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HEALTH SYSTEM

Tunjung Dharmalia, dr, MPH


DEFINITION
Health services include all services dealing with the diagnosis and
treatment of disease, or the promotion, maintenance and restoration of
health. (WHO)
System: A set of things working together as parts of a mechanism or an
interconnecting network; a complex whole (Oxford Dictionary)

“A health system consists of all organizations, people and actions


whose primary intent is to promote, restore or maintain health”
A well-functioning health system working in harmony is built on
having trained and motivated health workers, a well-maintained
infrastructure, and a reliable supply of medicines and technologies,
backed by adequate funding, strong health plans and
evidence-based policies. (WHO)
6 BUILDING BLOCKS OF A HEALTH SYSTEM
1. Good health services are those which deliver effective, safe, quality personal and non-personal
health interventions to those that need them, when and where needed, with minimum waste of
resources.
2. A well performing health workforce is one that works in ways that are responsive, fair, and efficient
to achieve the best health outcomes possible, given available resources and circumstances (i.e there
are sufficient staff, fairly distributed; they are competent, responsive, and productive).
3. A well functioning health information system is one that ensures the production, analysis,
dissemination and use of reliable and timely information on health determinants, health system
performance, and health status.
4. A well functioning health system ensures equitable access to essential medical products, vaccines
and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientifically
sound and cost-effective use.
5. A good financing system raises adequate funds for health, in ways that ensure people can use
needed services, and are protected from financial catastrophe or impoverishment associated with
having to pay for them. It provides incentives for providers and users to be efficient.
6. Leadership and governance involves ensuring strategic policy frameworks exist and are combined
with effective oversight, coalition-building, regulation, attention to system design and accountability.
•Globally, health is a US$3.5 trillion industry, or equal to 8% of the world's GDP
SOME IMPORTANT HEALTH SYSTEM FUNCTIONS
Stewardship
Health Financing
Health Service Provision
Health Workforce
STEWARDSHIP AND REGULATION
The specific role of government at
national, provincial, and district level.
The role can be:
Making policy
It is influenced
Making regulation and imposing by
Monitoring the situation decentralization
policy
Provide supports for the needy
HEALTH FINANCE
Who finance health sector? Government, community (incl. private),
or both?
In 2005 WHO Member States committed to develop their health
financing systems so that all people have access to the services and
not suffer from financial hardship paying for them

Universal Coverage
COUNTRIES WHICH INCREASED GOVERNMENT EXPENDITURE (%)
GDP Per Capita (USD)
Location diff GGE on Health diff
1995 2008 1995 2008
Thailand 2793.79 4042.78 1249.00 47 75.1 28.1
Libyan Arab
Jamahiriya 5283.52 14802.20 9518.68 51.9 75.9 24.0
Lebanon 3357.11 7137.51 3780.41 28.3 49 20.7
Indonesia 1055.51 2245.49 1189.98 35.7 55.3 19.6
Republic of Korea 11467.81 19161.89 7694.08 36.3 54.9 18.6
Bhutan 563.16 1812.32 1249.15 65.1 80.3 15.2
Nepal 203.52 437.87 234.35 26.5 39 12.5
Yemen 272.91 1174.53 901.63 31.5 40.7 9.2
Qatar 15479.08 86435.82 70956.74 62.2 70.1 7.9
Syrian Arab Republic 780.04 2648.82 1868.78 39.7 45.1 5.4
Brunei Darussalam 16049.59 30390.64 14341.04 76.3 81 4.7
Cambodia 302.38 710.21 407.83 18.9 23.1 4.2
Pakistan 495.49 986.64 491.14 25.8 29.7 3.9
Viet Nam 284.13 1047.13 762.99 34.9 38.5 3.6
Mongolia 540.38 1990.59 1450.21 75.9 78.7 2.8
India 382.22 1066.69 684.47 26.2 28 1.8
Papua New Guinea 984.45 1217.97 233.52 79.4 80.1 0.7
Bangladesh 296.20 497.21 201.01 35.2 35.7 0.5
Bahrain 10125.60 28240.48 18114.88 69.6 69.7 0.1
Jordan 1603.68 3905.18 2301.50 62.1 62.2 0.1
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COUNTRIES WHICH DECREASED GOVERNMENT EXPENDITURE (%)
GDP Per Capita (USD)
Location diff GGE on Health diff
1995 2008 1995 2008

United Arab Emirates 17604.89 58272.39 40667.50 79 67.3 -11.7


Oman 6355.28 21648.57 15293.29 83.9 73.2 -10.7
Timor-Leste 387.83 453.32 65.49 89.5 80.2 -9.3
Philippines 1059.38 1843.95 784.56 39.5 32.9 -6.6
Singapore 23915.62 39949.51 16033.88 41.6 35 -6.6
Kuwait 15089.73 54260.08 39170.36 82.6 76.8 -5.8
China 604.23 3413.59 2809.36 51.2 46.7 -4.5
Iran 1540.68 4699.90 3159.21 49.9 45.7 -4.2
Sri Lanka 720.66 2019.99 1299.33 46.6 42.9 -3.7
Malaysia 4313.52 8211.51 3897.99 47.3 44.1 -3.2
Saudi Arabia 7796.67 19200.42 11403.75 67.8 64.9 -2.9
Japan 41967.65 38267.92 -3699.74 83 80.9 -2.1

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ANALYSIS
Government funding percentage Government funding percentage
decreased: increased:
These countries had achieved universal These countries did not have long
coverage history of universal coverage
Governments seek more private Government has political motive for
financing universal coverage.
Members of communities are not Try to cover the poor
satisfied with government service Using massive government revenue to
provision: e.g Malaysia finance universal coverage.
More private hospitals and private May contract private hospitals for more
financing equitable health service
ANALYSIS
More Public Finance
Some Government want the Universal coverage for humanity and political reasons
International pressure for more universalism

More Private Finance


Some members of communities (the affluent ones) demand better health service
Some governments view private financing as the key for reducing government
budget on health
FUNDAMENTAL PROBLEMS TO MOVE CLOSER TO
UNIVERSAL COVERAGE
Availability of resources
Overreliance of direct payments at the time people need care
The inefficient and inequitable use of resources
WHO RECOMENDATIONS
1. Raising sufficient resources for health
 Increase the efficiency of revenue collection
 Reprioritize government budgets
 Innovative financing, i.e sin tax

2. Removing financial risks and barriers to access


 Prepayment methods
 Pooled funds
 Cross-subsidization
Other barriers to accessing health services: transport costs, lost income  refunds, vouchers, conditional
cash transfer

3. Promoting efficiency and eliminating waste


 Good governance
 Focusing on promotion and prevention services
HEALTH SERVICE PROVISION
What kind of services? Primary health care, secondary and
tertiary ones?

Who provides the health service? Government or Private or both?

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POLICY IMPLICATIONS
PUBLIC HOSPITALS/HEALTH PROVIDERS PRIVATE PROVIDERS
PRIMARY HEALTH CARE
Public
Private
SECONDARY & TERTIARY SERVICES
HEALTH WORKFORCE
Who are they?
What are the problems?
INDONESIA IS EXPERIENCING CRITICAL SHORTAGE OF DOCTORS, MIDWIVES
AND NURSES

Sumber: WHR 2006

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HOW MANY ARE REALLY NEEDED?  PERCEPTION OF 32 DISTRICTS*

Need Availability GAP (%)


Doctor 987 593 39,9
Specialist Doctor 64 30 53,1
Dentist 497 294 40,8
Midwife 4565 2951 35,4
Nurse 4492 3295 26,6
Pharmacist 89 47 47,2
Dietician 652 404 38,0
Public Health 415 312 24,8
Sanitarian 737 530 28,1
Public Health 182 82 54,9
Epidemiologist 21 0 100,0
Total 13.793 9.216 33,2

*) Bappenas Study in 2005 24


DOCTOR DISTRIBUTION IN 2003-2004

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SPECIALIST DISTRIBUTION (KKI, 2008)
Province Number % Cumulative People served Ratio

DKI Jakarta 2.890 23,92% 23,92% 8.814.000,00 1 : 3049

Jawa Timur 1.980 16,39% 40,30% 35.843.200,00 1 : 18102

Jawa Barat 1.881 15,57% 55,87% 40.445.400,00 1 : 21502

Jawa Tengah 1.231 10,19% 66,06% 32.119.400,00 1 : 26092

Sumatera Utara 617 5,11% 71,17% 12.760.700,00 1 : 20681

D.I.Jogjakarta 485 4,01% 75,18% 3.343.000,00 1 : 6892

Sulawesi Selatan 434 3,59% 78,77% 8.698.800,00 1 : 20043

Banten 352 2,91% 81,69% 9.836.100,00 1 : 27943

Bali 350 2,90% 84,58% 3.466.800,00 1 : 9905

Sumatera Selatan 216 1,79% 86,37% 6.976.100,00 1 : 32296

Kalimantan Timur 203 1,68% 88,05% 2.960.800,00 1 : 14585

Sulawesi Utara 173 1,43% 89,48% 2.196.700,00 1 : 12697

Sumatera Barat 167 1,38% 90,86% 4.453.700,00 1 : 26668

Propinsi Lainnya 1.104 9,14% 100,00% 52.990.200,00 1 : 47998

12083 100,00% 224.904.900,00 1 : 18613


INSENTIF REGULATION
Permenkes No.132/Menkes/Per/IV/2006
tanggal 21 April 2006:
insentif bagi dokter spesialis, dokter/dokter gigi,
bidan PTT yang bekerja di daerah sangat
terpencil di seluruh Indonesia