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NATIONAL HEALTH SYSTEM

HERQUTANTO
ENDANG BASUKI
JUDILHERRY BUSTAM

Introduction
Health is one of basic human rights (WHO,1948)
Health is the state of physical, mental, and social

well-being and not merely the absence of disease


or infirmity (WHO, 1946)
Ottawa Charter for Health Promotion. WHO,
Geneva, 1986:
Health is a resource for everyday life, not the object of living. It is
a positive concept emphasizing social and personal resources as
well as physical capabilities

Health is A Right
health, which is a state of complete physical,

mental and social wellbeing, and not merely the


absence of disease or infirmity, is a fundamental
human right and a most important world-wide
social goal.

Alma Ata Declaration-1973

ELEMENT OF A SYSTEM
1.
2.
3.
4.
5.
6.

INPUT
PROCESS
OUT PUT
FEED BACK
IMPACT
ENVIRONMENT

ENVIRONMENT

INPUT

PROCESS

OUTPUT

FEEDBACK

ENVIRONMENT

OUTCOME

Important Distinctions
Health vs. Health Care

Health refers to a state of the human body and mind


Health Care refers to chemicals, devices, and services used
by people to improve their health

Overall goals for health systems:


Improving health and reducing health inequalities
Enhancing responsiveness to the legitimate

expectations of the population


Assuring fairness of financial contributions.

Dr Shahram Yazdani

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Universal functions of a health system:

1.

2.
3.
4.

Delivering services (provision)


Creating resources (investment and training)
Financing (collecting, pooling and purchasing)
Stewardship (oversight).

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Health Systems Function and Goals


Functions the Systems
Perform

Goals/Outcomes of the
Health System

Delivering services
(provision)

I
N

Coverage
Creating resources

Responsiveness to
people

(investment and training)

P
U

Health

Financing (collecting,
pooling, purchasing)

T
S

Stewardship
(oversight)

Provider
Performance

People protected
from financial risk
Adopted from WHO (2002)

... give up your focus on curative care, don't spend

money on expensive hospitals (you don't need


them if you have enough prevention...) , stop
looking after the rich urban dwellers (even if they
are politicians), invest in prevention, promotion,
community participation... its definitely much
better! Reform! Remove the imperfections in your
health systems - embrace primary health care.

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health care resources are scarce in the

developing world, and that demand will always


exceed the supply therefore, Governments have
to make choices about how they allocate these
resources to the ever-increasing demands that
are placed upon them. A significant obstacle in
the road to Health for All was identified someone has to pay for it, and to do so they
have to take money away from something else.
A difficult dilemma for any government
Evans J, etal (1981) New Engl J Med Vol 305 (19) 1117-1127

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HEALTH SYSTEM

Sub-System
Health Service

SubSystem
Health Financing

Health Financing

Health Service

HEALTH SYSTEM
Quality control

Financial Control
QUALITY

7 Principal Health Systems


1.
2.
3.
4.
5.
6.
7.

Primary health service delivery system


Health workforce
Leadership and governance to assure quality
Health systems financing
Supplying medical products and technologies
Health systems information
Households

Broad Definition of Financing


Collect
Fund

Pool the Risk

Allocate
Resource

$
$
$

Payment

The Fourteen Principles


1.
2.
3.
4.
5.
6.

Fundamental
Importance
Universal Access
Comprehensive
Benefits
Equal Benefits
Fair Burdens
Generational
Solidarity

Task Force on National Health Reform


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formed by President Clinton

7.
8.
9.
10.
11.
12.
13.
14.

Wise Allocation
Effective Treatment
Quality Care
Efficient Management
Individual Choice
Personal
Responsibility
Professional Integrity
Fair Procedures

1. Fundamental Importance
Healthcare is of fundamental moral importance

because it protects our opportunities to pursue goals,


reduces our pain and suffering, prevents premature
loss of life, and gives us the information we need to
plan our lives.

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2. Universal Access
Everyone must have access to healthcare services

without financial or other barriers.

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3. Comprehensive Benefits
The healthcare system should meet the full range

of healthcare needs. Ideally, the program should


cover primary, preventive, chronic, and long-term
care, as well as acute, home, and hospital care and
treatment for mental and physical illness.
Obviously, not every possible service can be
provided, but when there must be limitations, they
should be placed on the least important benefits
relative to their costs.
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4. Equal Benefits
Healthcare services should only reflect differences in

healthcare needs and not other individual or group


differences. The drafters of the reform plan were
emphatically opposed to a two-tier healthcare system
and clearly indicated that whereas in other realms of
societal endeavor two tiers might be acceptable,
healthcare is too important to basic human
functioning.

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5. Fair Burdens
The costs and burdens of meeting healthcare needs

should be spread across society by a progressive tax,


with payments scaled according to ability to pay.

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6. Generational Solidarity
The system should respond to needs at each stage of

life, with benefits and burdens fairly shared across


generations.

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7. Wise Allocation
Society must wisely balance what it spends on health

with other priorities such as education, housing, and


defense. It will therefore have to set limits on the
amount to be spent on healthcare, as well as
prudently allocate resources within the healthcare
budget itself. Unfortunately, in too many countries
military expenditures often greatly exceed those on
health.

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8. Effective Treatment
Since funds will always be limited, it is a medical as

well as ethical responsibility to spend only on


services whose effectiveness has been proven
(evidence-based medicine) and to avoid spending on
ineffective or doubtful services, whether diagnostic
or therapeutic. This clause also mandates spending
on research, particularly outcomes research.

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9. Quality Care
This clause mandates creation of systems of quality

assurance in all aspects of the system.

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10. Efficient Management


The system should be simply organized and easy for

patients and professionals to use and should


minimize administrative costs.

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11. Individual Choice


In the true spirit of American individualism, the

authors of the reform plan proposed that the


healthcare system permit maximum freedom of
choice among providers, plans, and treatments.
Other Western countries have traditionally placed
lesser emphasis on such freedom of choice. In the
U.S., managed care plans are increasingly
restricting options, precipitating considerable
displeasure among patients as well as among
physicians.

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12. Personal Responsibility


The healthcare system should help citizens take

responsibility for protecting and promoting their


own health and that of their families. This is meant
to include the provision for education, counseling,
and treatment to encourage healthy behavior
patterns.

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13. Professional Integrity


The system must respect the clinical judgment of

health professionals and protect the professionalpatient relationship while ensuring that the
professionals fulfill their responsibilities to their
patients.

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14. Fair Procedures


To protect these principles and values, fair and open

democratic procedures should exist for making


decisions and resolving disputes.

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Decentralization
The term decentralization has been used to connote a

variety of reforms characterized by the transfer of fiscal,


administrative, and/or political authority for planning,
management, or service delivery from the central MOH
to alternate institutions. These recipient institutions may
be regional or local offices of the same ministry,
provincial or municipal governments, autonomous
public service agencies, or private sector organizations.

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Improvement in health sector performance


through decentralization
1.

2.
3.
4.

5.

Improved allocative efficiency through permitting the


mix of services and expenditures to be shaped by local
user preferences;
Improved production efficiency through greater cost
consciousness at the local level;
Service delivery innovation through experimentation
and adaptation to local conditions;
Improved quality, transparency, accountability, and
legitimacy owing to user oversight and participation in
decision making; and
Greater equity through distribution of resources toward
traditionally marginal regions and groups.

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Aspects of Decentralization
Aspects of Decentralization

Responsibility for Health Care Services


Management of Labor Inputs
Management of Procurement
Management of Investments
Financing

Transfers of Budgets/Poverty Targeting


Powers to Manage Revenue from Fees

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INDONESIA NATIONAL
HEALTH SYSTEM
HERQUTANTO
ENDANG BASUKI
JUDILHERRY BUSTAM

Introduction
To achieve the state of health, several efforts need to

be done, including creating a health system


How is the health system in Indonesia, and how is it
in the future?

Indonesian National Health System


2004

Present Situation

Maternal Mortality Rate (MMR): 373/100.000

live birth (Household survey 1995)


Infant Mortality Rate (IMR): 50/1000 live birth
(Susenas 2001)
Life expectancy is 66.2 years (1999)
Human Development Index: Indonesia ranks 112
out of 175 countries (UNDP, 2000)

What is National Health System?


NHS is a structure that reflects the countrys

coordinated and integrated efforts to achieve the


highest health level for all Indonesian people as the
realization of social welfare stated in the preamble of
the 1945 constitution
Coordination between government and private
sector, including the public

Philosophy
Ideal Philosophy: Pancasila (Five Principle)
Constitutional: the 1945 constitution

Chapter 28 A
Chapter 28 C verse 1
Chapter 28 H verse 1 and 3
Chapter 34 verse 2 and 3

Basic Principle
Humanity
Human Right
Fairness
Community Empowerment
Partnership
Effectiveness and efficiency
Good Governance

Position of NHS
Supra system: National Administrative/

Governmental system
Interaction with other system:

National Education system


National Economic system
National Food Resilience System
National Defense system

NHS is supra system for Local Health System

Sub-system of NHS
Healthcare system
Health finance system
Healthcare human resource system
Drugs and health logistic system
Community empowerment system
Health management system

Healthcare System

Affordable

Accessible

Healthcare
system

Highest Level
Of Health Status

Quality

Characteristic of Healthcare
Public Health

Parameter

Individual health

PH specialist
Prevention
Community
High
Yes
Subject
Salary
Community
Exist
Complex

Personnel
Main Goal
Target
Efficiency
Advertising
Regulation
Income
Responsibility
Monopoly
Administration

Doctor
Cure
Individual
Low
No
Object
Fee
Patient
Not exist
Simple

Factors affecting healthcare

Government
Policy

Health Science
& Technology

Health
care

Community
Needs &
Demand

Main element
Public health (public goods):

Health promotion
Health maintenance
Communicable Disease Control
Mental Health
Non-communicable Disease Control
Environmental health & basic sanitation
Community nutrition
Drug and logistic safety
Disaster and Emergency Management

Main element
Individual health (private goods):

Health promotion
Health prevention
Ambulatory care
Hospital care
Disability limitation
Rehabilitation
Traditional and alternative medicine
Physical fitness and cosmetics

Public Health
Primary: Health Center/Puskesmas

Center of health-oriented development


Center of community empowerment
Center of basic healthcare services:

Secondary: District MOH


Tertiary: Central & Provincial MOH

Individual health
Primary: Puskesmas, private practice, midwifery,

dentistry, 24-hour clinic, Polindes, Pos Obat Desa,


Posyandu
Secondary: hospital care (type C & B), specialist
practice, specialist clinic, dentist specialist practice
Tertiary: hospital care (type B & A), specialist
consultant practice, dentist specialist consultant

Health Finance System

Main element
Fund raising: activities to raise funds needed to

organize healthcare services or health maintenance


Fund allocation: allocation of funds raised from
government, public or private sector
Fund expenditure: using the fund allocated through
budgeting.

Human resource system

Main element
Planning: type, number, specification
Training & education: recruitment and development

of human resource
Placement: distribution, utilization, supervision,
monitoring

Drug & Logistic

Main element
Drug and logistic supply: efforts to supply drugs and

logistic suitable with the needs and demands of the


community
Drug and logistic distribution: efforts to distribute
drugs and logistic
Drug and logistic quality: effectiveness, safety and
expiry of drugs and logistic

Community Empowerment

Main element
Individual empowerment:
Minimum target: practicing healthy and clean lifestyle
Maximum target: active involvement as health cadre
Group empowerment: to serve, to advocate, to watch
Community empowerment

Health Management

Main element
Health administration: planning, doing, checking,

and taking action (PDCA)


Health information: collecting & managing data as
an input for the decision makers
Science & technology: result of research and
program development
Health regulation: rules and regulation as a
guideline for health development

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