INFORMATION ON SOCIAL DETERMINANTS
Country Issues and Challenges :
Policy-oriented research should be focused and systematic in nature, and / or test
specific policy options for replicability. While some initiatives have been commissioned to
inform the policy process in Indonesia, it appears that such research has primarily been
descriptive in nature vs. policy-option oriented. Even though descriptive provide the foundation
for targeting initiatives in many cases, the need exists to apply policy-oriented methodologies
that will highlight the advantages and disadvantages of specific policy options and their replicability.
The effectiveness of such research depends on whether it provides an objective analysis of
a specific policy option. Objectivity and credibility are key considerations that rely on the
professional affiliations both of the research institute and the researchers themselves, and
sources of funding. Objectivity in policy-oriented research is a particularly important issue
given that many public health researchers often act as advocates for certain strategies or remain
affiliated with the MoH and/or its training institutions, and not viewed as neutral or objective.
The findings of policy-oriented research are only effective if they inform the decision-making
process. It appears that the need within this area is to develop the very mechanisms that feed
research findings into the strategic planning process, i.e., designing specific policy options for
evaluation, presenting the positive and negative aspects of the options and necessary institutional
arrangements, and presenting objective recommendations.
Expected Contribution :
- Evidence base in place that supports a policy framework for health as a means of poverty
reduction, identifies the role of the private sector in health service provision, and informs a
systematic monitoring and evaluation of performance.
HEALTH CARE FINANCING
Country Issues and Challenges :
The development of National Health Account is an on-going process and should be updated
every year. At the same time there is also an urgent need to develop sub-national health accounts
as a response to decentralization process. The main problem of creating NHA and also sub-national
health accounts is public sector data availability, especially if WHO classification and function
will be followed. Therefore, efforts are being carried out to optimize use of secondary data that
are available, this include also estimation of private sector expenditures. It is also anticipated
that there will be changes in the structure of the budget document that will influence data collection
of public expenditures. In the next biennium, this effort should be further strengthened and supported.
During biennium 2002-3, WHO has supported the development of a framework for Social Health Insurance.
WHO SEARO and also other donor such as GTZ and European Union also support this effort. Towards the end
of 2002, there was a consensus on the way forward, and the documents fit well to the Presidential Task
Force on Social Insurance Scheme, including health. It is expected that a law will be passed in 2003
for Social Health Insurance. At the same time, it is observed that there is scarcity of human resources
in this area. Therefore, capacity building is needed.
Expected Contribution :
- National and Sub-national Health Accounts established and utilized.
- Concept refinement and strategies in implementation of Social Health Insurance supported.
INFORMATION FOR POLICY
Country Issues and Challenges :
For assessing the population health, fairness in financing and facility performance we rely
on three pillars in health information:
the medically certified cause of death by age and sex
the national surveys and
the facility based information including the medical record.
Ongoing developments, national (decentralization) and international (MDG, WHS) call for a revision
of methods, mechanisms and tools to obtain and analyze the required information.
The assessment of the disease burden is a part of national policy. Accurate information appropriately
interpreted will contribute to timely and correct interventions and health promotion. There have been
some attempts in the past to get accurate data on cause of death; however, none of the past attempts
were sustainable. The MoH is taking important initiatives to establish reliable cause of death reporting.
A system of cause of death reporting is proposed to be implemented in 5 sub-districts in Jakarta and,
like with similar systems in other countries, a more representative sample will be covered within a 3-year period.
One of the main instruments to assess health status, fairness in financing and responsiveness is
the National Health Surveys are carried out every 3 years (Susenas). The quality of the surveys is
recognized as good. However, the use of the data is not optimal and the general orientation within
the setting of decentralization has to be reviewed. There is an increasing demand to study the burden
of disease by district, the fairness in financing, responsiveness and other topics related to health
system performance assessment. The development of SURKESDA (a district version of the national health
survey) is a priority area in the National Institute for Health Research and Development and various
techniques developed by WHO HQ relating to surveys for Health System Performance Assessment
(World Health Survey) can be used to strengthen and revise the use of health surveys in Indonesia.
Decentralization policies transferred operational planning, management, and budgeting to
the district, and an information system is needed to support this process. The method used to
collect facility-based information, Simpus, has in the transition towards decentralization been
severely disrupted. Accuracy of routine and facility based data is important and it is recognized
that the quality of the data is critically dependent on its use at all levels within the system.
Previous assessments have indicated that the use of information in facilities is poor in support
to care provision and use of information is poor on district management level in support to the system.
Health Systems Performance Assessment (HSPA) at district level has been translated into the MoH
context of District Benchmarking. The assessment of district performance has been requested by
Ministerial decree. Some of the work to obtain this assessment has been undertaken in 2003.
It is expected that the final method will be available in 2004 or beginning of 2005. This method
is to standardize the parameters, the elements and indicators used so that one single construct
can be used to assess all districts in Indonesia. The elements used are health status, fairness
in financing and responsiveness and they are evaluated according to coverage and level as appropriate.
The final result is used to make judgments on allocation and on intervention to improve the performance
of the health system.
The decentralization policies transferred the management of health services to the district level.
Many tools, standards and norms have not yet been completed and many are not used, to ensure a
continuous level of health care provision. Methods are needed to improve this situation. This
may include health and demographic profile assessment; evidence-based planning with emphasis on
reducing important health problems and inequalities, adequate budgeting and developing a plan of
work and indicators for monitoring.
Health workers, health students and also the public need to be informed and need access to
information materials, knowledge bases and educational materials. This remains difficult in
Indonesia. Many Institutions take initiatives and produce web-based and other information. CD-Rom
is another alternative widely used throughout the country. The approach is very fragmented and it
is difficult to find and access this information. A network of institutions producing information
and educational materials will improve the knowledge and the motivation of health workers.
Expected Contribution :
- Support the collection of information to estimate the health status of the population of Indonesia.
- Improvement and re-orientation of national and sub-national health surveys.
- Improved use of information for care provision and management at primary care level.
- Assist the MoH in developing a standard assessment and planning method for all districts.
- Provide tools and methods to improve the knowledge and enhance the motivation of health workers.
RESEARCH POLICY AND PROMOTION
Country Issues and Challenges :
In the biennium 2002-3, efforts have been done to strengthen the capacity of research
institutions in Indonesia. This includes among others, establishment of Hellis library in NIHRD,
establishment of National Commission on Research Ethics, strengthening the role of stewardship
of NIHRD in health research activities, mapping of fund flows for health research.
In addition, through the ICP programme, research management modules had been developed and
ready to be field-tested. In the last biennium, efforts had been taken to incorporate medical
ethics into the curriculum of the medical schools. The case studies had been selected and tried
out in two medical schools. These efforts need to be improved and scaled up.
Expected Contribution :
- Research management strengthened.
- Technical support for strengthening the National Commission on Health Research Ethics
and Medical Schools on ethical issues provided.
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