THE STRATEGIC AGENDA FOR INDONESIA: THE NEXT FEW YEARS

Overall Goals
WHO Strategic Agenda: Principal Components
WHO Strategic Agenda : Key Functions
Principal Components: A Brief Overview
Conclusion

Overall Goals

The overall goal of the World Health Organization in Indonesia is to improve the health of the people of Indonesia by supporting health sector development, advocating health promoting policies and providing technical leadership in collaboration with the government, donor partners and other actors in health. In particular WHO will work towards a more equitable and efficient health system.

These goals will only be achieved through an optimal mix of partnerships in health. In addition, WHO will also contribute its experiences to other countries, globally as well as regionally.

In line with WHO Corporate Strategy and a re-evaluation of its comparative advantages, WHO over the next 5 years intends to take a more selective and strategic approach to its work in Indonesia and support to the MoHSW, in relation both to areas of activity and to the functions it performs. To achieve greater impact, it will focus intensively on a limited number of priorities.

WHO Strategic Agenda: Principal Components

As set out above, Indonesia is engaged in a fundamental reform of its government system, with material consequences for the health sector. Against this background, a key objective of WHO'S strategy will be to work with other developmental partners to secure a more equitable, efficient and effective health system and the adoption of pro-poor health policies. WHO will work with the government to narrow the gap between policy intentions and policy implementation. It will seek to improve the process of developing health policy, planning, regulation and financing, leading to a more equitable, responsive and financially fair health system.

While initiatives to improve the health system will affect all WHO activities in Indonesia during this period, selected technical areas also deserve high priority. In the light of the country's needs, the government's policies, the activities of other development partners and WHO'S own objectives, WHO'S country cooperation strategy for Indonesia for the next few years will focus on six principal components:

1. health policy and system development
2. communicable disease control
3. the health of women and children
4. promoting a healthy environment and healthy lifestyles
5. emergency preparedness and response
6. partnerships and coordination.

The following chart demonstrates the shift in the technical effort in each of these components, in moving from the current position to the strategic agenda outlined here. In relative terms, technical requirements would increase by about 26%, with the greatest increase for health systems. These increases over existing levels would be funded by extra budgetary funds, and re-allocation of existing regular budget funds for technical assistance.

WHO Strategic Agenda : Key Functions

WHO is already engaged in a shift of functions. As the government's own funding for health has increased and the MoHSW has received major support from the development banks (ADB and the World Bank), WHO'S direct support for implementation has become much less significant. Large fellowship programmes offered by the development banks mean that WHO has become a minor actor in this area also. By contrast, WHO continues to play a major and influential role in the MoHSW because of the presence of a large number of technical staff and consultants, and its influence in setting standards and developing guidelines. Under this country cooperation strategy, WHO will move towards providing more technical support and expertise in priority areas, and away from large local cost activities and fellowship programmes.

WHO has defined 5 sets of functions which it carries out at country level:

• Function 1 - supporting limited essential routine implementation
• Function 2 - catalysing adoption of technical strategies and innovation; country-specific adaptation of guidelines; seeding large-scale implementation
• Function 3 - supporting research and development; policy experimentation; development of guidelines, stimulating monitoring health and health sector performance; trends assessment and anticipation
• Function 4 - providing information, sharing knowledge (global, inter-regional, inter-country); advocacy; generic policy options and positions; cases studies, standards and guidelines
• Function 5 - providing specific high-level policy and technical advice; serving as a broker and arbiter; exercising influence on policy, action and spending of governments and development partners.

The following table sets out the WHO country office team's view of the relative emphasis in function for each principal component of the WHO strategic agenda over the next few years, taking into account the current status of the health situation and health programmes.

In general, WHO will pay most attention to policy development, knowledge-sharing and advocacy. Direct implementation will be severely restricted except in the case of emergency activities, and higher priority will be put on catalysing the implementation of standards and guidelines to meet conditions in Indonesia.

Principal Components: A Brief Overview

Health policy and system development

This is where WHO will concentrate most of its effort over the next five years. The government is clearly expecting the Organization to help shape, and develop responses to, health sector elements of overall reform such as decentralisation, privatisation, civil service reform and poverty reduction. These include such areas as health financing, corporatisation of health facilities, new institutional arrangements and changes in employment conditions of health personnel. For example, there is urgent need to redefine the functions of the health system at different levels of government; and to determine how health institutions should develop to ensure increased effectiveness and community support.

WHO'S strategy to improve the health system demands both ensuring close links with other development partners, and providing specific expertise where it is most needed.

With this in mind, WHO will put emphasis on supporting the central Ministry of Health and Social Welfare and, where appropriate, other levels of government and organisations in tackling the challenges of decentralisation:

• understanding and developing the MoHSW's new roles and functions under a decentralised health system
• effecting the MoHSW's shift from provision of services to policy formulation
• promoting an epidemiological approach to health planning
• improving the quality and use of information to better manage a decentralised health system
• developing an integrated surveillance system for the district
• improving the decentralised management of drugs, and promoting rational drug use.

In relation to the other priority issues for the country over the next few years, WHO will concentrate on supporting the MoHSW in:

• tackling health financing issues, including monitoring health expenditures and service utilisation, and promoting pre-paid health service schemes
• enhancing quality assurance in service provision
• addressing policy issues in human resources development and personnel management, through redirecting fellowships
• reorienting medical and allied health education to better address public health problems and the needs of the patients.

Communicable Disease Control

During the next few years, WHO will continue to support the MoHSW in designing and implementing effective communicable disease control programmes to reduce excess mortality, morbidity and disability, especially in populations with limited access to health services. Vertical strategies will be revisited to adjust to a decentralised health system approach building a rapid response to epidemics and newly emerging communicable diseases.

WHO'S effort in this area will be directed to supporting the MoHSW, and other organisations where appropriate, in:

• strengthening communicable disease control programmes, including EPI, at district level
• controlling tuberculosis, with increased support from WHO
• increasing emphasis on control of vector borne diseases, especially malaria, dengue, and filariasis
• strengthening surveillance and outbreak response to emerging and re-emerging diseases
• strengthening health laboratory services
• enabling central communicable disease control institutions to support a decentralised health system.

The health of women and children

One of the goals of the government is to solve some of the major health systems problems affecting reproductive health, and strengthen initiatives to improve comprehensive health services for women and children.

In support of this goal, WHO will:

• assist in the development of national policies, strategies and action plans on nutrition, child and adolescent health and reproductive health for application at district and provincial levels
• assist in the development and introduction of Making Pregnancy Safer
• concentrate on promoting an effective referral system from the family upwards
• scale up and expand the IMCI approach, especially focusing on nutrition, and include interventions at the community and family levels
• support programmes improving the health of women, including action to reduce violence against them.

Promoting healthy environment and lifestyles

Currently many health promotion activities have limited impact due to lack of targeting. The strategic agenda for this component will concentrate on integrating health promotion into key health programmes in Indonesia. WHO will play a more strategic role in environmental health, developing clear policies and priorities for a healthy environment.

Specifically, WHO will:

• promote selective approaches to environmental health risk management
• assist in the development of a national policy and strategic plan for non-communicable diseases
• assist in the development of a national mental health policy and strategic plan
• undertake activities to support the Tobacco Free Initiative
• foster advocacy in dealing with substance abuse
• facilitate the integration of health promotion into disease control programmes.

Emergency preparedness and response

The Government of Indonesia has been challenged by the needs of those traumatised and internally displaced as a result of civil unrest and natural disasters in several provinces of Indonesia. Indonesia has only recently experienced complex disasters, and the institutional experience to deal with them is limited. The strategic direction of WHO in this area will be to foster the development of a national capacity for emergency preparedness and response to emergency public health needs. WHO will also work closely with other UN agencies to improve the effectiveness of collaboration, on the basis of more clearly defined roles and responsibilities. This relates closely to the following component on partnerships and coordination.

WHO will therefore:

• encourage the adoption of international best practices and minimum standards in emergency management
• support the development of emergency management capacity in government ministries
• emphasise the need for emergency mitigation and preparedness, including better hazard and vulnerability assessments
• increase the resources for emergency relief activities in support of disaster-affected populations
• work more closely with other UN agencies.

Partnerships and coordination

WHO has, and will continue to fulfil, a major role in coordinating donor assistance in the health sector. This is an area where WHO can provide special technical input, with substantial benefit for the health sector in Indonesia. Its role in supporting the Minister of Health and Social Welfare offers an appropriate opportunity for promoting effective policies, and seeking to ensure that those adopted are reflected in the government's medium-term expenditure framework. Alongside this, WHO intends to act as a broker and arbiter, and seek to influence developmental partners and government agencies. In particular, WHO will advocate a broader sector-wide approach as opposed to project-oriented interventions.

WHO will:

• play an increased role in coordinating donor assistance, including supporting "Partners for Health"
• provide specialist support for the Minister of Health's reform process
• mobilise more resources from donor agencies both for the government, and for WHO'S own programmes
• emphasise advocacy for establishing health in the development agenda.

Conclusion

Improving the health of more than 200 million Indonesians is a challenge before the government and WHO in Indonesia. While considerable progress has been made over the last two decades, resulting in gains in life expectancy and reduction in infant and maternal mortality, many problems remain. Many of these problems relate to broader health system issues, impacting on the health of women and children; control of communicable diseases; spread of emerging and reemerging infectious diseases; environmental health; non-communicable diseases and effectively handling issues relating to complex emergency situations. This situation is further complicated by the ongoing political, social and economic changes. Major reforms are currently underway in all these areas, including the health sector. These changes will have a far-reaching impact on the way health services are administered and delivered.

This WHO country cooperation strategy defines the broad framework for WHO'S work with the Government of Indonesia over the next few years. It takes into account Indonesia's health needs, its government's policies and expectations, the activities of other development partners and WHO'S own principles and priorities, all of which are examined in detail in previous sections.

WHO's overall approach has been to be more selective and strategic, both in the range of functions proposed and in the prioritisation of components. In general, WHO in Indonesia will focus more on policy advice, knowledge-sharing and advocacy and move away from supplementation of MoHSW budgets and operational support, except in relation to complex emergencies of the kind currently facing Indonesia. This implies a change in expenditure patterns, and an increase in the provision of high-level and high quality technical resources - for example, as a result of the shift from providing WHO fellowships to assisting in the development of a human resources development plan.

At the same time, the re-ordered priorities will demand a change in the areas as well as the nature of the support required, most notably an increased demand for health policy and systems expertise. A rough estimate suggests that well over one-third of the WHO assistance likely to be required over the next few years in Indonesia will be devoted to health policy and systems support, particularly in relation to the country's current drive for rapid decentralisation. Alongside this, there will continue to be need for WHO support in selected technical areas like communicable disease control, the health of women and children, and promoting a healthy environment and lifestyle. WHO is currently playing a critical role in helping Indonesia cope with the public health consequences of natural disasters and civil unrest, but this should diminish somewhat as its efforts to foster a national capacity for emergency health preparedness and response bear fruit. The strategic agenda also envisages that WHO will be a major player within the overall partnership at country level, in particular in advocating a shift from current project-oriented interventions to a broader sector-wide approach for health.

The concerted support of WHO as a whole will be marshaled to execute this country cooperation strategy. It will entail substantial changes, both in the WHO office in Indonesia and in the timely and appropriate support to be provided by the South East Asia Regional Office, Headquarters and WHO elsewhere in the world. Assisting the government in its ambitious decentralisation programme will benefit in particular from practical experience and expertise from other countries. WHO Indonesia in turn may have lessons for other countries. Resource implications, while challenging, are manageable. Additional funding will be required for increased staff and consultants at a time when the WHO country budget will continue to fall, but - with a large and growing donor community in Indonesia - WHO believes this country cooperation strategy will provide the basis for mobilising further resources both for the government, within its own medium-term framework, and for WHO'S own programmes.

The over-riding aim throughout will be to secure WHO'S goals of improving the health of the people of Indonesia and working towards a more efficient and equitable health system.