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Born in Cirebon , West Jawa Dokter from UNIVERSITAS INDONESIA

Adang Bachtiar. Born in Cirebon , West Jawa Dokter from UNIVERSITAS INDONESIA Master of Public Health: HARVARD-USA Doctor of Science: JOHNS HOPKINS-USA Post Doc in Statistics: UNIV of MICHIGAN-USA Current Activities: Indonesian Public Health Association , President

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Born in Cirebon , West Jawa Dokter from UNIVERSITAS INDONESIA

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  1. Adang Bachtiar • Born in Cirebon, West Jawa • Dokter from UNIVERSITAS INDONESIA • Master of Public Health: HARVARD-USA • Doctor of Science: JOHNS HOPKINS-USA • Post Doc in Statistics: UNIV of MICHIGAN-USA • Current Activities: • Indonesian Public Health Association,President • Global Fund TB at FPH-UI, Director • Health Professions Coalition for Anti Smoking,Chairman • National Expert Panel on TB,Health Policy Spesialist • Indonesian Healthcare HIV/AIDS Roadmap development,Head of Team • Komnas Penelitian & Pengkajian Penyakit Infeksi (PINERE) Litbangkes Kemenkes, Expert Panel • Indonesian MCH-Nutrition Eval Team,Head of Team • Dept of Health Policy & Administration, UI,Past Chairman; Advice & examnine more than 150 PhD dissertations • National Health Research Committee,Expert Panel • Research Committee in Hospital, Expert Panel

  2. PUBLIC HEALTH GOOD GOVERNANCE The role of public health profession adang@post.harvard.edu - 2013  DEFINITION  ANALYSIS  STRATEGIES  MOBILISATION

  3. …the rule of law, predictable administration, legitimate power and responsive regulation …  DEFINITION Kofi Annan, UN Secr Gen

  4. EFFORTS FOR GOOD GOVERNANCE (G-G) • Health Sector Reform: • Sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector (Berman, 1995). • Financing of health • User charges (Jampersal) • Community financing schemes (Dana sehat) • Insurance (Jamkesda, Jamkesmas, SJSN) • Stimulating private sector growth (Hospital Law no 44/2011) • Increase resources to health sector (5% APBN + 10% APBD, BOK, DAK, Dekon, etc)  DEFINIITION

  5. EFFORTS FOR GOOD GOVERNANCE • Health Sector Reform: • Sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector. • Organization and Management • Decentralization (Govt Reg no.38/2008, no.19/2010) • Contracting out of services (PTT) • Public-private mix (TB program)  DEFINIITION

  6. EFFORTS FOR GOOD GOVERNANCE • Health Sector Reform: • Sustained, purposeful change to improve the efficiency, equity and effectiveness of the health sector. • Good Governance / Public Sector Reform • Downsizing public sector (Family Physician) • HRH productivity improvement (MTKI/MTKP; Financial Audit) • Introduction of competition and quality (Hospitals w global standard) • Improving geographic coverage (Priority of DTPK, PTT program) • Increasing of local governments (CCF of local govts) • Targeting role of public sector through packages of essential services (Puskesmas revitalization)  DEFINIITION

  7. G-g FOR SUSTAINABLE DEVT “Good Governance and sustainable development are indivisible… Without good governance – without the rule of law, predictable administration, legitimate power and responsive regulation - no amount of funding, no amount of charity will set us off the path to prosperity” Kofi Annan, UN Secretary General  DEFINIITION

  8. Health politics capacity for PH devt; equity; sustainability Law enforcement; security assurance and peaceful env “Zero Tolerance” Anti Corruption HEALTH STATUS Participation & Empowerment for Health Development G-g for health status attainment  DEFINIITION Modified from: ECA Africa Governance Report, 2004

  9. G-G PRINCIPLES • Principles of Public Sector Governance • Accountability • Transparency • Integrity • Stewardship • Leadership • Efficiency  DEFINIITION

  10. ACCOUNTABILITY • Ability to describe clearly and/or detailed justification of activity plans with clear responsibility of any transaction and decision; its outcomes and further consequencies • Have strategic roles in public services • Ability to explain on budget plan-execution-and monitoring, use and implement the budget plans for and only for public health interventions • The aboves explicitly express public interest, above all individual interest, and abide to rules Modified fr: www.records.nsw.gov.au  DEFINIITION

  11. ACCOUNTABILITY LEVELING • Individual • PH officers commitment; responsibility; and high professional skills and competencies • Organizational • Each unit has objectively measurable otputs related to PH goals • Community at large • Assuring PH professional conduct in front of public  DEFINIITION

  12. TRANSPARAnCY • Systematically develop public health information system for each individual to be able to make decision for own’s health  DEFINIITION

  13. INTEGRITY  DEFINIITION

  14. STEWARDSHIP & PUBLIC HEALTH LEADERSHIP • The indicators are • Ability for strategic thinking • Establish productive working conditions • Softskills-softskills-softskills (integrity) • Output oriented  DEFINIITION

  15. Part-2:THE ANALYSIS

  16. Public Health Problemsin Indonesia

  17. 1-Healthcare services • 2-Health Sector Program & Policies • 3-Other Sectors Development

  18. PH SERVICES: Limited accesibility

  19. 1.Weighing pregnant woman 2.Fundus uteri height 3.Blood pressure meas. 4.Iron tablets 5.Tibia sign for pre-eclampsia DECREASING QUALITY OF MIDWIVES

  20. 120.0 100.0 80.0 60.0 40.0 Kuintil-1-2 Kuintil-3-4 20.0 Kuintil-5 0.0 0 1 2 3 4 5 6 7 8 9 10 11 Age of baby (in month) Low Exclusive Breastfeeding Catatan: SDKI 2007, 6-7 bulan  7,2%; 4-5 bulan  17,8%

  21. Health centres limited accessibility, availability, effectivity Barrier to access for poor people Health technology assmt & use(-) Inadequate drug supplies and logistics Substandard health care quality Inadequate HC need assessment Limited monev & superv Low ability in budget advocacy Inadequate healthcare quality climate Difficulties in HRH placement Low Financial accountability system Bachtiar, 2008

  22. Using Baldrige Framework: • Low healthcare performance, related to: • Low healthcare leadership at healthcentre • Limited HRH capacitation and management • Ineffective health information system at health centre • Limited community empowerment Bachtiar et al, MCH & Nutr Midterm Ev , 2012

  23. Problems #2:Health Programming & Policies

  24. Primary health care is neglected (2010 Health Facility Survey) • No maintenance for health devices and appliances • Limited procedures for clinical pathway/governance • Limited local government’s budget for operational and maintenance • Difficult HRH recruitment and placement

  25. Chronic problems in drugs’ accessibility and availability • Inadequate Health information System, i.e. non-existence Knowledge Mgmt System • Data collection abilities • Data analysis capacity • Information uses for decision making • Information uses for capacity development • Mostly it’s related to limited financing health system

  26. LOW PRIORITY TO HRH DEVT • HRH contributes at leat 80% for the success of PH efforts • Anand S, Bärnighausen T. Health workers and vaccination coverage in developing countries: an econometric analysis. The Lancet, 2007, 369: 1277–1285. • Speybroeck N et al. Reassessing the relationship between human resources for health, intervention coverage and health outcomes. Background paper prepared for The world health report 2006. Geneva, World Health Organization, 2006 (http://www.who.int/hrh/documents/reassessing_relationship.pdf). • Weaknesses: • HRH production system (Relevancy-Quality-Effectivity) • HRH planning capacity • Recruitment and deployment • Performance monitoring and development • Incentive and career mobility • HRH information system

  27. INDONESIA – COUNTRY WITH HRH CRISIS

  28. LOW QUALITY WORK Low correlation b/w Immuniz & Measle Prev Riskesdas, 2007

  29. Poor/rich district GPs Mostly in Cities Doctors tend to open private practices in (big) cities, even in a (very) high competition. It is assumed relate to incomprehensive ability Poor people Proportion MDs in district area (log)

  30. Concentrated in Java-Bali MD Nurse Public Health Nutritionist 10.333 47.317 11.771 4.058 2.726 6.480 17.537 1.511 722 1821 516 2.987 4.922 1.033 837 284 20.443 113.024 7.481 2.403 943 3.843 693 181

  31. hrh to ph index District City PHP Index No. Doctors at Health Center

  32. PHC SUSTAINABILITY

  33. Gani, 2011

  34. In Conclusion:Non-Pyramidical “Energy” for Health Personal HC PH efforts

  35. Problems #3:LOCAL GOVERNMENT

  36. Limited understandingof Human Development Index Approach, i.e. MDG targets • Poverty as health risk (vice versa), limitly understood • Non synchronize sectors development to support HDI/MDG goals • Inappropriate, inadequate and delayed budget transaction implementation • Fragmented funding sources for health development • Limited budget accountability • Low priority HRH mgmt at local governments

  37. WTP=Clean w/o restriciton WDP=Clean, but with some notes/restriction Disclaimer=Couldn’t declare accountability Adverse=Non accountable

  38. R&D and clinical trials Corruption chain in drugs availability Patent Manufacturing Overstated results Research priority Registration Collusion Bribery Pricing Fraud Selection Falsify bills Med Cartel Procurement & import Research falsification Substandard med Distribution Promotion Conflict of interest Unethical donation Inspection Unethical promotion Regulatory breech Stealing Decision pressures Tax fraud WHO, 2007

  39. CORRUPTION COUNTRY

  40. STEWARDSHIP & LEADERSHIP ??INILAH Elite Bangsa Indonesia.. • Persoalan bangsa tidak berhasil dituntaskan secara substansial bahkan bertendensi hanya memindahkan persoalan • Melemahkan sendi-sendi berbangsa • Akan tenggelam dalam krisis dimensi lebih luas, kompleks dan dalam • Salah satu penyebabnya adalah: • Para pemimpinnya telah mati rasa.. • Tidak konsisten antara ucapan dan perilaku • Kalahnya keluhuran budi • Kerdilnya semangat kebangsaan • Interaksi transaksional yang paling rakus Ahmad Syafii Ma’arif, 2010

  41. IMPACT TO PH ACHIEVEMENTS • Health outcomes: • Life expectancy at birth :67 • IMR :31 • MMR :240 • Health Inputs: • Govt health expenditure : 6.2% • Hospital beds (per 10,000) : 6 • # Doctor (per 10,000) :1.3 • # nurses & midwives (per 10,000) :8.2  ANALISIS

  42. MDG Progress (Peter Warr-ANU, 2010)

  43. CONCLUSION: Inefficient Health System Neglected PHC priorities Misdirected & Overheated Personal Care Overloaded hospital care, anger and critics Soc Det of Health esp. Poverty Low capacity for PHC devt Unhealthy life styles Educate for curative only Budget orientationfor curative Non-vitalized PHC infrastructures Limited budget for PHC Limited synergy of Acad-Buss-Govt for Comm Empowerment Limited ability for healthy life style regulations Failure in gatekeeping PHC system Low understanding of community empowerment PHC considered not for profit only Low ability in health politics Low non standardized health profession’s competencies Modif: Bachtiar, 2011. WHO Meeting for CHW at Srilanka

  44. PROFESSIONAL RESPONSIBILITY Part-3  STRATEGIES

  45. FrAMEWORK-1: ZERO TOLERANCE TO CORRUPTION Designing PH progr Asesmen Risiko. Ulasan mutu Kendali internal Effective saction Penundaan & pembatalan. Kepatuhan thd ethical conduct. Merit based performance Visi: Zero-Tolerance PH capacitation Komitmen Pemr. Staf mumpuni S.o.p kerja, Kapasitas audit Klausul perjanjian Rules & regulations Kebijakan Korupsi Klausul2 & perjanjian Supervision system Verifikasi on-site, Expert support Siklus PDCA Ulasan target periodik • Proactive prevention • Pemberdayaan masy sipil utk akuntabilitas & transparansi, • Kapasitasi internal, Kontrak terbuka

  46. COMPREHENSIVE EFFORTS

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