Indonesian Health Care Decentralization 2000 2007 -Impact on Geographical Inequity -Policy Analysis and Scenario Planning

Laksono Trisnantoro Center for Health Service Management Gadjah Mada University Medical School

Preface
Decentralization policy in Indonesian health sector had been implemented since 2000. Has decentralisation improved the efficiency and equity of health services? Has decentralisation succeeded in increasing the role, capacity, and participation of local governments for health development?

Content
Facts on health data around years of decentralisation Decentralisation policy implementation and geographical inequity 2000 2007 Reflection Stakeholders analysis What Next and the Scenarios

the Facts

Dengue Haemorhagic Fever

Decentralization

Source: Bappenas, 2008

Malnutrition Problem

Decentralization
MoH Projection
Source: Bappenas, 2008
6

Under Five Mortality

Decentralization

Source: Bappenas, 2008

7

Infant Mortality Rate

.

Decentralization

Source: Bappenas, 2008

8

Maternal Mortality Rate

Decentralization

Source: Bappenas, 2008

Delivery attended by trained health workers

Stagnant

Decentralization

10

Since 2001,
- the health program (national budget) for the poor had improved the utilization of public hospital by the poor - Kakwani Index is improving
0.2 0.1
Hospital Inpatient Care

Kakwani Index

0 KI 2001 -0.1 -0.2 KI 2004

Hospital Outpatient Care Non-hospital Inpatient Care Non-hospital Outpatient Care All Public Health Care

-0.3 -0.4 Tahun

Source: Equitap, 2006

IMR URBAN/RURAL

U5MR ISLAND GROUPS

IMR ISLAND GROUPS

Specialist distribution
Jakarta: 24% of specialists, serves around 4% community in a relatively small area

Provinces in Java: 49% of specialists, serves around 53% community Rest of Indonesia: 27% of specialists, serves around 43% community in a very large area
Source: Indonesian Medical Council, 2008

Specialist distribution
Province Number
2.890 1.980 1.881 1.231 617 485 434 352 350 216 203 173 167 1.104

%
23,92% 16,39% 15,57% 10,19% 5,11% 4,01% 3,59% 2,91% 2,90% 1,79% 1,68% 1,43% 1,38% 9,14%

Cumulative
23,92% 40,30% 55,87% 66,06% 71,17% 75,18% 78,77% 81,69% 84,58% 86,37% 88,05% 89,48% 90,86% 100,00%

People served
8.814.000,00 35.843.200,00 40.445.400,00 32.119.400,00 12.760.700,00 3.343.000,00 8.698.800,00 9.836.100,00 3.466.800,00 6.976.100,00 2.960.800,00 2.196.700,00 4.453.700,00 52.990.200,00

Ratio
1 : 3049 1 : 18102 1 : 21502 1 : 26092 1 : 20681 1 : 6892 1 : 20043 1 : 27943 1 : 9905 1 : 32296 1 : 14585 1 : 12697 1 : 26668 1 : 47998

DKI Jakarta Jawa Timur Jawa Barat Jawa Tengah Sumatera Utara D.I.Jogjakarta Sulawesi Selatan Banten Bali Sumatera Selatan Kalimantan Timur Sulawesi Utara Sumatera Barat Propinsi Lainnya

12083 Source: Indonesian Medical Council, 2008

100,00%

224.904.900,00

1 : 18613

Number of Hospital Bed

Java Island Private Hospitals increased faster than public hospital Out of Java Island Public hospitals increased more than in Java Island More hospital construction, especially in the better off provinces

Critical Question based on the facts:

Decentralisation policy in Indonesian health sector:

Is it good? Is it bad?

Data Interpretation
The answer is debatable: the decentralisation policy has not provided a convincing result on the performance of health status
This was concluded at the 6th annual meeting on health care decentralization in Bali (2007).

In terms of geographical equity:

Is Bad.
Based on the IMR data in eastern part of Indonesia

Decentralisation policy raised systemic problems:

Chain of Command break down Information break down Health human resources problems Little ownership from Becomes a scapegoat the local government, (kambing hitam) of except for curative care Indonesian health (free medical services) system failure

The issue
The decentralisation policy is not proper for Indonesian health sector

OR

The decentralization policy in health sector is proper, but not yet implemented properly

The analysis
Analysing the policy and its early implementation Reflection Analysing the stakeholders position Projecting the policy in the future using scenarios

Decentralization Pendulum:
swinged to decentralisation far-end point in 2000

Law 22/99

centralization De-centralization

1999 - 2003
Table Source of Funds Trends
60.00% 50.00%

Period of decentralisation. Euphoria.

Central Government

Percentage

40.00% 30.00% 20.00% 10.00% 0.00%

Central government budget decreased. Provincial and district budget increased

Provincial Government Regency/Municipality Govt Foreign Funds

1999

2000

2001 Year

2002

2003

But,
fund allocated in the General Allocation Fund (DAU) and the Local Revenue & Expense (APBD) was not adequate for health also occurred in rich provinces and districts which should have provided more budget to the health service (low commitment).

health sector experienced a fund shortage, the system became disrupted, and loss of coordination.

Period of re-centralising thought: around 2004

The Ministry of Health considered this as a matter of disrupting the health system. With some good will, the MoH increased the financing from the central.

Some MoH leaders thought for returning back to centralised system Health Sector Decentralisation was labelled as wrong policy

Decentralisation Pendulum: swinged back

(but, health is still a decentralised sector)
Law 32/04 centralization De-centralization Law 22/99

Central Government Budget

1998 DitJen etc 627,2 Central Gov.Units 692,9 DAU + DAK 172,3 PAD + DAU +DAK 118,9 1999 1.252,6 1.210,1 220,6 175,5 2000 1.102,7 1.041,9 323,4 193,1 2001 808,0 935,5 1.043,1 1.509,6 2002 1.208,0 1.143,2 1.040,3 1.777,6 2003 2.153,2 1.976,0 1.829,7 2.695,9 2004*) 2.065,0 2.027,7 1.948,7 2.898,1 2005**) 7.916,0 2.755,1 2.055,8 3.086,5 Notes Ditjen etc Sectoral Funds/Decon (?) DAU+DAK = APBD I PAD+DAU+DAK = APBD II

Central Government Health Development Budget

9.000,0 8.000,0

Budget in Billion Rupiah

7.000,0 6.000,0 DitJen etc 5.000,0 4.000,0 3.000,0 2.000,0 1.000,0 1998 1999 2000 2001 2002 2003 2004*) 2005**) Central Gov.Units DAU + DAK PAD + DAU +DAK

2004-2006
Although: the Law no 32/2004 stated that health is a decentralised sector
Health Finance is becoming more centralised using the increase of deconsentration budget (centrally managed budget)

Political power is moving more to central government

Debate on re-centralisation was heated

Problems in central government finance channelling

2006: Problems of central government absorption 2007: Problems in financing poor family insurance scheme
DitJen etc Central Gov.Units DAU + DAK PAD + DAU +DAK 1998 627,2 692,9 172,3 118,9 1999 1.252,6 1.210,1 220,6 175,5 2000 1.102,7 1.041,9 323,4 193,1 2001 808,0 935,5 1.043,1 1.509,6 2002 1.208,0 1.143,2 1.040,3 1.777,6 2003 2.153,2 1.976,0 1.829,7 2.695,9 2004*) 2.065,0 2.027,7 1.948,7 2.898,1 2005**) 7.916,0 2.755,1 2.055,8 3.086,5 Notes Ditjen etc Sectoral Funds/Decon (?) DAU+DAK = APBD I PAD+DAU+DAK = APBD II

Central Government Health Development Budget

9.000,0 8.000,0

Budget in Billion Rupiah

7.000,0 6.000,0 DitJen etc 5.000,0 4.000,0 3.000,0 2.000,0 1.000,0 1998 1999 2000 2001 2002 2003 2004*) 2005**) Central Gov.Units DAU + DAK PAD + DAU +DAK

Empirical experience: centralisation is not easy in a decentralized government system

2000- 2007 Reflection

The Big Bang Political Process in 1999

President Habibie and parliaments political decision for preventing Indonesian break up Radical change at provincial and district level: A merger between Health Office at local government and Branch of MoH Sudden transfer of health finance

Reflection 1

Central Ministry of Health remains in the same organizational structure and function

Health decentralisation policy in Indonesia

Induced by political pressure Technically health sector was not ready Not a Ministry of Health initiative Local government capacity for managing health was low

Reflection 2 Decentralisation Laws

The Hope
Health Status
Private Sector and Community

Input

Strengthen Government Health Organizations

Other Factors

Reflection 2 Decentralisation Laws

The Facts in 2000-2007

Input

Confusion on the role of Government at each level

Private Sector and Community

Health Status

Government regulation (PP) no 25/2000 on authority distribution was confusing one

Other Factors

Ineffective GR 25/2000
In such unprepared situation the negative impacts of decentralisation emerged as experienced by various countries the failure of the system, lack of coordination, inadequate resources, poor career path of human resources (HR), and excessive political influence. The Regulation No.25/2000 on the transfer of government level authority is not effective

Government Regulation 25/2000

Was written just one year after the Law No 22 stipulated in 1999 Based on political euphoria of decentralization Undermining the role of provincial government Lack technical implementation

Reflection 3

Government Finance problems

Complexity of channelling Health Finance from mechanism central government had Relying too much on problem in its allocation deconcentration fund and absorption (againts the Law no 33/2004) Late disburstment Limited scope of DAK (around July, fiscal year budget starts in January) Low absorption

Reflection 4

2000-2007: The era of confusion and

strange situation
Change without significant change
Change in the Laws but no significant change in the technical process and the improvement of health status indicators. Indonesian health sector is a decentralised sector but experiencing: a more centralised financing system (06-07). Not coordinated change.

Conclusion: The policy implementation is poor

What Next?
Pesimistic? Decentralisation seems to be in the dark tunnel without no end. Optimistic?

A light in the dark tunnel:

The Stipulation of Government Regulation no 38/2007, following Act no 32/2004 A three year of making process, for replacing the confusing GR no 25/2000

the new hope for a clear transfer of authority from central, provincial to district government

Decentralisation Laws GR: 38/2007

New Hope
Health Status Improvement
Private Sector and Community

Other Input

Strong legal basis for Government function at each level

Other Factors

2000-2007: Period of transition

2008

is the new beginning of decentralisation in health

Is that easy?
The future is not certain still. Depends on how the different views on decentralisation policy among various stakeholders can be resolved Leadership of central and local government.

Stakeholder analysis,
Using Reich approach; (1) deciding who played a role as stakeholders in decentralisation policy; (2) examining the strength and its influence; (3) observing their attitude toward the policy whether they support or reject.

Who are the stakeholders?

Central government: The Ministry of Health, The Ministry of Home Affairs, The Ministry of Finance, The Ministry of Welfare, National Planning Development Body, House of Representatives, Local Government, and Local House of Representatives. The society: non governmental organization, profession association, hospital associations. Private sectors were government hospital, private hospital, Universities. Foreign donors such as World Bank, ADB, AusAid, GTZ.

The stakeholders subjective assessment

Strong support Moderate support Low support indiffe rent Quite opposite opposite Extremely opposite

Striking subjective assessment: the MoH position

Strong support Moderate support Low support indiffe rent Quite opposite opposite Extremely opposite

Ministry of Health during transition period (2000 2007) did not fully support
Objective indicators The difficulties of ministry of health for arranging the guidelines and policy The disappearance of decentralisation strategy in 2005 national health policy MoH organizational structure did not change Subjective indicators The reluctance to use innovative budget for decentralisation policy implementation at national level Statements from topleader which blame decentralization policy

During 2000 - 2007

Technical aspect of health decentralisation policy lacks MoH leadership Norms and standards for : Health insurance scheme Surveillance and health informatics Hospital licensing Health Service Quality system Not well addressed.

Local Government
Better off Provinces/District In favor for decentralization Worse off Provinces/District Not supportive

Other stakeholders
Support the decentralisation policy decentralization policy in health sector is proper, but not yet implemented properly

GR no 38/2007 was prepared by Ministry of Home Affairs and supported by all Ministries National parliament has no intention to pull out health from the decentralized sector list

Two uncertain important players in the future

Central Government (MoH) Local Government
The future is uncertain: How is the support for decentralisation policy by these two players?

4 possible scenarios
Central government supports decentralisation in health sector

Local government does not support decentralisation in health sector

Local government supports decentralisation in health sector

Central government does not support decentralisation in health sector

Scenario 1: Agreement for decentralisation

The best scenario: a harmony between central and local government. The central government, especially Ministry of Health, has high spirit to implement decentralisation the local governments also have high spirit.

Lesson from other countries

The experiences from several countries showed:
Agreement between central and local government is one of the important factors which determine the success of decentralisation.

Scenario 2: Half-hearted decentralisation

not ideal scenario. Ministry of Health and the elements of central government demand to recentralisation. The local government: tied up to decentralised system because the Decentralisation Law and GR no 38/2007.

Trigger many half-hearted implementation of decentralisation policy. The half-hearted implementation will bring negative impact. No good result would be achieved if the program was conducted half-heartedly.

In this scenario
the role and capacity of local governments for managing health sector will not be improved Why? No guidance and stewardship role from central government Have been happened at present condition in Indonesia.

Scenario 3: Agreement for recentralisation

This scenario showed the agreement between central and local government to recentralise health sector. Central government had no willingness to run decentralisation in health sector and so did the local government. As a result, Law No. 32/2004 will be amended so that health sector became centralised sector.

Scenario 4: Halted decentralisation.

Central government (Ministry of Health and House of Representative) had high spirit to implement decentralisation The local government did not want to support the implementation. This scenario shows the difficulties to implement decentralisation.

Closing Remark
Which scenario is the most likely happened?
The New Minister of Health (2009) has new policy Stressing decentralization

the MoH position is moving

Strong support Moderate support Low support indiffe rent Quite opposite opposite Extremely opposite

Closing Remark
Which scenario is the most likely happened in the future?

Left to the discussion

Thank-you