TANTANGAN PENGEMBANGAN TENAGA KESEHATAN DI INDONESIA

Sutopo Patria Jati FKM UNDIP

Siapa tenaga kesehatan ?

Tenaga kesehatan adalah setiap orang yang mengabdikan diri dalam bidang kesehatan serta memiliki pengetahuan dan/atau keterampilan melalui pendidikan di bidang kesehatan yang untuk jenis tertentu memerlukan kewenangan untuk melakukan upaya kesehatan. (UU No 36 2009 ttg Kesehatan == > digunakan juga utk Draft RUU Tenaga Kesehatan 2011)

Evaluasi tentang Nakes

Terbatasnya tenaga kesehatan dan distribusi tidak merata. Indonesia mengalami kekurangan pada hampir semua jenis tenaga kesehatan yang diperlukan. Pada tahun 2001, diperkirakan per 100.000 penduduk baru dapat dilayani oleh 7,7 dokter umum, 2,7 dokter gigi, 3,0 dokter spesialis, dan 8,0 bidan. Untuk tenaga kesehatan masyarakat, per 100.000 penduduk baru dilayani oleh 0,5 Sarjana Kesehatan Masyarakat, 1,7 apoteker, 6,6 ahli gizi, 0,1 tenaga epidemiologi dan 4,7 tenaga sanitasi (sanitarian). Banyak puskesmas belum memiliki dokter dan tenaga kesehatan masyarakat. Keterbatasan ini diperburuk oleh distribusi tenaga kesehatan yang tidak merata. Misalnya, lebih dari dua per tiga dokter spesialis berada di Jawa dan Bali. Disparitas rasio dokter umum per 100.000 penduduk antar wilayah juga masih tinggi dan berkisar dari 2,3 di Lampung hingga 28,0 di DI Yogyakarta. (Depkes, 2008)

 (i) there is a shortage and inequitable distribution of medical doctors and specialists; (ii) the education of health professionals is of poor quality and the accreditation and certification system is weak; (iii) health workforce policy development and planning are not based on evidence or demand, but rather on standard norms that do not reflect real need or take into account the contribution of the private health sector; nor have they adapted to a decentralized paradigm, and finally; (iv) the growing and changing demand for health care due to demographic and epidemiological changes will increase the burden on the already ineffective heal (WB, 2009)

PROYEKSI KEBUTUHAN NAKES ?

PROYEKSI KEBUTUHAN NAKES ?

FAKTOR PENYULIT DALAM PENGELOLAAN NAKES

TRANSISI DEMOGRAFI DAN EPIDEMIOLOGI YG MENGUBAH DEMAND DARI YANKES; PENINGKATAN DEMAND TERJADI PADA KELOMPOK USILA YG SEMAKIN BANYAK; SERTA DEMAND UTK PELAYANAN YG LEBIH MODERN & LENGKAP KHUSUSNYA RANAP. POLA PERENCANAAN NAKES DI INDONESIA SUDAH SANGAT LAMA MENGGUNAKAN MODEL RASIO DIBANDINGKAN MODEL DEMAND DAN NEED .

Indonesia s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.

75+ 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 -15,000 -10,000 -5,000 0 5,000 10,000 15,000 -15,000 -10,000 -5,000

75+ 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 0 5,000

Males Females

10,000

15,000

Population in Thousands 2000 Source: BPS 2005.

Population In Thousands 2025 10

Utara-Selatan (Biosecurity/Ideoscape) Peny berbasis perilaku: Napza-HIV & Kes Jiwa (Socioscape) Industrialisasi & efek GRK (Technoscape)

Communicated dis. (Mediascape)

The Bottom Billions (Pemiskinan/ Finanscape)

Disaster (Environscape)

Mobilisasi & Pandemi (Ethnoscape)

KOMPETENSI SPESIFIK, JUGA KOMPREHENSIF:

HDI

Sumber: FA Moeloek, 2010

Figure 1

Source: The Lancet 2011; 378:1139-1165 (D p

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis
Rafael Lozano, MD, Haidong Wang, PhD, Kyle J Foreman, MPH, Julie Knoll Rajaratnam, PhD, Mohsen Naghavi, MD, Jake R Marcus, MPH, Laura Dwyer-Lindgren, BA, Katherine T Lofgren, BA, David Phillips, BS, Charles Atkinson, BS, Alan D Lopez, PhD and Christopher JL Murray, MD

Figure 4

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8) Terms and Conditions

Figure 5

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8) Terms and Conditions

Figure 6

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8) Terms and Conditions

Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.

With subsidies declining again (in 2009) there might be increased space for the health sector
7%

6%

5%
Subsidies

4%
% of GDP

3%
Interest payments

2%
Education Infrastructure National Defense Govt Apparatus Agriculture Health

1%

0% 1994 1996 1998 2000 2002 2004 2006 2008*

World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

17

There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.

World Bank. 2008. Investing in Indonesias Health: Health Expenditure Review 2008. 18

# Health center 1,000 1,200 200 400 600 800

0
West Papua North Sulawesi Maluku Papua Bali East Kalimantan West Sumatra D I Yogyakarta

Health Center Ratio bed per 10,000 Health center ratio per 100,000

DKI Jakarta Gorontalo North Maluku Nanggroe Aceh Darussalam South Sulawesi South Kalimantan Central Sulawesi Central Kalimantan East Nusa Tenggara Bengkulu West Kalimantan Bangka Belitung Island Jambi Central Java North Sumatra South East Sulawesi South Sumatra Riau East Java West Nusa Tenggara Lampung West Java Banten Indonesia

4 Ratio

10

TANTANGAN PENINGKATAN ASPEK KUANTITAS (PENYEBARAN NAKES)

The ratio of physicians to population also masks significant inequities among urban and rural areas.

Source: KKI 2008.

20

Distribution of Physicians in Indonesia, 1996-2006

Table 3-1: Distribution of Physicians in Indonesia, 1996-2006 Per 100K Residents 1996 2006 National 15.65 18.36 Urban 40.24 36.18 Rural 5.39 5.96 Java & Bali Urban Rural Sumatera Urban Rural Other Provinces Urban Rural Source: PODES 1996 and 2006. 16.18 38.97 4.37 14.62 41.98 5.85 15.09 44.76 7.59 18.53 34.06 4.49 18.72 41.16 7.63 17.44 40.63 7.66

% change 17.4 -10.1 10.6 14.5 -12.6 2.8 28.1 -1.9 30.4 15.6 -9.2 0.9

PTT Scheme Helps to Increase Recruitment to Rural Areas

PTT Doctors Recruited and location classification Ordinary 1992-2002 Average per year 2003-2006 Average per year 2006-2007 Average per year 19,549 1,955 3,826 957 995 498 Remote 7,042 704 2,517 629 1,489 745 Very Remote 3,270 327 1,885 471 1,700 850 Total 29,861 2,986 8,228 2,057 4,184 2,092

Source: Ruswendi, D., 2007

even though midwives are almost everywhere and are equally distributed.

Government target is 100 midwives per 100,000 population by 2010.

Note: All types of midwives included. Source: Indonesia Health Profile 2008. 23

Distribution of Midwives in Indonesia, 1996-2006

Table 3-3: Distribution of Midwifes in Indonesia, 1996 & 2006 Per 100K Residents 1996 2006 National 35.22 36.86 Urban 30.26 31.36 Rural 37.29 40.69 Java & Bali Urban Rural Sumatera Urban Rural Other Provinces Urban Rural Source: PODES 1996 & 2006 27.55 23.84 29.47 53.73 46.45 56.06 39.07 43.25 38.02 26.12 25.08 27.06 54.09 48.05 57.07 51.45 42.23 55.34

% change 4.64 3.63 9.12 -5.19 5.21 -8.19 0.67 3.45 1.80 31.67 -2.36 45.55

Facility Staffing of Puskesmas and Pustu, 1997-2007

Table 3-4: Facility Staffing of Puskesmas and Pustu, 1997-2007 National Urban 1997 2007 1997 2007 Puskesmas Number of MDs No MD (%) Number of Midwives Number of Nurses Pustu Number of Midwives Number of Nurses 0.98 1.08 0.81 1.06 1.14 1.21 1.06 1.19 0.84 0.99 0.50 0.86 1.51 3.4 5.85 5.05 1.90 7.0 3.69 6.14 1.63 2.44 4.99 4.88 2.04 6.18 3.78 6.02 Rural 1997 2007

1.29 5.08 7.30 5.34

1.58 8.65 3.51 6.42

Distribution of Physicians Providing Private Health Services

Per 100 k of population 2006 13.71 27.65 4.01 15.44 28.06 4.03 11.91 26.59 4.65 10.31 26.90 3.30

National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other provinces Urban Rural

1996 9.90 26.50 2.98 10.98 25.98 3.21 9.15 28.53 2.95 7.27 26.57 2.40

% change 38.45 4.33 34.65 40.54 7.98 25.43 30.08 -6.79 57.80 41.69 1.26 37.78

Distribution of Midwives providing private health services, 1996-2006

1996 8.57 1.66 11.45 6.97 1.77 9.66 14.24 1.81 18.22 7.33 0.86 8.96 per 100 k of population 2006 20.64 21.07 20.34 20.95 20.58 21.28 27.55 29.15 26.76 12.07 13.56 11.43 % change 140.84 1169.28 77.64 200.57 1062.71 120.29 93.47 1510.50 46.87 64.67 1476.74 27.57

National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other provinces Urban Rural

Midwife availability has increased significantly, however, TBA remains the preferred choice of provider for childbirth.
28

SBA VS Ratio midwife, 2007

120 120

SBA VS Ratio TBA, 2007

% Delivery by health professional 60 80 100

DIY

DKI

% Delivery by health professional 60 80 100

DKI

DIY

CJ EJ WJ

CJ EJ WJ

40

20 40 60 80100 Ratio midwife per 100000 pop

40

200 Ratio TBA per 100000 pop

400600

Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007) Ratio Traditional Birth Attendant (TBA) (PODES, 2008) Note Abbreviation: DKI=DKI Jakarta, W J=W est java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java

World Bank. 2010. Presentation on and then she died.. Indonesia Maternal Health Assessment.

There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.

30

TANTANGAN PENINGKATAN ASPEK KUALITAS PELAYANAN OLEH NAKES ?

Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.
Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers

World Bank. 2010. Presentation on and then she died... Indonesia Maternal Health Assessment.

32

Ob-Gyns provide the most comprehensive services but reach only a limited population.
Antenatal Care Services by Type of Assistance in West Java (DHS 2007)

World Bank. 2010. and then she died... Indonesia Maternal Health Assessment.

33

BAGAIMANA DENGAN TENAGA KESEHATAN MASYARAKAT ?

NO 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

PRODI Ilmu Kesehatan Masyarakat Epidemiologi Ilmu Kesehatan Masyarakat Epidemiologi Ilmu Kesehatan Masyarakat Kesehatan dan Keselamatan Kerja Analis Kesehatan Gizi Kesehatan Lingkungan Epidemiologi Promosi dan Perilaku Kesehatan Kesehatan Ibu dan Anak Analis Lingkungan Hiperkes dan Keselamatan Kerja Analis Kesehatan

JENJANG S-3 S-3 S-2 S-2 S-1 D-IV D-IV D-III D-III D-III D-III D-III D-III D-III D-III

JML 2 1 20 2 143 2 4 6 12 6 40

KODE 13-001 13-002 13-101 13-102 13-201 13-301 13-302 13-401 13-402 13-403 13-404 13-405 13-406 13-407 13-408

Sumber : Data EPSBED Tgl 03 Maret 2010

Modifikasi Penyajian DR.Arsitawati 2010

Jumlah Progam Studi & Mhsw Kesmas

jumlah institusi kesehatan 160 140 120 100 80 60 40 20 0 142 =250-350mhsw/PS 45000 40000 35000 30000 25000 20000 15000 10000 5000 0

jumlah Mahasiswa

38647 20 2457 S1 S2 jenjang pendidikan 2 42 S3

Jumlah Perguruan Tinggi

Jumlah Mahasiswa

Modifikasi dari:ARUM_BAPPENAS_MARET 2010

S1 Region A 3 3 B 10 20 2 2 5 1 40 C 10 9 1 2 12 34 Tdk Ada Data 24 23 5 13 1 66 A 2 2 B 1 1 2

S2 C 2 1 3 6 Tdk Ada Data 7 3 10 A 0 B 1 1

S3 C Tdk Ada Data 1 1 Total

Sumatera Jawa Bali, NTT Kalimantan Sulawesi, Maluku Papua JUMLAH

51 65 4 9 34 2 165

70% S1= Kategori C + Blm terakreditasi 80% S2= Kategori C + Blm terakreditasi
Sumber : Data BAN PT tgl 03 Maret 2010 Modifikasi Penyajian DR.Arsitawati/Staf khusus Wamendiknas 2010

PERKIRAAN KEBUTUHAN SKM

Institusi/ Sarana Pusat Dinkes Provinsi Dinkes Kab/Kota RS Puskesmas Jumlah 69 33 495 1,372 8,548 Kebutuhan per institusi 20 20 20 5 4 Total Kebutuhan 1,380 660 9,900 6,860 34,192 52,992

Modifikasi dari: ARUM_BAPPENAS_MARET 2010

Konsep yang ditawarkan oleh IAKMI Pusat? Pusat?

HARI INI Upaya yg perlu MASA DEPAN
Orgn Profesi menentukan kriteria akreditasi, profesi & sertifikasi OP menetapkan standar profesi dan kode etik nya serta menerapkan dengan segala sangsi

Akreditasi, kualifikasi & sertifikasi belum berkembang Masing-2 unit pelayanan menetapkan peraturan, sop, compliance profesi kesmas berdasarkan kebutuhan setempat Masyarakat & industri kesehatan tidak perduli (ignore) dan tidak terlibat (involve with trust) thd profesi kesmas Misconduct & SKM yg dibiarkan dan ditangani bawah tangan shg tdk memuaskan masy Pengembangan profesi kesmas terutama tanggung jwb pemerintah & masy bukan profesi itu sendiri

OP melaks advokasi & sosialisasi keprofesian dg customernya

Kepercayaan masy thd SKM

OP yang menerima mandat untuk pengemb anggota & profesinya

UNTUK BERUBAH MEMERLUKAN

Implementasi & LessonsLearned Norma Baru Profesi Agenda Perubahan Keprofesian

Sosialisasi Kebijakan & Program

Survei & analisis situasi

Aktivasi Kelompok Penekan Diskursus Politik

Kesadaran Kolektif profesi Modifikasi dari Tarlov, 1999

TERIMA KASIH