Introduction

 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.

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 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).

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 ... 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.

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  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
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 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

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formed by President Clinton 9
 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.

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 2. Universal Access

 Everyone must have access to healthcare services

without financial or other barriers.

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 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.

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 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
functioning.

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 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.

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 6. Generational Solidarity

 The system should respond to needs at each stage of

life, with benefits and burdens fairly shared across
generations.

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 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
health.

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 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.

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 9. Quality Care

 This clause mandates creation of systems of quality

assurance in all aspects of the system.

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 10. Efficient Management

 The system should be simply organized and easy for

patients and professionals to use and should
minimize administrative costs.

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 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
physicians.

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 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
patterns.

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 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
patients.

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 14. Fair Procedures

 To protect these principles and values, fair and open

democratic procedures should exist for making
decisions and resolving disputes.

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 Decentralization

 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.

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 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.

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 Aspects of Decentralization

 Aspects of Decentralization
 Responsibility for Health Care Services

 Management of Labor Inputs

 Management of Procurement

 Management of Investments

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

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INDONESIA NATIONAL
HEALTH SYSTEM

HERQUTANTO
ENDANG BASUKI
JUDILHERRY BUSTAM
 Introduction

 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
2004
 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 country’s

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
 Philosophy

 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

 Humanity
 Human Right
 Fairness
 Community Empowerment
 Partnership
 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
 Affordable

Healthcare Quality
Accessible
system

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

Government
Policy

Health Community
Health Science Needs &
care
& 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
 Rehabilitation
 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,
Posyandu
 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
budgeting.
Human resource system
 Main element

 Planning: type, number, specification

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

 Drug and logistic supply: efforts to supply drugs and

logistic suitable with the needs and demands of the
community
 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
development
 Health regulation: rules and regulation as a guideline
for health development