The Effect of Decentralization on Health System

Indonesia:
 

The challenges. 

Decentralization has given more power and authority to local government to allocate the fund provided by central government and manages their own health system locally. This system has resulted in some advantages in certain local governments and disadvantages in others region. In order to run this system successfully, the elected officials must have knowledge related to health system management. Basically, local governments are willing to pay contracted amount for medical education. This is due to general perception of society that always relates health to medical disciplines. This condition could lead to other negative impacts on medical field that will be elaborated later. Health can be divided into personal and public. Most of the people are concerning about personal health that focus more on curative and rehabilitative management rather than public health system focus more on preventive and promotion measures. Other than that, local government also concern about the shortage of the medical officers rather than closing the gasp for deployment of public health professional. Moreover, some institutions planners simply looked at the MOH prediction for Human Resources for Health (HRH). The ratio is one HRH for 100 000 population. This ratio seemed to be simplified from other developed countries without considering about other aspects such as local government fiscal capacity, overall resources requirement and the need or demand for service. If these factors are not considered properly, its can lead to the overproduction of the HRH. In certain developed countries such as UK and Germany, this ratio could produce very good impact on their health system. In both countries mentioned above, the ratio of one family physician is for 2500 people.  In those countries, the presence of the formal health insurance in Netherlands and state’s role as insurer under National Health Service system in UK lead to the high demands of family physician services. Basically, overproduction can increase the unemployment rate and supplier-induced demand. This has deleterious effect on society because it can increase moral hazards in term of overutilization of medical, nurse personnel and etc. Even though, Indonesia is included in the list of countries with critical shortage of medical workers, the massive increase in term of quantity of the HRH will somehow give small impact on health system. This is due to the uneven distribution of the HRH between the regions. One of the factors that lead to the uneven distribution is lack of economic incentives by public health sector.

Learning from the other countries ........ 
 

Incentives Payment in China. 

In 1980, most of the village doctors in China practiced privately because of the collapsed of the commune based insurance schemes and the local government did not provide salary to the doctors. This condition led to some difficulties in TB treatment programme. Even though the drugs for TB are free, village doctors relied on payments for drugs and services. This had caused some problem because village doctors are important in diagnosis, treatment, and surveillance. The government had created incentives schemes for the doctors. US$ 1 would be paid for every patient enrolled in TB treatment programme, additional US$ 2 for every smear examination carried out in the county TB dispensary at 2 months and further US$ 4 for each patient completing the treatment. In order to ensure the quality of the treatment and reported information, random visits and examination were carried out. The reporting system monitored the performance. This intervention was highly successful with 2 years cure rate for new cases for TB was 95%.

References:

1. Jamison, D.T., Breman, J.G., et al. 2006. Priorities in Health. World Bank, Washington, DC.
2.  Thabrany, H. 2006. Human Resources in Decentralized Health Systems in Indonesia: Challenges for Equity. Regional Health Forum (Volume 10, Number 1). [online accessed on October 24th 2010]

URL: http://www.searo.who.int/LinkFiles/Regional_Health_Forum_Volume_10_No_1_08-Human_Resources_in_Decentralized_Health_Systems.pdf