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Health is one of basic human rights (WHO,1948)

Health is the state of physical, mental, and social
well-being and not merely the absence of disease
or infirmity (WHO, 1946)
Health is the state of physical, mental, and social
well-being that enables individual to have a
productive life socially and economically
(Indonesian Law no. 23, 1992)
Overall goals for health systems:

Improving health and reducing health inequalities

Enhancing responsiveness to the legitimate
expectations of the population
Assuring fairness of financial contributions.

Dr Shahram Yazdani
Universal functions of a health system:
1. Delivering services (provision)
2. Creating resources (investment and training)
3. Financing (collecting, pooling and purchasing)
4. Stewardship (oversight).

Dr Shahram Yazdani
... give up your focus on curative care, don't spend
money on expensive hospitals (you don't need
them if you have enough prevention...) , stop
looking after the rich urban dwellers (even if they
are politicians), invest in prevention, promotion,
community participation... its definitely much
better! Reform! Remove the imperfections in your
health systems - embrace primary health care.

Dr Shahram Yazdani
health care resources are scarce in the
developing world, and that demand will always
exceed the supply therefore, Governments have
to make choices about how they allocate these
resources to the ever-increasing demands that
are placed upon them. A significant obstacle in
the road to Health for All was identified -
someone has to pay for it, and to do so they
have to take money away from something else.
A difficult dilemma for any government

Evans J, etal (1981) New Engl J Med Vol 305 (19) 1117-1127
Dr Shahram Yazdani
The Fourteen Principles

1. Fundamental 7. Wise Allocation

Importance 8. Effective Treatment
2. Universal Access 9. Quality Care
3. Comprehensive 10. Efficient Management
Benefits 11. Individual Choice
4. Equal Benefits 12. Personal
5. Fair Burdens Responsibility
6. Generational 13. Professional Integrity
Solidarity 14. Fair Procedures

Task Force on National Health Reform

Dr Shahram Yazdani
formed by President Clinton 10
1. Fundamental Importance

Healthcare is of fundamental moral importance

because it protects our opportunities to pursue goals,
reduces our pain and suffering, prevents premature
loss of life, and gives us the information we need to
plan our lives.

Dr Shahram Yazdani
2. Universal Access

Everyone must have access to healthcare services

without financial or other barriers.

Dr Shahram Yazdani
3. Comprehensive Benefits

The healthcare system should meet the full range

of healthcare needs. Ideally, the program should
cover primary, preventive, chronic, and long-term
care, as well as acute, home, and hospital care and
treatment for mental and physical illness.
Obviously, not every possible service can be
provided, but when there must be limitations, they
should be placed on the least important benefits
relative to their costs.

Dr Shahram Yazdani
4. Equal Benefits

Healthcare services should only reflect differences in

healthcare needs and not other individual or group
differences. The drafters of the reform plan were
emphatically opposed to a two-tier healthcare system
and clearly indicated that whereas in other realms of
societal endeavor two tiers might be acceptable,
healthcare is too important to basic human

Dr Shahram Yazdani
5. Fair Burdens

The costs and burdens of meeting healthcare needs

should be spread across society by a progressive tax,
with payments scaled according to ability to pay.

Dr Shahram Yazdani
6. Generational Solidarity

The system should respond to needs at each stage of

life, with benefits and burdens fairly shared across

Dr Shahram Yazdani
7. Wise Allocation

Society must wisely balance what it spends on health

with other priorities such as education, housing, and
defense. It will therefore have to set limits on the
amount to be spent on healthcare, as well as
prudently allocate resources within the healthcare
budget itself. Unfortunately, in too many countries
military expenditures often greatly exceed those on

Dr Shahram Yazdani
8. Effective Treatment

Since funds will always be limited, it is a medical as

well as ethical responsibility to spend only on
services whose effectiveness has been proven
(evidence-based medicine) and to avoid spending on
ineffective or doubtful services, whether diagnostic
or therapeutic. This clause also mandates spending
on research, particularly outcomes research.

Dr Shahram Yazdani
9. Quality Care

This clause mandates creation of systems of quality

assurance in all aspects of the system.

Dr Shahram Yazdani
10. Efficient Management

The system should be simply organized and easy for

patients and professionals to use and should
minimize administrative costs.

Dr Shahram Yazdani
11. Individual Choice

In the true spirit of American individualism, the

authors of the reform plan proposed that the
healthcare system permit maximum freedom of
choice among providers, plans, and treatments.
Other Western countries have traditionally placed
lesser emphasis on such freedom of choice. In the
U.S., managed care plans are increasingly
restricting options, precipitating considerable
displeasure among patients as well as among

Dr Shahram Yazdani
12. Personal Responsibility

The healthcare system should help citizens take

responsibility for protecting and promoting their
own health and that of their families. This is meant
to include the provision for education, counseling,
and treatment to encourage healthy behavior

Dr Shahram Yazdani
13. Professional Integrity

The system must respect the clinical judgment of

health professionals and protect the professional-
patient relationship while ensuring that the
professionals fulfill their responsibilities to their

14. Fair Procedures

To protect these principles and values, fair and open

democratic procedures should exist for making
decisions and resolving disputes.


The term decentralization has been used to connote a

variety of reforms characterized by the transfer of fiscal,
administrative, and/or political authority for planning,
management, or service delivery from the central MOH
to alternate institutions. These recipient institutions may
be regional or local offices of the same ministry,
provincial or municipal governments, autonomous
public service agencies, or private sector organizations.

Dr Shahram Yazdani
Improvement in health sector performance
through decentralization
1. Improved allocative efficiency through permitting the
mix of services and expenditures to be shaped by local
user preferences;
2. Improved production efficiency through greater cost
consciousness at the local level;
3. Service delivery innovation through experimentation
and adaptation to local conditions;
4. Improved quality, transparency, accountability, and
legitimacy owing to user oversight and participation in
decision making; and
5. Greater equity through distribution of resources
toward traditionally marginal regions and groups.

Dr Shahram Yazdani
Aspects of Decentralization

Aspects of Decentralization
Responsibility for Health Care Services

Management of Labor Inputs

Management of Procurement

Management of Investments

Transfers of Budgets/Poverty Targeting
Powers to Manage Revenue from Fees

Dr Shahram Yazdani


To achieve the state of health, several efforts need to

be done, including creating a health system
How is the health system in Indonesia, and how is it
in the future?
Indonesian National Health System
Present Situation

Maternal Mortality Rate (MMR): 373/100.000

live birth (Household survey 1995)
Infant Mortality Rate (IMR): 50/1000 live birth
(Susenas 2001)
Life expectancy is 66.2 years (1999)
Human Development Index: Indonesia ranks 112
out of 175 countries (UNDP, 2000)
What is National Health System?

NHS is a structure that reflects the countrys

coordinated and integrated efforts to achieve the
highest health level for all Indonesian people as the
realization of social welfare stated in the preamble of
the 1945 constitution
Coordination between government and private
sector, including the public

Ideal Philosophy: Pancasila (Five Principle)

Constitutional: the 1945 constitution
Chapter 28 A

Chapter 28 C verse 1

Chapter 28 H verse 1 and 3

Chapter 34 verse 2 and 3

Basic Principle

Human Right
Community Empowerment
Effectiveness and efficiency
Good Governance
Position of NHS

Supra system: National Administrative/

Governmental system
Interaction with other system:
National Education system
National Economic system
National Food Resilience System
National Defense system
NHS is supra system for Local Health System
Sub-system of NHS

Healthcare system
Health finance system
Healthcare human resource system
Drugs and health logistic system
Community empowerment system
Health management system
Healthcare System

Healthcare Quality

Highest Level
Of Health Status
Characteristic of Healthcare
Public Health Parameter Individual health

PH specialist Personnel Doctor

Prevention Main Goal Cure
Community Target Individual
High Efficiency Low
Yes Advertising No
Subject Regulation Object
Salary Income Fee
Community Responsibility Patient
Exist Monopoly Not exist
Complex Administration Simple
Factors affecting healthcare


Health Community
Health Science Needs &
& Technology Demand
Main element

Public health (public goods):

Health promotion
Health maintenance
Communicable Disease Control
Mental Health
Non-communicable Disease Control
Environmental health & basic sanitation
Community nutrition
Drug and logistic safety
Disaster and Emergency Management
Main element

Individual health (private goods):

Health promotion
Health prevention
Ambulatory care
Hospital care
Disability limitation
Traditional and alternative medicine
Physical fitness and cosmetics
Public Health

Primary: Health Center/Puskesmas

Center of health-oriented development

Center of community empowerment

Center of basic healthcare services:

Secondary: District MOH

Tertiary: Central & Provincial MOH
Individual health

Primary: Puskesmas, private practice, midwifery,

dentistry, 24-hour clinic, Polindes, Pos Obat Desa,
Secondary: hospital care (type C & B), specialist
practice, specialist clinic, dentist specialist practice
Tertiary: hospital care (type B & A), specialist
consultant practice, dentist specialist consultant
Health Finance System
Main element

Fund raising: activities to raise funds needed to

organize healthcare services or health maintenance
Fund allocation: allocation of funds raised from
government, public or private sector
Fund expenditure: using the fund allocated through
Human resource system
Main element

Planning: type, number, specification

Training & education: recruitment and development
of human resource
Placement: distribution, utilization, supervision,
Drug & Logistic
Main element

Drug and logistic supply: efforts to supply drugs and

logistic suitable with the needs and demands of the
Drug and logistic distribution: efforts to distribute
drugs and logistic
Drug and logistic quality: effectiveness, safety and
expiry of drugs and logistic
Community Empowerment
Main element

Individual empowerment:
Minimum target: practicing healthy and clean lifestyle
Maximum target: active involvement as health cadre

Group empowerment: to serve, to advocate, to watch

Community empowerment
Health Management
Main element

Health administration: planning, doing, checking,

and taking action (PDCA)
Health information: collecting & managing data as
an input for the decision makers
Science & technology: result of research and program
Health regulation: rules and regulation as a guideline
for health development