Healt Development Plan Indonesia 2010

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HEALTH DEVELOPMENT PLAN

TOWARDS

HEALTHY INDONESIA 2010

1999

Ministry of HealthRepublic of Indonesia.


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BY THE BLESSING OF THE ONLY GODI PROCLAIM

THE DEVELOPMENT MOVEMENT WITH HEALTH CONCERNSas the National Development Strategy in order to materialize

HEALTHY INDONESIA 2010.

JAKARTA, 1ST MARCH 1999PRESIDENT 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 Indonesia2010 is belonged to all the people of Indonesia. Hence a harmonious, effective andefficient cooperation is required in its realization implementation.

With the completion of this Health Development Plan towards Healthy Indonesia2010, 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 allrelated 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 andhard 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, InsyaAllah (God willing) civil society that we all wish for, i.e. a social order that is healthyphysically, 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 inimplementing the health development. Amen.

Jakarta, October 1999Minister of Health of the Rep. of Indonesia

Prof. Dr. F.A. Moeloek

TABLE OF CONTENTS


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Preface

Analysis of Situation and TrendsDevelopmentProblemsOpportunities

ThreatsStrategic Issues

Principles, Vision and Mission of Health DevelopmentPrinciples of Health DevelopmentVision of Health DevelopmentMission of Health Development

Direction, Objectives, Targets, Regulations and Strategies of HealthDevelopment

Direction of Health DevelopmentObjectives of Health DevelopmentTargets of Health Development

Regulations of Health DevelopmentStrategies of Health Development

Programs of Health DevelopmentPrinciple Programs of Health DevelopmentPrioritized Health Programs

Requirements for Health ResourcesManpower resourceFacility resourceFinancial resource

Organization and Motivation in ImplementationGeneral affairs

OrganizationImplementation motivationIntra and Inter-sectoral Co-operationCultivation

Supervision, Controlling and EvaluationSupervisionModel and Mechanism of SupervisionControlling and EvaluationIndicators of Health Development

ClosureLists of Tables and Appendices

Preface


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

In order to achieve the national aims, a planned, comprehensive, integrated, directed andcontinuous national development is conducted. The aim of the national development is toachieve 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 ofthe Rep. of Indonesia which is independent, sovereign, unitary, and having peoplessovereignty within the nations living situation that is safe, peaceful, in order anddynamic as well as within the worlds social environment that is independent, friendly, inorder and peaceful.

To achieve the national developments aims requires among other things human resource

of integrity, autonomous and qualified. The data from UNDP of year 1997 states that thehuman development index in Indonesia is still at the 106 rank out of 176 countries. Thelevel of education, income and health of Indonesian people is indeed still unsatisfactory.

Recognizing the achievement of the national developments aims is the will of all thepeople of Indonesia, and in order to face the even tighter free competition in the globalera, efforts to increase human resource quality must be implemented. In this case theroles of health developments success is very decisive. The healthy people will not onlysupport the success if the education program, but also push the increase in productivityand income of the people.

To accelerate the success of health development requires health development policies thatare more dynamic and proactive by involving all the related sectors, the government, theprivate, and the society. The success of health development is not only decided by theperformance of health sector alone, but also very much influenced by dynamic interactionof various sectors. Attempts to make the national development with health concerns asone of the new missions and strategies must be able to become the commitment of allsides, beside shifting the old health developments paradigm into the Health Paradigm.

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

Analysis of the Situation and Trends


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The existing health development programs so far being implemented has succeeded inincreasing health level of the people significantly, though there are still various problemsand obstacles that will influence health development implementation. To identify the

problems and obstacles requires analysis of the situation and trends in the future. Beloware described the development, problems, opportunities, threats and strategic issues of

health development Indonesia is facing these days.

A. DEVELOPMENT

1. Health Level

Up to now the infant mortality rate (IMR) has been lowered with a lowering rate of onaverage 4.1% per annum. While in 1967 the IMR in Indonesia was still ranging 145 per1000 live births, in 1991 IMR was already 51 per 1000 live births (Supas 1995) (seetables 1 and 4). The under-five-years death rate (UFDR) (0-4 years) has also beenlowered 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 andUFDR between provinces still vary wide. Mean while the MMR has also lowered from540 per 100.000 live births in 1986 to become 390 per 100.000 live births in 1994 (table3). In line with this development, life expectancy at birth has also been increased fromaverage 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 theunder 5 years children has dropped from 18.9% in 1978 to 14.6% in 1995 (Susenas1995). The total prevalence of (mild, moderate and severe) PEM has dropped from48.2% 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 1992concluded that blindness due to vitamin A deficiency was not a community health problem any more. SKRT (Household Health Survey) discloses the prevalence ofpregnant women suffering from iron deficiency has dropped from 63.5% in 1992 to50.5% 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 decliningfigure. 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, severalother 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 positivecases confirmed laboratorically. Neonatal tetanus has been decreased from 3.77 per10.000 live births in 1990 to become 1.56 per 10.000 live births in 1995. Schistosomiasisin endemic areas has decreased from 3.48% to become 1.64%. Several contagiousdiseases 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, thenincreased again to 0.20 per 1000 in 1998. Parasite rate (PR) of malaria outside Java-Baliwhich was formerly 3.97% in 1995 increased to 4.78% in 1997. Incidence rate of DHFwhich was noted as 23.22 per 100.000 residents in 1996 increased to 35.19 per 100.000residents 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 2.4per 1000 residents at the end of Pelita VI, though it has not been evenly distributed


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among all the provinces. In certain regions as West Java, Aceh, and Bali, the prevalencesof 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, where14 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 prevalenceof AIDS is 10 folds higher than the national, i.e. as high as 1,0 per 100.000 people. InIrian Jaya the prevalence of AIDS is 40 folds higher than national figure, i.e. 4,4 per100.000 people.

Degenerative diseases and non-contagious diseases also show rising trend. The resultsHousehold Health Survey of 1995 show that 83 per 1.000 people suffering fromhypertension, 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 oldand above 15 years old are respectively 104 and 140 per 1.000 people. Blindness is alsorising 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).

2. Facilities

Health development that have been implemented during the last 30 years has succeededin preparing health service facilities and infrastructures evenly throughout Indonesia. Atthe present time to fulfill basic health service there are 7.243 puskesmas available where1.676 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 beenserved by governments health service facilities. The ratio of puskesmas to population isrecorded 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) ownedby the government, consisting of 21 units Treatment Clinics for Lung Diseases (BP4), 7Public Eye Health Clinics (BKMM) and 1 Public Sports Health Clinic.

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

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

To expand the coverage and reach of puskesmas services various facilities of healthefforts with communitys resources have been developed. Now it has been recorded243.783 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 inreferral health service facilities. At the present there are 4 units of A Class General


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Hospital, 54 units of B Class General Hospital, 213 units of C Class General Hospital, 71units of D Class General Hospital, 335 units Private General Hospital, 77 units ofGovernments Special Hospital, and 139 units of Private Special Hospital. Total beds arereaching 120.000 units, so the ratio to residents is 1:1.700. The rate of utilization and thecapability 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 HealthLaboratory Offices (BLK), 27 Food and Drugs Supervision Offices (BPOM) and 10Environmental Health Technique Offices (BTKL). Private laboratory services have alsoimproved very fast. At present there are registered 599 units private clinical laboratoriesdistributed among 27 provinces.

For the purpose of assuring the smoothness in medicines distribution in governmentalsectors especially for the puskesmas there have been built 314 units of district/ municipal

pharmaceutical warehouses (GFK). While in the private sector there have beenoperational 5.724 units of dispensaries throughout Indonesia.

3. Health Manpowers

The number and distribution of health manpower have improved significantly enough sothat 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 6thousands or so of pharmacists distributed throughout Indonesia. The number anddistribution of nurses and midwives are also improving very fast. There are registeredabout 160 thousands or so of nurses with various levels of education. While the numberof midwives is registered 65 thousands persons or so including 52.042 persons in thevillages. 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 manpowerin 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 nutritionalfield 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 regionalgovernment 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 about90.000 persons more are staffs of regional government.

4. Health Inventories

At present there are 224 units pharmaceutical industries consisting of 4 BUMN (stateowned enterprises), 35 PMA (foreign investments), and 185 domestic private ones. Sincethe enforcement of CPOB (good medicine manufacturing practices) in 1996, there are162 pharmaceutical industries that have had the capability to manufacture medicinesaccording to CPOB.

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


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

In 1992 the number of Indonesian indigenous medicinal industries was 449 unitsconsisting of 429 units of small scale traditional medicine industries (IKOT) and 20 unitsof traditional medicine industries (IOT). In 1998 the number of Indonesian indigenousmedicinal industries has increased into 678 consisting of 602 units IKOT and 76 IOT.Unincluded in the above records are manually mixed jamu (Indonesian indigenousherbs) 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.

5. Health Financing

In the last 30 years the governments commitment for health financing has increased.While the health budget in 1987/1988 was 2,32% of total governments spending, then in1997/1998 the health budget was 4,55% of total governments spending.

The funding from private sector primarily the societys spending is the largest portion ofthe health funding. The contribution of private sector and society in funding health isabout 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 PublicHealth Maintenance Assurance Program (JPKM) which has been developed in alldistricts/ 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 JPKMdevelopment result coverage up to the end of 1999 are as the following: (1) civilservants health maintenance and pension revenue of 17,2 millions members, (2)maintenance for employees and families of 1,6 millions members, (3) private healthmaintenance of 600.000 members and (4) health funds of 22 millions membersdistributed 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 SafetyNet program in Health Sector there are 326 JPKM executors which are distributed in alldistricts/ municipalities.

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

6. Policies

The health development which had been done in nearly the last 40 years has undergoneenormous changes and improvements in policies. In Pelita I the policies were more


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emphasized on consolidation. The service functions were directed more towardsintegration and comprehensively being focused more on the governmental sectors. In theyears 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) onhealth facilities and manpower. During Pelita III and IV, beside equality, attention is

also given to health service quality improvement. The matter is reflected among otherson the change in puskesmas function to become caring puskesmas. Next, during Pelita Va policy has been determined to put midwives in the villages.

In terms of hospital services, since Pelita V and specifically in Pelita VI, much attentionhas been put to improve service quality through standardization of services, developmentof accreditation instrument and compilation of indicators of hospital instruments

performance. During this same period decentralization is also implemented, i.e.delegation of a part of functions to the regions, without being followed by changes inresources.

During Pelita V the policy on medicines is directed to the use of generic drugs, where allgovernments health facilities are obliged to use generic drugs.With the issuance of act (UU) number 23 Year 1992 about Health, then a renewal hashappened in the written laws about health development. The act offers a legal base,direction and various national policies for health development which formerly was basedon the National Health System (SKN). Policies that integrate funding system and healthmaintenance system are clearly stated in the act number 23.

In order to protect the society from abuse and misuse of drugs, the act number 5 year1997 about Psychotropics and the act number 22 year 1997 about Narcotics were issued.For the sake of consumer protection, it is also enacted the act number 8 year 1999

concerning the protection against pharmaceutical preparations and foods. One of theaims of the act is to increase the quality of goods and /or services that assure thecontinual production of health goods and/ or services, comfortability, safety and survivalof consumers.

The development of state governance at the present time shows a very strong wave ofdecentralization. The implementation of act number 22/ 1999 on Regional Governmentand the act number 23/ 1999 on Financial Balance between Central and Region willstrongly influence the execution of development including the health development.

Decentralization of health efforts offer authority to the districts and municipalities to self

determine the health developments priority of the respective regions according to localcapabilities, conditions and needs. As a consequence the success in health developmentin the future will depend very much on the capability of the manpower resources in theregions.

The trends which occur in the world nowadays are the increasing roles of the third partyin regulating health funding through the insurance system, either public or private one.This condition will also become more flourished in Indonesia in the future when trades

between countries become more free. Hence the policies to be adopted in healthdevelopment effort through pre-service payment (pre-paid) system will very stronglydecide the direction of health service conferral to the public more evenly and with more

adequate quality.


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B. PROBLEMS

1. Health Level

Morbidities of some contagious diseases being observed which formerly were declining

or undetected, but recently have shown increasing trends, such as malaria, DHF and HIV/AIDS. Besides with the increasing openness of Indonesia toward outside world and theease in transportation, there is a potential for the occurrence of new contagious diseaseswhich hitherto have not existed in Indonesia. On the other hand, the degenerativediseases, non-contagious diseases, and traffic accidents have also shown increasingtrends. The problem of blindness is also rising significantly enough.

The trends in morbidity of contagious diseases, non-contagious diseases, degenerativediseases, injuries due to traffic accidents, and other health problems as well as otherdiseases are problems that will influence the health level of the public in the future, allthat require optimal management steps.

2. Cross-Sectoral Cooperation

Health problems are national problems that can not be disconnected from the variouspolicies of other sectors, hence their solution should involve other sectors as well. Themain issue is how to improve cross-sectoral cooperation more effectively?

The health development so far has not produced optimal results due to the lack of cross-sectoral supports. There are sectoral programs which have not or not enough healthconcerns so that they bring negative impacts to the health of the society. Part of thehealth problems are caused by several factors, primarily the environment and behavior,

related closely to various policies and program implementation in sectors outside thehealth. For the reason, a very nice cross-sectoral approach is required, so that the relatedsectors can always calculate the impacts of their programs toward the public health.

For the same reasons, increase in attempt and management of health services can not beseparated from the roles of other sectors covering funding, regional governance anddevelopment, work force, education, trade, and social and cultural affairs.

3. Health Development Policies

Even though the health development policies have been directed to and prioritized on

basic health services, emphasizing more on preventive and instructional health efforts, but the public perception tends to remain oriented on disease curative and healthrehabilitation. The attempt to increase public awareness to create healthy life style(Healthy Paradigm) is hard to achieve, as it is not supported by the factors of socialeconomic, educational level and public cultures.

The healthy life style that has not been well created as stated above is made even worseby the highly expensive costs spent by patients or their families in order to get cure andrehabilitation at the health service facilities such as the hospitals. Beside that, the loss in

productivity is another burden that should be born by the patients family. In otherwords, such model of services is not only inefficient, but also wasting much costs. While

in the other side, the fund from government is declining.


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Beside that, the Indonesian territory which is geographically very wide with varyingtribes, cultures, religions and various communities, has not been given enoughconsideration in deciding health policies. So far the decision making in healthdevelopment policies is viewed to be strongly centralized with the consequence that partof the programs are not suitable to the regional or local needs and requirements. As a

result the health development being conducted so far is viewed to be not yet fullyeffective and efficient.

4. Health Development Expenditure System

As a result of the strong roles of the central government in deciding policies, the mode ofspending given by the central government is based on budget allocation which has beendecided with its detailed activities. The mode of spending like that plus the inadequatewage system of the civil servants have made it very difficult to produce an appropriateincentive system for budget efficiency. The matter is worsen by the many regulationsmade by the government and applied uniformly, which has abolished the spirit for

competition and obstructed the creation of efficient management model.

Subsidy given by the government for health sector in PJP I (1 st phase of long termdevelopment) is only about 2.5% from Gross Domestic Product (GDP) which is far fromthe minimum standard recommended by WHO i.e. 5% from GDP. In practice therelatively small budget subsidized by the government mostly is given in the form ofsubsidy to the service provider as regular spending (including wages), developmentspending, and operational costs as well as maintenance costs. In other words, the modeof funding practiced so far is not oriented to the needs of the public and is not directlydirected to subsidy the poor people.

The subsidy given by the government is only 30% of the total health costs. While 70%of the health costs are still the responsibility of the public, and it is dominated byindividual cash payment system. As a consequence of the above situation is the difficultyin applying cost control policies and it is also burdening the consumers of health services.In fact the health costs are inclined to increase even more and become unaffordable whenthe mode of payment stated above is still going on.

5. Health Development Implementation

The mode of policy determination and mode of payment already being applied so farhave brought strong influence on the implementation of health development. The quality

of health service which is good and in line with prevailing standards is hard to find,especially for the poor people and those living in remote areas.

Beside that, health development implementation is still not yet supported by theutilization of progresses in applied science and technology. More over, the executors ofhealth development have not fully applied high level of ethics and morale. As aconsequence of that condition is health development implementation in Indonesia has notfully implemented professionally.

6. Quality of Health Facilities

Even though the number and distribution of health facilities have been regarded adequate,but from the aspect of service quality the services are still below standard. Other health


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facilities such as hospitals even have not met the minimum requirement yet. In such asituation, the quality of health services being offered are still far from expectation.

The conducive climate for increased private participation from either domestics or abroadin offering health services has not been created optimally. Bureaucracy in licensing and

regulating which should be followed is in fact like a barrier for private sectorparticipation in health development.

7. Health Manpower

The weakness of health development from the point of view of health manpower isregarding the uneven distribution, yet inadequate educational quality, unbalanced healthmanpower composition due to over dominance of medical manpower and the low

performance and productivity.

Cross-sectoral coordination especially with the Education and Cultural Dept. in terms of

increasing the number of graduates of 4 basic medical specialists badly required bydistrict hospitals in order to improve their service quality is still lacking. Beside that,review and re-structuring of other health manpower educational systems are also needed,either those run by the government or the private.

One of the issues in health manpower development is the manpower utilization, wheretheir uneven distribution becomes a principle problem. Beside that, the careerdevelopment of the manpower becomes a matter that strongly needs to be developed, itcovers manpower of both the public sector and the private sector. All the aforementionedefforts need the support of comprehensive, integrated and effective manpowerinformation system.

8. Health Inventory

The majority of medicinal raw materials for the pharmaceutical industries and the healthinstruments using high technology are still dependent on import hence their prices risedue to depreciation of Rupiah against foreign currencies.

Acceptability towards all levels of the society who need them is striven for through thesupply of medicines in 2 channels i.e. the services channels of the public sector and the

private sector. In the public sector the efficient management of medicines, including thepurchasing and integrated planning at districts and direct medicine distribution at GFK, is

an absolute matter. In this case, the ability to analyze essential drug requirement usingbottom-up planning according to disease pattern is a main matter. Beside that there is amatter of coordination complexity.

Another problem is concerning the maintenance of health inventories, besidestandardization and calibration of instruments being used.C. OPPORTUNITIES

Various opportunities for success of health development in achieving Healthy Indonesia2010 among other things are:

1. Demography


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The number of Indonesian people is still increasing with a decreasing rate. In 1980 theIndonesian population totals 147,49 millions, it increases to 179,38 millions in 1990, and

projected to 210,439 millions in year 2000. Indonesian population in 2010 is projected tobe ca 235 millions. The growth of population is also signaled by the change in age

structure of the population where there is a shift from young population age structure toold population age structure.

The large number of Indonesian population and the productive age structure are potentialmarket and resources for the development of nation-wide health efforts. Beside that,various changes occurring on the demographic characteristics as a result of developmentsuccess such as education and social economic sectors will open the opportunities for theimplementation of health services that are more effective, efficient and qualified.

2. Laws and Politics

Reform in the legal and political sectors as required by the society opens bigopportunities for improvement of system and values in various sectors, including healthsector. This big opportunities can be utilized optimally to produce clean governance withhealth concerns for the interest and prosperity of the people.

The governance system of the Unitary State of the Rep. of Indonesia based on the 1945Constitution gives freedom to the regions to execute governance autonomically. Infacing the domestic as well as international development vis-a-vis the global competitionwhich is in principle a free competition, then the implementation of regional autonomywith wide, real and responsible authorities proportionally is an opportunity which can beused by the regions to prepare themselves as well as possible. With the implementation

of the Act No. 22 year 1999 about Regional Governance and Act No. 25 year 1999 aboutEconomic Balance between Central and Regional Governments, it is also an opportunityfor the regions to implement development including development in health sector, toaccelerate even distribution and justice according to local problems, potentials andvariousity by involving the publics participation.

3. Globalization

Globalization in economic sector with its main core being free global trading givesopportunity for Indonesia to take part in international trading. In the health sector, theopportunity is mainly the chance for health workers to work abroad.

For that efforts to increase quality of the health workers to equal those from the othercountries should be done among other ways through improvement in education system.The entry of foreign capital to Indonesia will expand even more the employmentopportunities for health workers, beside it will help accelerate the transfer of technologiesthat are needed for the improvement of quality and professionalism of health services inIndonesia.

4. Economic Crisis

The economic and credibility crises hitting Indonesia until now is a good opportunity to

do various changes in health sector, including to eliminate various bureaucratic obstaclesin the effort to increase efficiency and partnership in development implementation.


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Difficulty in getting health services due to low purchasing power opens bigger chance fordevelopment and consolidation of JPKM.

5. Natural Resources

Indonesian soils and oceans are very rich in various sources for medicinal materials orsimplicia. Indonesia has the largest biologic varieties in the world with ca 30.000 typesof plants, and part of those plants are sources of natural medicinal materials. This is avery big opportunity to produce medicinal materials as well as completed productsdomestically by ourselves.

6. Progress in Science and Technology

The progress in science and technology in the telecommunication, information andtransportation sectors which are becoming better opens opportunity to accelerate theachievement of equality in health services. While progress in science and technology in

health and medical sector gives opportunity for the improvement of the quality of healthservice efforts which should yet be balanced and harmonized with faith, devotion andethics.

7. Cooperation and Partnership

In the global era there are many changes that have occurred in national, regional, as wellas international levels which bring multidimensional impacts and which possess highintensity of interrelationship between sectors. Hence, cooperation and interconnectionare the main pre-requisite to achieve a new era which is better off based on the new

paradigm based on the win-win principle.

The phenomenon of partnership that is equal, open and mutually beneficial is a goodopportunity especially for the development of private businesses either of national,regional, or international scales for the development of basic and referral health services,

prevention of diseases, and promotion of health.

D. THREATS

1. Macro Economic Situation

The macro economic situation which has not recovered from economic crisis is one of thebiggest and heaviest threats to national development, especially the health developmentas the consequence of the even more limited existing resources. This situation becomesmore severe with the still high level of dependence upon imported goods forimplementation of health services. The macro economic situation recovery is very muchinfluenced by political situation which is not yet stable enough till now. Hence, though atnational level there is already a commitment to give larger allocation for health fundingup to 5% of GDP, but there is still a real threat from the macro economic situation that

the resource may still not yet preparable within 2-3 years time ahead.


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2. Demographic Structure

The great number of population, the relatively still high growth rate, the still low level ofeducation and income, as well as uneven distribution among regions can be a threat todevelopment, including the health development. Beside that the age structure that tends

to be young together with the increasing number of elderly groups become the doubleburdens of development.

3. The Economic Condition of Society

The blow of prolonged economic crisis has also shown increase in the number of poorpeople together with the decline in various health indicators, especially the rise of overtKEP incidence primarily among infants and children. This condition is a threat to theachievement of health developments target as one of the efforts in increasing thenations productivity. The declining economic condition of the society also influencesaccess of the people toward health services, especially for the poor people. Efforts done

through the JPSBK (social safety net in health sector) have indeed increased the access,but in the long run this program is hard to sustain by the available resources.

The various worriness in economic sector that is easy to be triggered into riots and alsoconflicts occurring in various regions in Indonesia which have been unsettled so far

become threats toward health development and at the same time become obstacles toachieve the healthy Indonesia.

4. Geography

The geographic condition of Indonesia that is an archipelagic country with more than

17.000 islands and the very great area of ocean is a threat in the implementation of healthdevelopment. An archipelagic state like this in fact needs transportation andcommunication facilities as well as a high operational cost.

On the other side with the openness of various archipelagoes, Indonesia becomessusceptible to the possible entry of prohibited goods/ drugs illegally. Beside that thegeographic condition that consists of active volcanoes chain that can erupt at no time, andthe frequent earth quakes can bring natural disasters threatening the social life. WhileIndonesian location in the tropical region is an accurate reservoir for the reproduction ofvarious vectors and pathogens.

Indonesia being on the cross-road position between big countries in the world, is in thetransportation line, this potentially can bring negative impacts toward public health withthe possibility of entry of various negative habits toward health and various diseases fromoutside world.

5. The Low Health Behavior, Morale and Ethics

Healthy life style is very much influenced by education level of the people. The lowlevel of education is one of the causes of low understanding of the people regardinghealth information and the formation of healthy behaviors.

Abuses of narcotics, psychotropic drugs and additives tend to rise, in fact it has touchedthe poor people and primary school children with even wider and more complicated


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escalation of the problem. So are the production and utilization of alcoholic beveragesand other addictives including cigarettes inclined to rise steadily with broad negativeimpacts to the public.

Beside that, various deviations in sexual behavior, lack of discipline in traffic

transportation, smoking habit and overt and unbalanced food consumption become threatsto the increment of public health level.

The use of prohibited chemical substances as food additives, sanitary problems as well ashygienic processing especially among household industries are also threats to theconsumer communitys health.

6. Decentralization of Health Management

Decentralization of health management is a political commitment that should beimplemented by the coming national leadership. There are two acts (UU) related to

decentralization have been issued, i.e. act number 22/ 1999 and act number 25/1999.

Experiences in many countries indicate clearly that when decentralization is done in ahurry with inadequate preparation either in concept or in operation, great difficulty willarise in its implementation. In the era of decentralization, the control from centralgovernment on various programs will decline drastically. If this is not supported by theincrease in capability at the provinces and districts/ municipalities then success in healthdevelopment will be strongly in danger.

7. Globalization

Globalization is a phenomenon occurring in the end of the 20th

century that is signaled bythe occurrence of inter-penetration and inter-dependence among all sectors, eithereconomic, political, or social and cultural. This situation causes the occurrence oftransformation of the nation society toward global society so that state boundaries

become unconspicuous any more.

Trades liberalization as the main sign of globalization beside the ease in transportation,communication and information contains great threat for developing countries includingIndonesia. The policies of GATS (General Agreement of Trade in Services) and TRIPS(Agreement on Trade Related Aspects of Intellectual Property Rights) will influence verymuch various aspects of public health services implementation in developing countries.

Entry of foreign capital and work force in the health service area can result in the evenmore rising in quality of health services and management. But negative impacts thatshould be anticipated are the closure of various already existing service facilitiesespecially those so far have given services to the less well to do people. This situationcan only be prevented by intensive attempts to improve professionalism and qualitymanagement in the existing health facilities. Other implications are regarding theintellectual property rights, including patent for various drugs and biomedical products.This situation can impede the usage of various products that otherwise can be used but

being constraint by regulation on intellectual property rights. This matter also bringsimplication for the rise in prices of medicines and various biomedical products andinstruments.


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Ease in transportation, communication, and various information dispersion will alsoinfluence the dispersion of diseases, narcotics, psychotropic drugs and other addictives,free sexual behavior and other unhealthy life styles. This situation has very greatinfluence upon the health level of society, especially the younger generation of thenation.

8. Environmental Pollution and Global Climate

In the future, the climate and environment will be less beneficial to health. Pollution tothe environments, including air, water, soil and food will increase. Air pollution in the

big cities in year 2000 is estimated to rise 2 folds from that of 1990 with its main sourcecoming from the emission of motor vehicles and industrial activities. Air pollution in therooms needs more attention as the still high prevalence of smoking habit in the society.Management of domestic wastes in the urban, either solid or liquid wastes, which has nottaken into consideration its impacts on public health is a threat to people living in theurban areas and their surroundings.

The limitation of clean water supply is a threat to the health of society. The limitation inpublic affordability especially in the rural and urban slum areas is also a serious challengefor the creation of healthy environment.

E. STRATEGIC ISSUES

After studying the various strengths, weaknesses, opportunities and threats as mentionedabove, then the strategic issues that should be dealt with are as follow.

1. Cross-Sectoral Cooperation

A part of the health problems are national problems that are inseparable from variouspolicies of other sectors so that the solution should strategically involve the relatedsectors. The main issue is the improvement in cross-sectoral cooperation, as cross-sectoral cooperation in health development so far has been frequently less success.

The change in societys behavior toward a healthy life and the improvement inenvironmental quality which strongly influences societys health level improvement needclose cooperation between various sectors related to the health sector. So is the increasein effort and management of health services inseparable from sectors governing finance,regional governance and development, work force, education, trading, and social cultural

affairs.

2. Health Sectors Human Resource

The quality of health sectors human resource is strongly determining the success ofhealth efforts and management qualified human resource in health sector must alwaysfollow the progress in science and technology, and strive to master the state of the artscience and technology. Beside that, the quality of the human resource is also determined

by the moral values being adopted and applied in the task execution. It is realized thatthe number of Indonesian human resource in health sector who follows the progress ofscience and technology and apply professional moral and ethical values is still limited.


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The emergence of competition in the free market era as a result of globalization should beanticipated by improving the quality and professionalism of the human resource in healthsector. This is necessary not only to increase the competitive capability of the healthsector, but also to help improve the competitive capability of other sectors as well, amongothers safeguard the export commodities of foodstuffs and finished food products.

In relation to decentralization of the governance execution, an increase in capability andprofessionalism of the health managers in every level of administration is a very urgingneed.

3. Quality and Accessibility of Health Services

Viewed from physical aspect, the distribution of health services facilities either puskesmas or hospitals and other health facilities including health efforts supportingfacilities can be regarded as evenly distributed all over the territory of Indonesia. Nonethe less it should be confessed that the physical distribution has not been fully followed

by increase in quality of services and accessibility by all layers of the society.

The quality of health services is very much influenced by the quality of physicalfacilities, types of work force available, medicines, health instruments and othersupportive facilities, services conferring process, and compensation received and theexpectation of the consumer society. Hence the increase in physical quality andaforementioned factors are preconditions to be fulfilled. Afterwards, the process ofservices conferral is to be increased through increase in quality and professionalism ofhealth resources as stated above. While the expectation of the consumer society is beingadjusted through improvement in general education, health information, goodcommunication between health providers and the public.

4. Prioritization, Funding Resource and Empowerment of the Society

So far health efforts are still lacking in prioritizing the approach of health maintenanceand promotion as well as disease prevention, and they are insufficiently supported byadequate funding resource. It is recognized that financial constraint from the governmentand the public is a big threat for the continuity of governments programs and a threat tothe achievement of optimal health level.

Hence, more intense effort is required to increase funding resources from the publicsector being prioritized for health maintenance and promotion activities as well as for

diseases prevention. Funding resources for curative and rehabilitative activities needmore exploration from resources in the society and directed to become more rational, andmore effective and efficient in order to increase the services quality. Various researchesindicate that most of the direct spending of the public are used not as effective andefficient as a result of unequal information between services providers and servicesreceivers (patients or their families). This situation urges the need for strategic steps increating funding system with prepayment property already known as JPKM.

The availability of limited resources, especially in the public sector requires efforts toincrease participation of the private sector especially in the attempt which are curativeand rehabilitative. The attempts are done through empowerment of the private sector to

become independent, improvement of equal partnership and mutual beneficiality betweenthe public and the private sectors so that available resources can be used optimally.


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Other matters that strongly require settlement are empowerment and independence of thepublic in health efforts that have not been as expected. Equality, openness, and mutuallybeneficial partnership in health efforts become a sine qua none for the civilization attemptof a clean and healthy life style, application of healthy life norms and health promotion.

Principles, Vision and Missionof Health Development

Principles, Vision and Mission of Health Development

The great effort of Indonesia nation in rectifying the national development orientationthat has been done in the last 3 decades requires total reform in development policies inall sectors. For health sector, the call for total reform emerges as there are stilldiscrepancies in health development results among the regions and communities, the

public health level is still left behind compared to neighboring countries, and due to the

lack of autonomy in health development. Beside that, health reform also is neededconsidering there are 5 main phenomena that have great influences toward the success of


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health development. First, basic changes in demographic dynamics that urge the birth ofdemographic and epidemiologic transition. Second, substantial discoveries in medicalscience and technology that open new horizon in looking at living processes, health,illness and death. Third, global challenges as a consequence of free trading policies, andfast revolution in information, telecommunication and transportation sectors. Fourth,

changes in the environment that influence the health level and efforts. Fifth,democratization in all sectors calling for empowerment and partnership in healthdevelopment.

In order to increase the resistance and struggling power of health development as themain asset of national development, re-evaluation of health development policies has

become a must. Changes in the understanding of the concept of health and sick and theincreasing treasure of science and technology with information about determinants ofdisease causation which is multi-factorial have aborted health development paradigmwhich puts priority on curative and rehabilitative health services.

The application of the new health development paradigm i.e. HEALTHY PARADIGM isan attempt to improve the nations health that is proactive. The healthy paradigm is ahealth development model which in the long run can push the society to becomeautonomous in maintaining their own health through heightened awareness on theimportance of health services that are promotive and preventive.

In order to materialize the HEALTHY PARADIGM as the new health developmentparadigm, a thorough review on principles, vision and mission of health developmentneeds to be done as soon as possible. The principles, vision and mission of healthdevelopment should not only be able to settle all 5 challenges of therefore mentionedconventional health development, but also should be able to anticipate various changes in

the future. To materialize HEALTHY INDONESIA in the future, the new principles,vision and mission of health development should be implemented consistently andcontinuously.

Principles of Health Development

The ideal principle of the national development is the Pancasila, while the constitutionalprinciple is the 1945 Constitution. Health development is an integral part of the national

development. On the Act number 23 year 1992 about health it is stipulated that health isthe condition of well being of the body, mind and social life that enables every person tolive productively socially and economically. While on the constitution of WHO year1948 it is agreed among other things that the achievement of the highest level of healthlevel is the fundamental right of every person regardless of his/ her race, religion,

political affiliation and social economic position. The principles of health developmentare basically truth values and basic rules as the foundation for thinking and doing inhealth development. The principles are the foundation for the compilation of vision,mission and strategies as well as principal directors in the implementation of healthdevelopment nation-wide which include:

1. Humanity


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Every health attempt should be based on humanity which is being spirited, moved andcontrolled by faith and devotion to The Only God. The health manpower needs to havenoble character and hold tight the professional ethics.

2. Empowerment and Autonomy

Every person and also the society together with the government have a role, vocation andresponsibility to maintain and improve the health level of each individual, family, societyand his/ her environment. Every health effort should be able to produce and push the

participation of the society. Health development is conducted based on trust and self-capability and strength as well as making the personality of the nation as the pivot point.

3. Justice and Equality

In the health development, each person has the same right in getting the highest healthlevel, regardless of differences in ethnicity, grouping, religion, and social economic

status.

4. Prioritization and Utilization

The implementation of qualified and following up to date science and technologys healthefforts should put priority on health maintenance, promotion, and disease preventionapproaches. Beside that, health efforts should be done professionally, effectively andefficiently by taking into consideration local needs and situation.

The health efforts are directed so that they would give maximal benefit for theimprovement of public health level, and they should be executed with full responsibility

according to the prevailing rules and regulations.

Vision of Health Development

The picture of Indonesian society in the future that is hoped to be achieved through healthdevelopment is the society, nation and state characterized by its people living in a healthyenvironment and with healthy living behaviors, having capability to reach qualifiedhealth services justly and evenly, as well as possessing highest level of health in all theterritory of Indonesia. The picture of Indonesian society in the future or Vision expect to

be reached through the health development is formulated as:

HEALTHY INDONESIA 2010

In the Healthy Indonesia 2010, the expected environment is the conducive one for therealization of healthy condition i.e. environment that is free from pollution, which isequipped with clean water, adequate environmental sanitation, healthy housing andsettlement, zone planning with health concerns, and the realization of social life that ishelping each other by keeping cultural values of the nation.

The expected social behavior of Healthy Indonesia 2010 is the proactive one to maintainand promote health, prevent risks for diseases, protect one from disease threats and active


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participate in healthy society movement. Furthermore, the expected capability of thesociety in the future is able to access qualified health services without obstruction, eithereconomic or non-economic one. The qualified health services referred before are thosesatisfying the users of the services and those being implemented according to standardsand ethics of professional services. Hopefully with the materialization of healthy

environment and living behavior beside the increase in the societys capability as statedabove, the health level of individuals, families and society can be upgraded optimally.

Mission of Health Development

In order to materialize the vision HEALTHY INDONESIA 2010, four missions of healthdevelopment have been determined as follow:

1. Activating national development with health concerns

The success in health development can not be merely decided by hard working of thehealth sector alone, but it is strongly influenced by the results of hard working and

positive contribution from various other developmental sectors. In order to optimize theresults and positive contribution, the acceptance of health concerns as the principalfoundation of national developmental programs should be striven for. In other words, tomaterialize HEALTHY INDONESIA 2010, the persons in charge of developmental

programs should put health considerations into all their developmental policies. Thedevelopmental programs that do not contribute positively to health, not to mention those

being harmful to health, normally should not be implemented. In order to realize thenational development that contributes positively to health as stated before, then allelements of the National Health System should take part as the main activators of thenational development with health concerns.

2. Urging societys autonomy for healthy living

Health is the joint responsibility of all individuals, society, government and private. Theroles played by the government, without awareness of individuals and society to maintaintheir health independently, will only bear little fruit. The healthy behavior and societyscapability to select and acquire qualified health services strongly decide the success ofhealth development. Hence, one of the main health efforts or missions in health sector is

to urge the societys autonomy for healthy living.

3. Maintaining and improving qualified, equal and accessible health services

Maintaining and improving qualified, equal and accessible health services contain themeaning that one of the responsibilities of the health sector is to assure the availability ofqualified, equal and accessible health services to the society. The implementation ofhealth services is not merely in the hands of the government, but it also involvesmaximally the active participation of all members of the society and various private

potentials.

4. Maintaining and improving health of the individuals, families and society as wellas their surroundings


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Maintaining and improving health of the individuals, families and society as well as theirsurroundings contain the meaning that the main task of the health sector is to maintainand improve the health of all citizens, i.e. every individual, family and society ofIndonesia, without leaving behind the attempts to cure diseases and or to recover health.

For the implementation of this task, health efforts implementation should prioritize on promotive and preventive efforts supported by curative and rehabilitative efforts. Tomaintain and improve the health of individuals, families and society, it is also necessaryto create healthy environment, and hence the tasks in environmental sanitation shouldalso be better prioritized.

Direction, Aims, Targets, Policiesand Strategies of Health Development

Direction of Health Development

Direction of health development towards Healthy Indonesia 2010 according to thenational development so far consists of:

1. Health development is an integral part of the national development. The concept ofnational development should have health concerns, i.e. taking into considerationseriously various positive and negative impacts of each activity toward public health.Health development is directed to improve quality of human resources who arehealthy, intelligent and productive, as well as capable of maintaining and improving

public health with high commitment toward humanity and ethics, and it isimplemented with the high spirit of empowerment and partnership. Healthdevelopment is executed with priority given to health promotion and disease

prevention efforts beside the curative and health recovery efforts.


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2. Health services run by either government or society should be implemented withquality, justice and equality by giving special attention to the poor people, children,and deserted elderlies, either living in urban or rural areas. Priority is also given toremote villages, new settlements, frontier zones and recesses inhabited by poorfamilies.

3. Health development is executed with the national development strategies with healthconcerns, professionalism, decentralization and JPKM by paying attention to variouschallenges existing now and in the future, among other things the economic crisis,change in demographic dynamics, change in ecology and environment, progress inscience and technology, as well as globalization and democratization.

4. The public health maintenance and promotion efforts are done through healthy living behavior improvement programs, healthy environment programs, public healthservices that are effective and efficient, being supported by surveillance, information,and management system that are reliable.

Improvement and revision of rules and regulations need to be done in order to supporthealth development and give legal protection to the public and health workers.

5. The supply and improvement of health facilities and infrastructures are to becontinued. Health researches and improvement need to be upgraded to support theimprovement in quality of health efforts. Supply of medicines and health instrumentsthat are safe and accessible to the society are stepped up through the development of

pharmaceutical and health instrument industries that are more advanced andsupported by medicinal raw materials industries that are reliable and the developmentof Indonesian indigenous drugs. Health funding is stepped up, either that coming

from the government or the public, it is managed effectively and efficiently as well asresponsibly.

6. In order to support all the health development efforts, manpower with nationalattitude, ethical and professional is required, it should also possess high dedicationspirit to the nation and country, being disciplined, creative, educated and skillful, withnoble character and able to hold tight professional ethics. Health manpower andsupportive manpower should be improved in quality, capability and distribution sothat they are evenly distributed and able to support the execution of healthdevelopment at every level especially in supporting the implementation of autonomyat the districts/ municipalities.

Aims of Health Development

The aims of health development toward Healthy Indonesia 2010 is to increase theawareness, will and capability for healthy life of every individual in order to materialize

public health level that is optimal through the creation of an Indonesian society, nationand country that is characterized by its residents living with healthy behavior and within

healthy environment, possessing capability to reach qualified health services justly and


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evenly, as well as having optimal health level throughout the territory of the Rep. ofIndonesia.

Targets of Health Development

The targets of health development in order to materialize Healthy Indonesia 2010 are:

1. Cross-sectoral cooperationThe significant rise in cross-sectoral cooperation in health development, positivecontribution from other sectors toward health, efforts to overcome negative impactsof development to health, and improvement in behavior and living environment thatare conducive to the achievement of healthy society.

2. Communitys autonomy and private partnershipThe significant rise in communitys capability to maintain and improve their healthcondition, and to reach proper health services according to needs. The significant risein health efforts originating from private resources and the number of communitymembers utilizing private health efforts.

3. Healthy living behaviorThe significant rise in the number of pregnant women examining themselves anddelivering attended by health manpower, the number of infants receiving completeimmunization, number of infants receiving exclusive breast feeding, number of theunder 5 years children having weighed each month, number of reproductive agedcouples using contraceptive, number of people taking balanced nutrition, number ofthose using sanitary toilet, number of people receiving clean water, number ofsettlements free from vectors and rodents, number of houses fulfilling healthycondition, number of people exercising and resting regularly, number of families withinternal and external communication, number of families practicing well theirreligious teaching, number of people not smoking and not drinking alcoholic

beverages/ addictive substances, number of people not having extra marital sex, andnumber of people becoming members of JPKM.

4. Healthy environment

The significant rise in the number of healthy regions/ areas, healthy public places,healthy tourism resorts, healthy working places, healthy houses and buildings,sanitary facilities, drinking water facilities, waste disposal facilities, healthy socialenvironment including social inter-courses, and environmental safety, as well asvarious standards and laws supporting the achievement of healthy environment.

5. Health effortsThe significant rise in number of qualified health facilities, coverage and reach ofhealth services, generic drugs usage in health sector, rational drugs usage, promotiveand preventive services utilization, efficiently managed health funds, and availabilityof health services according to needs.

6. Health development management


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The significant rise in health development information system, regions ability inimplementing health development decentralization, health leadership andmanagement as well as laws supporting the health development.

7. Health level

The significant rise in life expectancy, decrease in infant mortality rate and maternalmortality rate, decrease in morbidity rates of several important diseases, decrease indisability rate and dependency rate, increase in public nutritional state, and decreasein fertility rate.

Health Development Policies

In order to achieve health developments aims and targets toward realization of HealthyIndonesia 2010, the general health developments policies are:

1. Consolidation of Cross-Sectoral CooperationIn order to optimize the results of development with health concerns, thenconsolidation of cross-sectoral cooperation becomes the main concern, hence it needscareful coordination and consolidation. Socialization of health concerns to othersectors needs to be done intensively and periodically. Cross-sectoral cooperationshould cover planning, implementation and evaluation steps.

2. Improvement in Behavior, Society Empowerment and Private PartnershipEarly started healthy life style in the society should be up-graded through varioushealth information and education activities, so that it can turn into a part of livingnorms and cultures of the people in the context of increasing the awareness andautonomy of the society for living healthily. The roles of the society in healthdevelopment, i.e. mainly through application of public health development concept, isto be encouraged and even more improved to assure the fulfillment of health needsand continuity in health efforts.

Private partnership is developed further by facilitating primarily the construction ofreferral health service hospitals and other medical services, by attending theefficiency of the overall health service system. Private partnership is also increasedin prevention of diseases and improvement of health level.

The roles of professional organizations as part of the societys organizations are to bestepped up mainly in aspects related to compilation and supervision of professionalstandards and ethics in health services. Professional organizations are encouraged to

participate actively advancing science and technology in health, help government informulation of policies and management and supervision of health developmentimplementation and function also in providing input to development of health humanresources.

3. Improvement of Environmental HealthThe environmental health of settlements, working places and public places and

tourism resorts is to be improved through the supply and supervision of qualifiedwater especially the plumbing, regulation of rubbish disposal places, preparation of


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waste disposal facilities and various other environment sanitary facilities. So that theresidents can live healthily and productively as well as be prevented from dangerousdiseases which are disseminated through or caused by unhealthy environment.

The quality of water, air and soil is to be improved to assure healthy and productive

life so that the country is prevented from conditions that can incur health hazards.For that, improvement and revision of various rules and regulations, education onhealthy environment since early ages, and standardization of environmental qualityare necessary.

Control over agents, vectors and reservoirs of diseases is needed to create a healthyenvironment for the whole society. Special attention is directed to environmentaltroubles caused by technology utilization and dangerous substances, overtexploitation of natural resources, and those caused by disasters, either natural or manmade ones.

The global impacts of climate change should be cautioned especially those related tothe occurrence of various health troubles, beside negative impacts of foodstuffscarcity influencing the communitys nutrition.

4. Improvement of Health EffortsIn order to maintain public health status during the economic crisis, health efforts are

prioritized to overcome the aftermath of crisis beside to continue keeping healthdevelopment improvement. In overcoming the aftermath of crisis, special attention isgiven to high-risk groups from poor families so that their health level do not worsenand they remain productive. Government is in charge of health service fund for the

poor community.

After passing the economic critical period, health state of the society is managed toimprove through prevention and decrease in morbidity, mortality and disabilityespecially among the infants, under 5 years old children and pregnant, laboring and

puerperal women, through the healthy life promotive efforts, prevention anderadication of contagious diseases and the cure and rehabilitation of diseases. Themain priority is given to eradication of contagious diseases and outbreaks which tendto rise.

Greater attention is given to efforts to realize higher working productivity, through

various occupational health service efforts including nutritional improvement andwork forces physical fitness and other health efforts related to health of workenvironment and settlement areas, especially for people living in the slum areas.

Increase in health efforts is implemented through supporting private sector partnership and societys potentials. Improvement in health efforts of thegovernmental sector is prioritized on health services having broad impacts to publichealth. While individual health services of curative and rehabilitative nature aremainly trusted to private.

Basic health services that are implemented through puskesmas, helper puskesmas,

midwives at villages, and private health service efforts are improved in equality and


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quality. The same improvement is also applied on referral health services that areimplemented by hospitals owned by the government and the private.

Improvement in quality is done through positioning midwives at villages,development of existing puskesmas and construction of helper puskesmas equipped

with facilities. Improvement in service quality is done through implementation ofquality assurance by puskesmas and hospitals.

5. Improvement of Health ResourcesImprovement in health manpower should support all health development efforts anddirected to create health manpower that is expert and skilled in line with the progressin science and technology, devout and faithful to the Only God and holding tightlydedication to the nation and country as well as professional ethics. Up grading ofhealth manpower is aimed at improving empowerment or utilization of manpowerand preparation of health manpower, either from the public or the government, thatcan implement health development.

JPKM is developed further to assure implementation of health maintenance that ismore equal and qualified with controllable price. JPKM is run as a joint effort

between the society, private and government to fulfill the need for health service costswhich are rising continuously. Health service tariffs should be adjusted based on thevalue of goods and service received by the societys members getting the care. Theless well to do people will be helped through the JPKM system subsidized by thegovernment. At the same time, health insurance is also developed as a complement/companion to JPKM. The development of health insurance is under the cultivation ofthe government and insurance association. Beside that gradually the state owned

puskesmas and hospitals will be managed by self-financing system.

In the effort to increase health inventories, the purchase and production of medicalraw materials which have economic yield will be stepped up. Supply, production anddistribution of finished drugs will be increased in efficiency and quality so that thesociety will be able to get qualified drugs with affordable prices. Rational use ofdrugs, especially with generic drugs is encouraged through promotion andinstructional efforts for the health workers and general public. Traditional medicinesthat are useful to health will be utilized integrally in public health services. Besidethat, cultivation and utilization in the society will be improved further throughcultivation by the government or professional organizations.

Cultivation of the quality of foods and beverages that are marketed and consumed bythe society is improved to protect the society from substances and organisms harmfulto health.

6. Improvement the Policies and Management of Health DevelopmentPolicies and management of health development need to be improved more intenselyespecially through the strategic improvement in cooperation between health sectorand other related sectors, and between various health programs and between actorswithin the health development itself.

Health effort management which consists of planning, implementation actuating,

controlling and evaluation is executed systematically to ensure integrated and overallhealth efforts. The management is supported by information system which is reliable


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in order to produce right decisions and efficient working mechanism. Theinformation system is developed comprehensively at all levels of healthadministration as a part of modern administrative development. Organization ofMinistry of Health needs to be readjusted with the functions of regulating, national

planning, cultivation and supervision. Decentralization based on real autonomy

principle, dynamic, harmonious and responsible is accelerated through delegation ofresponsibilities of health effort management to the regions. The management abilityof health office (Dinas Kesehatan) is improved further so that it can do the planningand funding of health effort arrangement more responsibly. The improvement inmanagerial ability is done through a series of education and training in line with theexisting health development.

The aforementioned efforts need to be supported by the availability of adequatehealth funding. For the reason, improvement in health funding should be striven foreither that coming from national budget or from the regional budget. The source ofrevenue for health development can be explored from taxes on consumer goods that

are detrimental to health such as cigarettes and tobacco, and taxes on alcoholic drinks.In line with that, all revenues are allocated fully back by the government to fundhealth services and service quality improvement efforts.

7. Improved Protection of Public Health against the Use of Illegal Pharmaceuticals,

Foods and Health Instruments.Improved protection of public health against the use of illegal pharmaceuticals, foodsand health instruments is done through prevention of distribution of products whichdo not meet the conditions regarding quality, efficacy/ benefit and safety, besidethrough expansion of the span of their supervision. Beside quality and safetyconditions, the claims of certain products through advertisement and promotion

should be assured of their validity according to the scientific data supporting them.The communitys care regarding risks from using pharmaceuticals, foods and healthinstruments is also not less important to be increased through various communication,information and educational activities. So is the rational use of drugs by professional

personnel need to be encouraged through more concrete efforts.

Improved protection of society against danger of abuse and disuse of drugs, narcotics, psychotropics, addictive substances and other dangerous substances needs to beconsolidated through control of their production, distribution and use tightly. Therisks of toxicity due to use of products containing dangerous substances need to be

prevented as early as possible through intensification of the information dispersion.

In order to utilize the potentials of Indonesian indigenous medicines, various effortsshould be developed and conducted from up stream to down stream integrally andsystematically, cooperating with other related sectors. Beside that the image ofIndonesian indigenous medicines should be upgraded mainly domestically throughwide spread use for self-healing by the society and in the formal health services.

The even distribution and availability of drugs that are affordable and still beingprioritized nationally should be done consistently through the concept of essentialdrugs. So is the utilization of generic drugs which should be further up graded.

8. Improvement of Science and Technology in Health


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Research and development in health sector will be further up graded gradually andguided in order to support health efforts, primarily to support formulation of policies,to help solve health problems and overcome troubles in the implementation of health

programs. Research and development in health will be continually up graded throughthe partnership network and decentralized to become essential part of regional health

development. The upgrading of science and technology is encouraged to improve thehealth services, nutrition, drugs utilization, and Indonesian indigenous medicinedevelopment. Researches related to health economics are upgraded to optimizeutilization of health funds from government and private, as well as to improvegovernments contribution in health funding which is still limited. Researches insocial cultural field and healthy life style are done to develop healthy life style anddecrease existing community health problems.

Strategies of Health Development

Health development strategies aimed at achieving Healthy Indonesia 2010 are:

1. National Development with Health Concerns

All national development policies that are still or will be arranged should have healthconcerns. It means that national development programs should provide positivecontribution to health, at least in 2 aspects. First, toward the formation of healthyenvironment. Second, toward the formation of healthy behavior. It is utmostlyhoped that each national development program being done in Indonesia can bring

positive contribution toward the achievement of the healthy environment andbehavior.

While in micro, all health development policies that are and or will be arrangedshould further push the increase in health level of all members of the society. Whileit is known that the maintenance and promotion of health will be more effective and

efficient if done through promotion and preventive efforts, not curative andrehabilitative ones then it is logical that the former two services can be given priority.

In order to implement the development with health concerns, it needs socialization,orientation, campaign and training activities so that all stakeholders understand andcan implement the national development with health concerns. Beside that, furtherelaboration of activities is needed for the concept so that they become trulyoperational and measurable regarding all the achievements and impacts resulted.

2. Professionalism

Professionalism is implemented through the application of progress in science andtechnology, as well as through the application of moral and ethical values.


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The implementation of qualified services needs support from application of variousmedical progresses in science and technology. To materialize health services likethat, it is clear that development of health human resources is deemed to be veryessential. Professional health services cannot be realized when they are not supported

by executing manpower, i.e. health human resources that follow the state of the art ofscience and technology.

Moreover, for the implementation of qualified health services, it should also besupported by the application of high professional moral and ethical values. For therealization of health services like that, all health manpower are demanded to alwaysrevere professional oaths and code of ethics. Conducts being demanded from healthmanpower as stated above need periodic supervision through cooperation withvarious professional organizations.

For the implementation of professionalism strategy, the following should be carried

out: determination of standards of competence of health manpower, training based oncompetence, accreditation and legislation of health manpower, and other qualityimprovement activities.

3. Public Health Maintenance Assurance (JPKM)

In order to consolidate public autonomy in healthy life style, public participationneeds to be supported as broad as possible, including participation in funding. JPKMwhich is principally a structure of subsystem within health funding in the form of

public fund mobilization is a real shape of the publics participation, when it issuccessfully implemented will have a great role as well in accelerating equality and

accessibility of health services.

In the context of health service sub system structuring, the strategy of JPKM will beprioritizing promotive and preventive services, which when successfully implementedis assumed to be more effective and efficient in keeping and promoting health level

beside it will also bring positive influence as well in improving health service quality.

For implementation of the strategy, socialization, orientation, campaign and trainingto all related sides will be done so that they understand the concept and program ofJPKM. Beside that, rules and regulations, training of JPKM executing agents, andJPKM cultivation unit development will be constructed so that JPKM strategy can be

well implemented.

4. Decentralization

For the success of health development, arrangement of various health efforts shouldstart from the problems and specific potentials of each region.

Decentralization, whose core is delegation of greater authority to the regionalgovernments in regulating their own governance system and local affair is in factseemed to be more suitable for the management of various national development inthe future.


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It is a certainty that for the success of decentralization, various preparations isnecessary, including the utmost important are the organizational wares and the humanresources.

For the implementation of decentralization will be done analytical activities and

determination of roles of the central and regional governments in health sector,determination of health efforts that should be run by the regions, analysis of regionalcapabilities, upgrading of regional human resources, training, repositioning ofmanpower and other activities so that decentralization strategy can be implementedconcretely.

Health Development Programs

Program Principals of Health Developme

Documents

Healt Development Plan Indonesia 2010