Rita A. Widiadana – It has been almost 10 years since the Indonesian government imposed Law no. 22/2002 on decentralizing government functions and authorities to regional administrations, including healthcare.
The idea was brilliant. Yet, surveys and studies on some basic health indicators and people's access to public health services show conditions are deteriorating.
What has gone wrong with the implementation of the decentralization of the health sector? Since the law was enacted, the World Health Organization (WHO) has been skeptical of the policy.
"Decentralization has considerably weakened the unified national health system including the once established disease surveillance system as well as public health programs," WHO reports. It is not surprising that communicable diseases that were supposed to be eliminated are reemerging.
Polio and leprosy cases are reemerging, striking children and adults as well. Animal-borne diseases including avian influenza and rabies are also spreading.
Rabies is one of the most deadly diseases that has begun to spread across Indonesia recently. The outbreak of rabies has affected 24 of the country's 34 provinces, and claimed 143 lives a year on average. Before 1997, only five provinces were affected by rabies.
The current handling of the rabies outbreak in Bali is an example of the challenges of health decentralization.
Ngurah Mahardika, a professor of virology at the University of Udayana in Denpasar, lamented that the provincial administration faced difficulties in promptly addressing this epidemic and implementing measures to track the disease since it first emerged in November 2007.
Lack of coordination between provincial and regional health officers has escalated the number of victims, and has widely spread the disease to all regencies on the island. The disease has claimed 103 lives. Dog bite cases stood at 68,000 over the last two years.
"Rabies has spread so uncontrollably from one regency to the next. Weak health policies and unclear prevention and eradication concepts have worsened the problem," Mahardika said.
Bali had previously pledged to deal with the disease by using its own financing and expertise. However, in the end, the province needs help from other institutions including the ministry of health, WHO, and World Society for Protections for Animals.
Hasbullah Tabhrany, a public health expert, identified a number of problems faced by provinces in implementing the health decentralization system. "Decentralization in the health sector has widened the gap of availability of healthcare services and facilities in urban and rural areas." Tabhrany said previously.
The system also poses threats to public access to essential public health services such as maternal and child health, immunization, health promotion, disease surveillance, disease prevention and control including response to epidemics.
In addition, there were concerns that the existing huge gaps in the distribution of human and financial resources could widen further across provinces and across cities and districts within each province.
Dinnie Latief, an expert in health decentralization at the Health Ministry, said in a public seminar that many local authorities had limited understanding of health issues.
Many of the elected heads of provinces and regencies as well as legislators lacked knowledge and understanding about health issues, she said. It was reported that many governors, regents routinely resorted to populist notions of free healthcare as a vote buying strategy.
Few of these politicians or their senior bureaucratic advisors are looking beyond the next election to determine what is needed to improve the performance of the health system and the health of their people.
Decentralization has also affected the number of medical professionals working in regencies.
Until the late 1990s, the Health Ministry was obliged to deploy newly graduated doctors to remote districts as part of its mandatory service program. Under the decentralization system, the deployment of medical professionals is in the hands of provincial and regional authorities.
"In one village, a health community center Puskesmas was run by a former lurah, or subdistrict village head, instead of a doctor or a health professional," she added.
In the remote region of Ende in East Nusa Tenggara, a regent reported that 28 community health centers shared just four doctors. Given these circumstances, it is difficult to expect basic public health functions such as disease control and combating malnutrition.
Adang Bahtiar, chairman of the Indonesian Association of Public Health Experts, urged the Health Ministry to develop a clear guideline on the roles of central, provincial and district health authorities to avoid confusion. "The ministry should open a wide network with international agencies and donors to support health services in provinces and districts."
However, provincial and district authorities must improve their human resources, technical and financial capacities in handling health issues in their respective areas. It is a huge task to monitor and control health issues in 440 regencies and municipalities across the archipelago.