionist (D1) Pharmacist

Assistant pharmacist Analyst

Others

TOTAL

Source: Planning bureau, Health Dept. 1999

(Modified from the proposal of manpower requirement to support health program toward Healthy Indonesia 2010)

TABLE 15

PROJECTED REQUIREMENT FOR HEALTH MANPOWER UPTO 2010 AND THE TREND OF HEALTH MANPOWER SUPPLY

PER ‘5 YEAR DEVELOPMENT’ (PELITA)

AND ITS PROJECTED SUPPLY UNTIL YEAR 2010

ordinate: Persons; absisca: Pelita

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Appendices

TEAM COMPILER OF THE HEALTH DEVELOPMENT PLAN TOWARD HEALTHY INDONESIA 2010 AND INDICATORS OF HEALTHY INDONESIA

2010

1. TEAM COMPILER OF THE HEALTH DEVELOPMENT PLAN TOWARD

HEALTHY INDONESIA 2010

Cultivator Prof. Dr. FA Moeloek; Minister of Health RI

Chief Prof. DR. Dr. Azrul Azwar, MPH; Director General of

Community Health

Deputy Chief Prof. Dr. Umar Fahmi Achmadi, MPH, PhD; Head of

Resource & Development Health

Secretary Dr. Dadi S. Argadiredja, MPH; Head of Planning Bureau

Members 1. Dra. Hj. Zurmiati Bahrunsyah; Secretary of

Inspectorate General

2. Dr. Wibisono Wijono, MPH; Secretary of Dir. Gen. of

Community Health

3. Dr. Ingerani, SKM; Secretary of Dir. Gen. For Medical

Care

4. Dr. H. Haikin Rachmat, MSc; Secretary of Dir. Gen. of

Contagious Disease Eradication and Settlement Enviromental Health

5. Dra. Mawarwati Tedjo; Secretary of Dir. Gen. of Food

and Drug Supervision

6. Drs. I.B. Indra Gotama, SKM, MSi; Secretary of

Health Resource & Development Body Resource Person 1. Dr. E. Sutarto, SKM; Secretary General

2. Dr. Rusmono, SKM; Inspector General

3. Dr. Sri Astuti S. Suparmanto, MSc(PH); Director

General for Medical Care

4. Dr. Achmad Sujudi, MHA; Director General for

Contagious Disease Eradication and Settlement Environmental Health

5. Drs. Sampurno, MBA; Director General for Food and

Drug Supervision

6. Dr. Nardho Gunawan, MPH; Expert Staff of Minister

of Health in Environmental Health

7. Drg. Ibnu Effendi, DDPH; Expert staff of Minister of

Health in Organization and Institution

8. Dr. Brotowasisto, MPH; Consultant to Crisis Center

9. Dr. HR Hapsara, DPH; Consultant to Planning Bureau

Page 86 of 88 Bureau

11.Dr. Sofyan Mukti; Consultant to Planning Bureau

12.Representative of Bappenas

13.Representative of Department of Internal Affairs

14.Representative of Professional

15.Representative of Universities

16.Representative of Statistics Central Bureau

17.Representative of State Minister of Environmental

Health’s Office

18. Representative of Woman’s Role Office Secretariat Team

Chief Dr. Gunawan Setiadi, MPH; Head of General Planning

Division

Secretary Drs. Teguh Budi Santoso; Head of Long- and

Intermediate-term Planning Compilation sub-Division Technical Secretariat 1. Dr. H. Setiawan Soeparan, MPH; Head of

Developmental Program Planning and Compilation Division

2. Dr. Bambang Sardjono, MPH; Head of Developmental

Program Planning and Compilation Division 3. Drs. Johan Arief; Head of Health Resource Plan

Division

4. Mardiah Mawardi, MPH; Head of Evaluation &

Report Division

5. Drs. Abdurachman, MPH; Head of Program and

Report Compilation Division, Dir. Gen. of Community Health

6. Dr. Ali Alkatiri, MSc; Head of Program and Report

Compilation Section, Dir. Gen. for Medical Care 7. Dr. H. Wan Alkadri, MSc; Head of Program and

Report Compilation Division, Dir. Gen. of Contagious Disease Eradication and Settlement Environmental Health

8. Farida Nurbaiti, SKM; Head of Program and Report

Compilation Division, Dir. Gen. of Food & Drug Supervision

9. Drs. Tri Djoko Wahono; Program and Report

Compilation Division, Health Resource & Development Body.

10.Dr. Tarufie Alhayas; Head of Program and Report

Compilation Division, Inspectorate General

11.Ir. Herwanti Bahar, MSc; Head of Health Technology

Transfer and Plan sub-Division

12.Isti Ratnaningsih, MA; Staff of Planning Bureau

13.Drg. Sigit Wardoyo, Msc; Staff of Planning Bureau

14.Syahrial Ahmad, SKM; Staff of Planning Bureau

Administrative Staff 1. Suparianto, SE; Staff of Planning Bureau

Page 87 of 88 3. Supratikto; Staff of Planning Bureau

4. Marice B. Marpaung; Staff of Planning Bureau

MEETINGS ORGANIZED IN THE CONTEXT OF COMPILATION OF DEVELOPMENTAL PLAN TOWARD HEALTHY INDONESIA 2010 ...