Health Development Plan Towards Healthy Indonesia 2010

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HEALTH DEVELOPMENT PLAN

TOWARDS

HEALTHY INDONESIA 2010

1999

Ministry of Health

Republic of Indonesia.

By the blessing of The Only God

I proclaim

the Development Movement with Health Concerns

as the National Development Strategy in order to materialize

HEALTHY INDONESIA 2010.

JAKARTA, 1ST MARCH 1999

PRESIDENT OF THE REPUBLIC OF INDONESIA

BACHARUDDIN JUSUF HABIBIE

On the 1st of March 1999, President of the Republic of Indonesia,

Bacharuddin Jusuf Habibie, proclaims the Development Movement with Health Concerns as the National Development Strategy

in order to materialize HEALTHY INDONESIA 2010.

Healthy Indonesia 2010 is not belonged to Ministry of Health, Healthy Indonesia 2010 is belonged to all the people of Indonesia. Hence a harmonious, effective and efficient cooperation is required in its realization implementation.

With the completion of this Health Development Plan towards Healthy Indonesia 2010, we confer appreciation and thanks to all sides for their attention and helps so far.

This plan is compiled after receiving input from various departments, universities, experts, professional organizations, NGOs and international agencies. Even though all related aspects and factors have been attended in this document, none the less there are still shortcomings. Hence this document still requires revision.

Healthy Indonesia 2010 can only be achieved through the spirit, dedication and hard work from all of us. Without that, Healthy Indonesia 2010 would be just an empty slogan with no meaning. With high dedication, spirit and hard work from all of us, Insya Allah (God willing) civil society that we all wish for, i.e. a social order that is healthy physically, mentally as well as socially, the modern society that is civilized, faithful, devout, can be achieved by us.

May the Only God always give His guide and confer strength to all of us in implementing the health development. Amen.

Jakarta, October 1999

Minister of Health of the Rep. of Indonesia

Prof. Dr. F.A. Moeloek

TABLE OF CONTENTS

Preface

Analysis of Situation and Trends

Principles, Vision and Mission of Health Development

Programs of Health Development

Requirements for Health Resources

Organization and Motivation in Implementation

Preface

The national aims of the nation Indonesia as stated in the Preamble of the 1945 Constitution is to protect all the nation of Indonesia and all the territory of Indonesia and to promote public welfare, to develop the intellectual life of the nation, and to participate in implementing the world order based on independence, eternal peace and social justice.

In order to achieve the national aims, a planned, comprehensive, integrated, directed and continuous national development is conducted. The aim of the national development is to achieve a just and prosperous society with evenly distributed materials and spirituality based on Pancasila and the 1945 Constitution which is contained in the Unitary State of the Rep. of Indonesia which is independent, sovereign, unitary, and having people’s sovereignty within the nation’s living situation that is safe, peaceful, in order and dynamic as well as within the world’s social environment that is independent, friendly, in order and peaceful.

To achieve the national development’s aims requires among other things human resource of integrity, autonomous and qualified. The data from UNDP of year 1997 states that the human development index in Indonesia is still at the 106 rank out of 176 countries. The level of education, income and health of Indonesian people is indeed still unsatisfactory.

Recognizing the achievement of the national development’s aims is the will of all the people of Indonesia, and in order to face the even tighter free competition in the global era, efforts to increase human resource quality must be implemented. In this case the roles of health development’s success is very decisive. The healthy people will not only support the success if the education program, but also push the increase in productivity and income of the people.

To accelerate the success of health development requires health development policies that are more dynamic and proactive by involving all the related sectors, the government, the private, and the society. The success of health development is not only decided by the performance of health sector alone, but also very much influenced by dynamic interaction of various sectors. Attempts to make the national development with health concerns as one of the new missions and strategies must be able to become the commitment of all sides, beside shifting the old health development’s paradigm into the Health Paradigm.

The compilation of health development plan towards Healthy Indonesia 2010 is a concrete manifestation of the will to execute the national development with health concerns and the health paradigm.

Analysis of the Situation and Trends

The existing health development programs so far being implemented has succeeded in increasing health level of the people significantly, though there are still various problems and obstacles that will influence health development implementation. To identify the problems and obstacles requires analysis of the situation and trends in the future. Below are described the development, problems, opportunities, threats and strategic issues of health development Indonesia is facing these days.

1. DEVELOPMENT

1. Health Level

Up to now the infant mortality rate (IMR) has been lowered with a lowering rate of on average 4.1% per annum. While in 1967 the IMR in Indonesia was still ranging 145 per 1000 live births, in 1991 IMR was already 51 per 1000 live births (Supas 1995) (see tables 1 and 4). The under-five-years death rate (UFDR) (0-4 years) has also been lowered significantly. In 1986 it was still 111 per 1000 live births, in 1993 it was lowered to become 81 per 1000 live births. None the less, the differences of IMR and UFDR between provinces still vary wide. Mean while the MMR has also lowered from 540 per 100.000 live births in 1986 to become 390 per 100.000 live births in 1994 (table 3). In line with this development, life expectancy at birth has also been increased from average 45.7 years in 1967 to become 64.4 years in 1991 (Supas 1995) (see table 2).

The prevalence of moderate and severe Protein Energy Malnutrition (PEM) among the under 5 years children has dropped from 18.9% in 1978 to 14.6% in 1995 (Susenas 1995). The total prevalence of (mild, moderate and severe) PEM has dropped from 48.2% in 1978 to 35.0% in 1995 (see table 6). So are the other nutritional problems, such as blindness due to vitamin A deficiency, iron deficiency anemia, and iodine deficiency, have shown decrements. The result of xerophthalmia survey done in 1992 concluded that blindness due to vitamin A deficiency was not a community health problem any more. SKRT (Household Health Survey) discloses the prevalence of pregnant women suffering from iron deficiency has dropped from 63.5% in 1992 to 50.5% in 1995. Among the pre-school age group, it dropped from 55.5% to 40.5%. Prevalence of problems due to iodine deficiency (GAKY) has also shown a declining figure. The total goiter rate (TGR) was 37.2% in 1982 and declined to 27.7% in 1990.

Indonesia has been declared as free from variola by WHO in 1974. Beside that, several other contagious diseases have been decreased in their morbidities, e.g. framboesia, leprosy, poliomyelitis, neonatal tetanus and schistosomiasis. While in 1995 there were still 4 cases of poliomyelitis confirmed laboratorically, in 1997 there was no positive cases confirmed laboratorically. Neonatal tetanus has been decreased from 3.77 per 10.000 live births in 1990 to become 1.56 per 10.000 live births in 1995. Schistosomiasis in endemic areas has decreased from 3.48% to become 1.64%. Several contagious diseases being observed were showing increasing trends of morbidity, such as malaria, DHF and HIV/AIDS. Annual parasite incidence (API) of malaria decreased from 0.21 per 1000 residents in 1989 to become 0.09 per 1000 residents in 1996 in Java-Bali, then increased again to 0.20 per 1000 in 1998. Parasite rate (PR) of malaria outside Java-Bali which was formerly 3.97% in 1995 increased to 4.78% in 1997. Incidence rate of DHF which was noted as 23.22 per 100.000 residents in 1996 increased to 35.19 per 100.000 residents in 1998. Lung TB is still an illness requiring attention as though its prevalence has been decreased from 2.9 per 1000 residents in the period 1979-82 to become ca 2.4 per 1000 residents at the end of Pelita VI, though it has not been evenly distributed among all the provinces. In certain regions as West Java, Aceh, and Bali, the prevalences of lung TB were still ranging between 6.5-9.6 per 1000 residents.

At the end of 1999 there were 23 provinces already reporting the existence of HIV, where 14 of them reporting of AIDS. National prevalence of AIDS in Indonesia is 0.11 per 100.000 residents with prominent disparities between provinces. In Jakarta the prevalence of AIDS is 10 folds higher than the national, i.e. as high as 1,0 per 100.000 people. In Irian Jaya the prevalence of AIDS is 40 folds higher than national figure, i.e. 4,4 per 100.000 people.

Degenerative diseases and non-contagious diseases also show rising trend. The results Household Health Survey of 1995 show that 83 per 1.000 people suffering from hypertension, and ischemic heart disease and stroke are suffered by 3 and 2 per 1.000 people respectively. Emotional mental disturbances among people aged 5-14 years old and above 15 years old are respectively 104 and 140 per 1.000 people. Blindness is also rising significantly from 1,2 percent in 1982 to become 1,47 percent in 1995. Traffic accident in Indonesia in 1994 reaches 34.407 victims, it rises to 49,098 victims by 1997. Mortality due to traffic accident rises from 3,2 per 100.000 people in 1994 to become 4,1 per 100.000 people in 1997 (see table 8).

1. Facilities

Health development that have been implemented during the last 30 years has succeeded in preparing health service facilities and infrastructures evenly throughout Indonesia. At the present time to fulfill basic health service there are 7.243 puskesmas available where 1.676 of them have been up graded to become caring-puskesmas that have in-patient beds, 21.115 helper puskesmas and 6.849 mobile puskesmas. Hence there are at least one puskesmas in each sub-district in Indonesia, and more than 40 percents villages have been served by government’s health service facilities. The ratio of puskesmas to population is recorded to be 1:27.600 and helper puskesmas to population is 1:9.400.

Beside that, there are also available special Treatment Clinics (Balai Pengobatan) owned by the government, consisting of 21 units Treatment Clinics for Lung Diseases (BP4), 7 Public Eye Health Clinics (BKMM) and 1 Public Sports Health Clinic.

Beside that there are also various basic health service facilities owned by government’s sectors outside the health sector, such as the correctional institution, state owned enterprises (BUMN of the plantation, mining dept.) and so on.

In the private sector, basic health services are arranged in the form of general practitioners, practicing midwives, private clinics and delivery clinics. The society and private in the remote areas need much basic health services.

To expand the coverage and reach of puskesmas services various facilities of health efforts with community’s resources have been developed. Now it has been recorded 243.783 units of posyandu with active cadets total 1.078.208 persons, 20.880 Polindes (Village Delivery Hut), 15.828 POD (Village Medicine Post) and 1.853 Pos UKK (Occupational Health Efforts Post).

The even distribution of basic health service facilities is also followed by the increase in referral health service facilities. At the present there are 4 units of A Class General Hospital, 54 units of B Class General Hospital, 213 units of C Class General Hospital, 71 units of D Class General Hospital, 335 units Private General Hospital, 77 units of Government’s Special Hospital, and 139 units of Private Special Hospital. Total beds are reaching 120.000 units, so the ratio to residents is 1:1.700. The rate of utilization and the capability of services of hospitals are increasing from year to year (see table 9).

In order to support the basic and referral health services have been developed 27 Health Laboratory Offices (BLK), 27 Food and Drugs Supervision Offices (BPOM) and 10 Environmental Health Technique Offices (BTKL). Private laboratory services have also improved very fast. At present there are registered 599 units private clinical laboratories distributed among 27 provinces.

For the purpose of assuring the smoothness in medicines distribution in governmental sectors especially for the puskesmas there have been built 314 units of district/ municipal pharmaceutical warehouses (GFK). While in the private sector there have been operational 5.724 units of dispensaries throughout Indonesia.

1. Health Manpowers

The number and distribution of health manpower have improved significantly enough so that now there are registered about 32 thousands or so of medical manpower (physician, specialist, and dentist) and 7 thousands or so of dentists, including specialists, and 6 thousands or so of pharmacists distributed throughout Indonesia. The number and distribution of nurses and midwives are also improving very fast. There are registered about 160 thousands or so of nurses with various levels of education. While the number of midwives is registered 65 thousands persons or so including 52.042 persons in the villages. Hence it means that nearly all villages in Indonesia have midwives already.

In order to support the development with health paradigm there have also been manpower in the field of public health. At present there are registered about 11 thousands or so of public health manpower with various expertise including among them in the nutritional field about 1.500 persons, and in environmental health about 4 thousands so persons.

The total number of health manpower working in the Ministry of Health and regional government throughout Indonesia in 1998 is registered about 400 thousands so persons, where 302.947 persons out of them are central health personnel. While the rest about 90.000 persons more are staffs of regional government.

1. Health Inventories

At present there are 224 units pharmaceutical industries consisting of 4 BUMN (state owned enterprises), 35 PMA (foreign investments), and 185 domestic private ones. Since the enforcement of CPOB (good medicine manufacturing practices) in 1996, there are 162 pharmaceutical industries that have had the capability to manufacture medicines according to CPOB.

Since early 1997 Indonesia has been able to produce generic drugs which are conducted by 4 BUMN and 60 private owned pharmaceutical plants. The generic drugs have been more and more accepted by the society.

In the attempt to cure and improve health a portion of the society use Indonesian indigenous medicines. Indonesia has the largest biologic varieties in the world with about 30.000 types of plants. About 940 of them have been known to possess medicinal effects and about 180 of them have been used in the native medicinal recipes by Indonesian indigenous medicinal industries.

In 1992 the number of Indonesian indigenous medicinal industries was 449 units consisting of 429 units of small scale traditional medicine industries (IKOT) and 20 units of traditional medicine industries (IOT). In 1998 the number of Indonesian indigenous medicinal industries has increased into 678 consisting of 602 units IKOT and 76 IOT. Unincluded in the above records are manually mixed ‘jamu’ (Indonesian indigenous herbs) businesses and ‘jamu’ vendors (see table 11).

The needs for vaccines in order to prevent diseases, among others the BCG, hepatitis, polio, measles, DPT and tetanus toxoid have been fulfilled from domestic production. Some of the health inventories such as health instruments have been manufactured locally, while those using high technologies are still being imported.

1. Health Financing

In the last 30 years the government’s commitment for health financing has increased. While the health budget in 1987/1988 was 2,32% of total government’s spending, then in 1997/1998 the health budget was 4,55% of total government’s spending.

The funding from private sector primarily the society’s spending is the largest portion of the health funding. The contribution of private sector and society in funding health is about 65 percents.

The majority of the society pay for their health still using the ‘fee for service’ model. Only 14 percents of the society are covered in the health insurance programs. The Public Health Maintenance Assurance Program (JPKM) which has been developed in all districts/ municipalities is hoped to be able to rationalize funding from the public as a base for achieving equality and improving health service quality. The details of JPKM development result coverage up to the end of 1999 are as the following: (1) civil servant’s health maintenance and pension revenue of 17,2 millions members, (2) maintenance for employees and families of 1,6 millions members, (3) private health maintenance of 600.000 members and (4) health funds of 22 millions members distributed in about 15.000 villages. Besides, up to recently there are 19 executing bodies (Bapel) of JPKM having license, and in the context of implementing the Social Safety Net program in Health Sector there are 326 JPKM executors which are distributed in all districts/ municipalities.

So far the health development has been built not only upon self strength, but it is also supported by foreign helps either in the form of off shore loans or grants. To some extent due to the economic crisis the foreign helps component in the health budget has shown rising tendency.

1. Policies

The health development which had been done in nearly the last 40 years has undergone enormous changes and improvements in policies. In Pelita I the policies were more emphasized on consolidation. The service functions were directed more towards integration and comprehensively being focused more on the governmental sectors. In the years 1980s the service model started to shift towards the private sector. In Pelita II the policies were prioritized on equity such as through Inpres (presidential instruction) on health facilities and manpower. During Pelita III and IV, beside equality, attention is also given to health service quality improvement. The matter is reflected among others on the change in puskesmas function to become caring puskesmas. Next, during Pelita V a policy has been determined to put midwives in the villages.