WHO

COUNTRY COOPERATION STRATEGY

INDONESIA
1

Draft: September 20, 2000 COUNTRY COOPERATION STRATEGY INDONESIA Section 2 Health and Development Challenge In more than 30 years since 1967, Indonesia made substantial progress. A period of economic growth was experienced which successfully resulted in raising the per capita income from USD 50 in 1968 to USD 1,124 in 1996. The Indonesian population increased from 147 million in 1980 to 179 million in 1990 and is projected to be 210 million in the year 2000. The annual population growth rate was 1.9% between 1980-1990, with a Crude Birth Rate of 22.5 per 1000 and a Crude Death Rate of 7.4 per 1000 in 1998. The population pyramid grew towards an older population with a life expectancy at birth of 64 years for males and 67 years for females (1996). The IMR gradually declined from 142 per 1000 in 1968 to 50 per 1000 in 1998 due to better socioeconomic development and improved preventive and curative services. The proportion of population living in poverty dropped from 60% in 1970 to an estimated 11-13% in 1996. Most of the poor lived in rural areas, in some of the remote islands or upland areas. The literacy rate for those aged 10 years or more was 89% in 1997. These achievements received a severe set back in mid-1997 when the Indonesian economy collapsed. The value of the currency plummeted, prices increased, and unemployment rose dramatically. In addition, parts of the country suffered from relatively long droughts and extensive forest fires. This sudden crisis resulted in political turmoil and change of government. Although the health status of Indonesians was not affected drastically in the short term, the economic crisis certainly slowed down the development of the health system. The ensuing political instability had a direct impact on economic recovery. It is feared that the effects of the political and economic crisis will be felt for several more years. Even though Indonesia is taking special steps to protect the health of its population through the modification of its Seventh Five -Year Plan (Repelita VII), the pace of progress in solving some of the health problems is slow. Compared to neighboring countries, health status of Indonesia still lags behind. Maternal mortality is very high at 390 per 100,000 live births (1995). Moreover, there are great regional disparities in health indicators. For example, IMR ranges from 27 in Jakarta to 90 per 1000 live births in West Nusa Tenggara (1998) Health Situation Communicable diseases continue to be a major cause of morbidity and mortality in Indonesia. Technical strategies for communicable disease control have already been accepted, adapted and adopted to country-specific needs. However, the implementation of the accepted strategies needs improvement, especially under a decentralised health system. Many of these problems are related to the improvement and strengthening of the district health system. Tuberculosis is a major health problem. It is the second highest cause of death and the first killer for infectious diseases. It is estimated that 175,000 people die every year from tuberculosis. The DOTS strategy has been expanded to 225 districts (74.8%) out of a total at 311 districts, covering 88 out of the 210 million people. Leprosy is on the verge of being eliminated and current efforts focus on final campaigns. Malaria is still a public health problem. Approximately 1.5 million cases are detected annually. In 1997, the parasite incidence ranged from 0.12 per 1000 population in Java and Bali

to around 40 per 1000 population, under 10 years of age in the outer islands. In 1998, there were malaria outbreaks in the highlands of Irian Jaya, and resurgence in Central Java. Dengue fever/dengue haemorrhagic fever usually occurs in epidemic proportions during the peak season, starting in November and peaking in May. In 1998, 30,000 cases were reported from cities and also from some rural areas. STDs remain a serious problem especially in high-risk groups and promotes the spread of HIV/AIDS. Control is complicated by social and cultural attitudes towards these diseases and their interventions. As of January 1999, the cumulative number of reported AIDS cases was 227, of which 113 AIDS patients died. The progression rate seems to increase slowly doubling in more than two years. However this may be due to under-diagnosis or under-reporting. The health of women and children continues to be a problem. With five million pregnancies every year in Indonesia, more than 20,000 women die annually during pregnancy and delivery. The high number of maternal deaths is especially a problem in rural areas with limited access to delivery by skilled attendants and an inadequate referral system. Almost 50% of women give birth without skilled attendants and 70% have no postpartum care during the six weeks following delivery. Many of the traditional infectious diseases of children have been controlled through immunization. Polio is close to elimination and current efforts focus on surveillance and final provincial Immunization Days campaigns. The last wild poliovirus isolated in Indonesia was in June 1995. 1999 represents the third year where national AFP surveillance has reached international performance targets. All surveillance indicators continue to improve. Routine EPI coverage has been maintained above 80% nationally with donor assistance; however, rates are falling in pocket areas. New immunization programmes, such as hepatitis B, are being implemented. Other initiatives are the School Immunization Month, TT immunization campaigns in high-risk areas, and improving injection practices. However, with decentralization of the health system, renewed efforts will be needed to ensure that immunization coverage is sustained. An important objective of the country is to reduce the IMR to less than 50 and the under-five mortality rate to 66 per 1000 live births. One of the strategies is the Integrated Management of Childhood Illness (IMCI). As the life expectancy of Indonesians improves, the concern is shifting from communicable diseases to degenerative diseases. This epidemiological transition has presented the health care delivery system with a double burden. Chronic conditions include cancer, circulatory diseases, metabolic disorders, congenital disorders, tobacco dependence, mental health and neurological disorders. Since these diseases are expensive and difficult to cure, it is appropriate focus be put on prevention of non-communicable diseases, especially promoting healthy lifestyles with emphasis on reducing tobacco dependence. Over the last two decades, though Indonesia has placed high priority on health promotion and prevention, the translation of these priorities into polices and implementation has been fragmented and ineffective. Indonesians are increasingly exposed to health risks from environmental hazards. Cases of severe urban air pollution and massive air contamination of ground and surface water resources by industries and households are common. Many potentially harmful chemicals are readily available to the public and are regularly used at places of work in agriculture, industry and commerce. Food contamination of both microbiological and chemical origin is a major issue. The haze from the forest fires in Indonesia has had significant disruptive social and economic effects on people living in affected areas. However, there is low commitment, the main obstacles being the complexity of the issues and a lack of clear institutional responsibilities, both in the public and private sectors.

Finally added to this situation, is large number of complex emergencies currently in the country. Vast displacements of populations have taken place in West Timor, Malukus, and Aceh provinces. The many areas of civil unrest, including the Timor crisis, and the many natural disasters necessitate an improved collaboration in the UN system and a clearer delineation of roles and responsibilities. In emergency response, WHO plays an active role in coordinating humanitarian action for displaced population and areas affected by social unrest and natural disaster in close collaboration with other UN agencies. The Response In order to improve this situation, the Ministry of Health instituted a new policy for health development the Healthy Paradigm. On 1 March 1999, the President signed a declaration proclaiming the start of the new development policy. National development in Indonesia will use a health-oriented national development approach -"Healthy Indonesia 2010". The new mission of the National Health Development Programme is: To lead and initiate health-oriented national development; To maintain and enhance health of individuals, family and community, along with their environments; To maintain and enhance quality, equitable and affordable health services; and To promote public self-reliance in achieving good health. In order to achieve these goals, the following serve as the four pillars in formulating the strategy for national health development: Healthy Paradigm, emphasizing health promotion; Professionalism; Community Managed Health Care Programme (JKPM); and Decentralization. This strategy underpins the current Long-term National Health Development Plan (1994-2018). The main focus of the new approach is: - Decentralization is the key to health sector reform. - Emphasis on health prevention and health promotion, rather than curative. - Effective human resources development programme, to support decentralization. - Access to quality basic health services through JPKM (Managed Care Approach). A Framework for Health Priorities for Indonesia has been developed. This will form the guidelines for all programs of the Ministry. Donor assistance will focus on supporting these priority programs. The challenge In the period of 2001 through 2005, Indonesia will face an important transitional period. After over 25 years of highly centralized government, Indonesia is going through rapid democratization and decentralization of political and bureaucratic power. Because the course of these political developments is not clear, it is likely that there will be periods of political instability and resulting adjustments. Furthermore, trends toward increasing democracy are likely to lead to changes in the function of the government itself. There are strong political movements towards good governance and reforms in the functioning of the public sector. Changes in these areas are likely to have major effects on the health sector. During this period of political change, Indonesia will also be recovering from the economic problems it has faced since the last quarter of 1997. The economic recovery itself is closely associated with the political developments. If the political situation stabilizes, economic changes are likely to proceed more quickly. However, continuing political uncertainties may hinder recovery and pose the risk of even more severe economic problems. Overall, it is likely that Indonesia will face severe monetary constraints over this period making it unlikely that there will be large increases in public sector expenditures. The political and economic situations will have overriding influences on health in Indonesia during this period. This is especially true in the area of decentralization. Successful programs that are highly centralized (such as immunization and drug supplies for health centers) may suffer severe initial setbacks in a decentralized system. Public health activities may not receive adequate funding under a local budgeting system. There are likely to be severe

disruptions in the health workforce in the public sector as personnel face sudden changes in their employment. Diseases of the poor - infectious diseases exacerbated by malnutrition are still major issues in Indonesia, especially Tuberculosis and Malaria. Efforts in the last few years have not yielded the expected results. Major part of the problem lies in broader issues of health system development. These include: efforts aimed at greater advocacy for health, effective mechanisms for financing of health care, efficient procurement and distribution of essential commodities, delivery of basic services through a wide range of delivery organizations both public and private, ensuring access to the most vulnerable sections of the population, and rigorous surveillance and monitoring the results. Development of an integrated approach to these health issues is especially important in the context of the current decentralization initiative of the Government of Indonesia. Nevertheless, it is acknowledged that Indonesias health system was facing severe problems even before the economic and political crises. Some basic changes in the health system were avoided because of the system inertia. The budget system in Indonesia is one of the most complicated in the world and consists of two major categories: the routine budget and the development budget. It is highly centralized, inflexible and fragmented. Every administrative level has a local budget, including a budget for health. However, at least 90% of government budget comes directly or indirectly from the central government so there is a heavy reliance on the centre. Based on the best available data, it is estimated that the total health development budget was 2.4% of the annual national development budget in fiscal year (FY) 1996/97 increasing to 3.0% in FY 1999/2000 or 0.4% of GDP in FY 1996/97 increasing to 1% in FY 1999/2000. The available budget fails to meet the health needs. Although the government is committed to putting health as one of the top priority areas to be addressed in the economic crisis, preliminary analysis of public expenditures shows decreasing health budget in real terms, especially for FY 1998/99. Funds flow into the sector from a variety of sources; the major ones being allocation of government revenues - both central and local government, payments by households (fees for services, drug purchases); employer contribution to health care by employees; limited support from NGOs, and foreign loans and grants. In the period 1985-1995, on average 30% of the health care expenditure came from government sources, while 70% came from nongovernmental sources, including the organized private sector (employer and insurance) and outof-pocket health expenditure from households. Priorities With this background, WHO Country Cooperation Strategy places its major focus on the health system development. Based on this, the priority issues in the next 5 years are: Decentralization is a key challenge for the future development of the health sector. In Indonesia, the current move involves all sectors. New roles for all levels of government will have to be developed and defined. Necessary precautions have to be taken to prevent any adverse effects of decentralization. Good governance should be the underlying principle. Equity in healthcare services. This issue is growing in importance due to the economic crisis. The government has a policy to promote access to health care for the poor and the vulnerable groups through the Health Card program, but it is not working well, and will have to be revisited. Health Card holders are eligible for free care at public facilities. Many district governments are reluctant to provide free services, especially in poor districts. Low utilization of public health facilities is a matter of concern especially in relation to the vast investment that has gone into building a vast network of facilities all across the country. Some of the reasons for this low utilization include poor quality of services and limited health insurance coverage. Related to this is the problem of blurred distinction between private and public health care. Most of the health personnel are also private providers after office hours. This creates a conflict of interest and impacts the functioning of the public health facilities The geographical distribution of health and health-related professionals is another key issue. Since 1992 the central government has a zero growth policy for civil servants. This restricts the availability of health personnel, especially in remote areas. To counter this, the MOH started the Contract Program. However, this initiative means that the young doctors are

uncertain about their future status lowering their motivation. Another major obstacle is the reluctance of health personnel, especially to work in rural areas and difficulties in posting female health workers in the periphery. This will become a key issue in the decentralized health system if health personnel are directly recruited and paid by district governments. . One area where the impact of the 1997 crisis was felt early on is drug supply. The currency devaluation caused prices to rise, which resulted in problems of availability and, even more, of affordability of drugs. Decentralized procurement of drugs will continue to be an important concern. There is a tendency of the health providers to use drugs irrationally. In early 1980s the MOH developed List of Essential Drugs that is periodically revised every three years. In addition, the MOH also campaigns for generic drugs and provides facilities for governmentowned drug production facilities and selected private drug manufacturers to produce generic drugs making them more affordable. The concept of autonomous hospitals or swadana was launched in 1988. This allows hospital managers to retain the hospital revenues as an additional source of operational costs. However, although there is some evidence that this initiative improves the quality of services, it has not achieved the objective of lowering public subsidies to these hospitals. Also, since fees have usually increased, access of the poor is likely to be even more difficult. Self-financing hospitals (autonomous hospitals) need to improve efficiency in the use of funds and facilities through devolution of health programme management. There is a need to take appropriate steps to sustain the private heath sector, in wake of the economic crisis. Section 3 Development Assistance and Partnerships: Aid Flows, Instruments and Coordination

Overall trends of foreign aid in the health sector Foreign assistance has been an important source of funds to finance the public sector in Indonesia, as can be seen in Table 1 below. With Indonesias rapid economic growth prior to the economic crisis of late 1997, public sector finances, including health, became less dependent on foreign assistance. However, as a result of the crisis, the government made extensive use of foreign funds to fill the gap between decreasing local revenues and increasing public expenditures. During the 1998/1999 fiscal year it was predicted that 25% of pubic expenditures would be financed by foreign assistance. Most of these funds were from IMF loans and sector loans from the World Bank and the Asian Development Bank, as well as bilateral donors such as the Government of Japan. These massive foreign funds were expected to stimulate the Indonesian economy and to provide a social safety net for the poor. Table 1: Public Finance - as percent of GDP at current market prices Foreign/ Revenues Expenditures Foreign Expenditures 94/95 - A 16.7% 9.1% 1.0% 11.0% 95/96 - A 15.3% 8.6% 0.2% 2.3% 96/97 - A 15.9% 9.2% 0.0% 0.0% 97/98 - E 15.9% 11.1% 0.7% 6.3% 98/99 - P 13.2% 12.9% 3.2% 24.8% 99/00 - P 13.3% 12.3% 1.8% 14.6% 00/01 - P 14.7% 12.4% -0.3% -2.4% A - actual; E - estimated P - predicted Source: World Bank, Indonesia CAS Progress Report, February 1999

The major contributors During the last three decades, there is a growing attention and interest of the international community in health development in Indonesia. International assistance in the health sector has increased from year to year as shown Table 2 with a six-fold increase over the last 15 years. At the same time, government health expenditures have also increased over this period.

Table 2: Total health expenditures in constant prices (billions of rupiah) Percent Fiscal Total Foreign Foreign Year Expenditures Assistance Assistance 84/85 1,102 58 5.3% 85/86 1,249 74 5.9% 86/87 1,166 43 3.7% 87/88 977 39 4.0% 88/89 1,183 194 16.4% 89/90 1,303 221 17.0% 90/91 1,517 189 12.5% 91/92 1,737 175 10.1% 92/93 2,104 305 14.5% 93/94 2,184 213 9.7% 94/95 2,278 124 5.4% 95/96 2,354 130 5.5% 96/97 2,592 118 4.5% 97/98 2,398 165 6.9% 98/99 2,105 376 17.9% Source: World Bank, Watching Brief, Issue 5, August 1999 However, foreign assistance has been especially important during economic crises, such as the oil crisis in the mid-1980s and the economic crisis in the late 1990s. Trends in this assistance are presented in Figure 1 below. In general, there has been a shift away from bilateral agencies towards multilateral agencies, especially the World Bank and the Asian Development Bank. The exception to this was a large contribution from the Government of Japan during the period of 1990-1994.

Figure 1: Total foreign assistance to the health sector 800 700 600 500 400 300 200 100 0 1975- 1980- 1985- 1990- 199579 84 89 1994 1999 Five-year period Billions of Rp.(nominal)

Bilateral Multilateral

Support to the health sector has been mostly classical project support. Many of the bilateral donors have concentrated on infrastructure development including equipment. Development bank funds have been used to support high priority areas, such as child health, water supply, family planning, nutrition and safe motherhood. Since a USAID project in the 1970s, donors have support provincial health projects with the objective of increasing the capacity of local staff to manage health programs. This has recently developed into a series of provincial projects aimed at decentralization and this pattern is likely to increase as donors deal directly with local government for their projects. The recent economic crisis has led to another change in the form of foreign assistance, especially projects funded by ADB and the IMF. Sector loans to health have started where funds are disbursed based on the implementation of agreed policies affecting the sector. These funds are flexible and minimize administrative procedures associated with traditional project. They also are fast disbursing to meet the financial requirements of a crisis. It is likely that sector loans and projects will continue to grow in health Donor Partnerships With the large number of donor-assisted projects and activities, often allocated to separate locations, making it difficult to coordinate and synchronize work between donors and the government. The results of projects were often unknown to others doing similar work. Even worse, the results of donor projects might not be used to guide programs supported by government funds. These problems are mainly a result of inadequate coordination among the donors. Analyses by each major donor agency have identified key issues in the Indonesian health sector such as high MMR, HIV/AIDS, tuberculosis, quality assurance and decentralization. These donors then propose projects to help solve the problems. Often the government resolved the problems of various donor interests and project requirements by assigning different provinces for each donor agency. However, this resulted in poor communication between projects, duplication of efforts and often the repeating of mistakes by different donors. While these problems of coordination are classic, the solution requires a high level of technical inputs to coordinate the planning and implementation of various projects with similar objectives. Nonetheless, the benefits in increased efficiency are obvious.

The economic crisis of late 1997 did manage to bring donors together with a sense of urgency in the health sector. Because of the sensitive economic and political situation, the donor agencies were concerned that more was needed to ensure better coordination and improve the implementation of projects in the health sector. In all these efforts aimed at minimizing the impact of the crisis on health, WHO played a key role in supporting the government in improving donor coordination. Between 16 February 1998 and 12 February 1999, WHO helped the MoH organize four meetings of donors. The response from the donor community was high. Another area that showed the benefits of donor coordination was polio eradication efforts. WHO and UNICEF provided extensive technical and fund-raising support to the government to ensure that effective activities were implemented. The resources dedicated to these efforts were extensive, implementation was smooth and donor cooperation was impressive. Unified donor support had the added benefit of reassuring the MoH that eradication activities were on-track. Efforts to coordinate foreign assistance were further assisted by the political mandate to implement decentralization. Major donors quickly met to assess the potential impact of decentralization on the health sector. It was agreed that decentralization was both a threat to the existing health system and an opportunity to make significant changes. Donors advocated major reforms in health but the pace of change was slow. Due to the delicate political and economic situation, donors realized that multiple and uncoordinated donor initiatives at this time could confuse the situation and jeopardize the opportunity provided by decentralization. It was realized that if donors made unified appeals or proposals to the government, it was more likely that these would be implemented. With this in mind, the Partnership for Health group was formed in late 1999. This group consists of major multilateral and bilateral agencies in health. It has no formal structure but is a forum for communications between major donors concerned about health policies and reforms, meeting at least once a month. Lastly, it should be noted that effective donor coordination has costs. The time taken talking with other donors can detract from the planning and implementation of focused activities needed to secure project funding. It can also introduce new constraints that delay or complicate project design. In addition, it requires technical support either from the time of existing staff or the assignment of new consultants. Nonetheless, the potential benefits are great. In this specific area, it is likely that WHO can provide special technical input that would have a substantial benefit for the health sector in Indonesia. The followings are some major issues in this area: Since the fiscal year 1982/1983, financial aid from foreign countries for health has been extensive. There were at least 13 sources of funds from foreign agencies, but the majority of this aid was for investment (infrastructure), and not enough was provided for system improvements to increase efficiency and effectiveness of the health system. The emphasis on infrastructure development will cause operational and a maintenance costs to rise in future, a matter of concern. For the current fiscal year (1990/2000), the national development budget was 83 trillion rupiah. Of this, 30 trillion were from foreign-assisted, direct project support and indirect support of 47 trillion from foreign assistance such as general and sector loans from the IMF, World Bank, ADB and OECF. Only 6 trillion were from the government's own revenues. Thus over 90% of development expenditures was funded (directly or indirectly) through foreign assistance. Section 4: WHO Current Country Programme WHO Operations Indonesia joined the World Health Organization on 23 May 1950, just months after the country was liberated on 27 December 1949. WHO has established a wide range of collaborative programmes with the Government of Indonesia. The central goal of the collaboration is the

attainment of the highest level of health by the population. Since its inception, WHO has been playing an important role in national health development. Over the years, as the issues in health sector became diverse, the scope of WHO collaborative activities expanded to cover a large number of projects. Many of these projects funded routine activities. However, in the 1996-1997 biennium WHO introduced umbrella projects aimed to make projects more coordinated, with effective linkages and with measurable and accountable products. In financial terms, Regular Budget provided USD 10.4 million in 1996-1997 and allocated USD 10.7 million for the 1998-1999 biennium. The Extrabudgetary component for 1996-1997 was USD 1.31million; for the 1998-1999 biennium, it was USD 2.4 million. In Indonesia, about 25% of RB funds are allocated for the WHO Country Office. The following table shows how the country RB funds were utilized during the 1996-1997 biennium. As can be seen, about half the country budget was spent on local cost and APWs.
Summary of component-wise expenditure in the 1996-1997 biennium (In US$ 000)
*

Indonesia

US$ %

Staff Cost 2,731 26.3%

duty trv 132 1.3%

STC 129 1.2%

CSA APW 2,191 21%

S&E 660 6.3%

FEL 492 3.5%

GEA mtngs. 1,004 9.6%

Temp. advsr 24 0.2%

GOE 271 2.6%

LCS 2,081 26.6%

total 9,719 100%

For the biennium 2000-2001, the plan shows a slightly different presentation of staff costs about 44.73% which includes duty travel. The supplies and equipment and the fellowships components are drastically decreased: 3.94% and 0.56% respectively. Financial and technical assistance from WHO has been prioritized and covers areas related to the MoH's strategy to minimize the effects of the crisis on health. The quality of the products is constantly monitored and reprogramming carefully reviewed. WHO's support for the Ministry of Health is relatively small given the Government's budget for health and the increased support from development banks. Nonetheless, WHO is strategically situated to provide key technical support as required, and to undertake advocacy for key areas of health development in the country. The support of WHO though the country programmes is especially important during urgent, immediate needs. WHO support can be divided into the following areas: Technical support for key programmes Technical support is provided for high priority areas, where the country needs special support. This includes STD and HIV/AIDS, TB Control and IMCI. In these areas, new programme guidelines and protocols must be developed, tested and expanded. All this requires extensive technical inputs with minimal funds for operations. Support for health sector policy and reform There are key areas of the health system where changes are essential. These include the referral system, decentralized planning at the district level, health insurance and health financing issues. Much of the effort concentrates on the background work analyzing current data and providing papers on key policy issues. Where necessary, limited field trials of innovations or training are undertaken to try out appropriate changes. Support for donor-assisted initiatives to improve health The large amount of project funds provided by donors can have considerable impact on the health sector in Indonesia. This is especially true since many donor-assisted projects concentrate on innovations rather than routine programmes. WHO provides technical support to facilitate their work. Advocacy and technical support for emerging priorities in health This involves support for health initiatives that are expected to grow in importance in the coming years. Although
*

Does not include ICP, regional and global funds. 10

resources are currently being used more for communicable diseases, as these are still widespread, non-communicable diseases are likely to become important in the next five years. Health promotion in areas such as tobacco or health, and occupational diseases requires increased support and development efforts. Limited technical support for all units This involves some activities for all units and programmes. It includes programme evaluations, assessment to identify current needs, shortterm technical training and attending technical meetings. Limited fellowships are supported.

There are some comparative advantages of WHO country Office. Sound and impartial technical advice in all areas. Ministry of Health perceives WHO as giving the best technical advice, which is non-partisan. Direct counterparts in the MOH at central level Large technical staff involved in different units in the MOH. Most WHO professional Staff work directly with the corresponding officials in the Ministry of Health. This helps access to the decision and policy makers in the Ministry. Being seen by government and donors as the leader in health. WHO is widely seen as being the primary agency in health not only by the Government, but also the donor community. WHO is not perceived as a major donor. Since the funds directly available with WHO are comparatively small, WHO is not seen as a donor agency, which is supply driven, as compared to other agencies with large funds, who are sometimes perceived as prescriptive. Technical backup from SEARO and HQ. It is an important advantage, to be able at short notice, to get expert advice and the best technical practices. Deep involvement in health system work and decentralization. This has been a special feature of the strength of WHO work in Indonesia. For the last 5 years WHO has been working closely with the Ministry in the area of health systems and decentralization giving appropriate technical advice and providing relevant experts. Good involvement with NGOs. While there is no formal mechanism for collaboration with NGOs, there is a good working relationship and cooperation between NGOs working in the health sector and the WHO country office. Good involvement with ministries outside health like the Ministry of Womens Role, Ministry of Education, the Family Planning Board etc There are some other issues that need to be considered. The most important of these are the difficulties in implementing the new and innovative approaches in a bureaucratic system. There is reluctance in making a substantive change. There is some reservation in inter-unit cooperation, with many bureaucrats very possessive about their own programmes. Intersectoral issues, such as tobacco and health or health insurance, are even more difficult because more than one department is involved. Some constraints of WHO country Office are: No presence at provincial/district level. This is especially critical at the current time when widespread decentralization is taking place. It is also important for a large country like Indonesia to have a presence at provincial level and increased interaction at the district level. No funds for routine implementation. Some small amounts have to be available even for routine activities in areas where other funding is not available. This would improve the working with MOH. WHO Staff and funds are linked to specific programs/MOH units. They are sometimes perceived as belonging to the unit with which they are attached. This constraints them from working across units and their limiting their contribution. Section 5: WHO Corporate Policy Framework: Global and Regional Directions Against a background of improved understanding of the importance of multisectoral responses which are required to achieve better health; the relationship between improved health and poverty reduction; the emergence of the private sector and civil society as important players

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to complement the evolving role of the state; the increased involvement of development agencies in the health sector; and the heightened importance of the safeguarding of health in the proliferating occurrence of conflict and disaster, WHO has re-evaluated the way in which it should work. In response to challenges emerging from the broadened context of international health referred above, WHO will strive to focus on the linkage between health and poverty reduction; will establish wider bases of consensus on health policy, strategies and standard by better managing research knowledge and expertise via negotiated partnership. In the South East Asian Region, the Regional Declaration for Health Development in the 21st Century has reaffirmed a commitment to the importance of access to health care by all through strengthening the capacity of the health sector to develop mutual partnerships within the context of strong regional solidarity. Regional parliamentarians have pledged to take appropriate measures in response to effects of globalization such as the further marginalization of the poor and the under-served, needs for improved measures for health care financing, decentralization, etc. Finally, the Calcutta Declaration (1999) has called for the promotion of public health as a discipline and essential requirement for further health development through achieving more evidence-based public health policies; reforming public health education, and training. The SouthEast Asia Region subscribes to the globally defined strategic directions of the Organization which provide the broad framework for focusing the technical work of the Secretariat: - reduction of excess mortality, morbidity and disability especially in poor and marginalized populations - promoting healthy lifestyles and reducing the risk factors to human health - developing health systems with improved equity of health outcome, responsiveness and financial fairness - developing an improved policy and institutional environment in the health sector and promoting linkages to social, economic, environmental policy Within the priority areas of work identified for focus from the global perspective, the Southeast Asia region will focus on malaria, HIV-AIDS, tuberculosis, maternal health, tobacco, major noncommunicable diseases, food safety, safe blood and health systems. The region will also focus on diseases for eradication and elimination (polio and leprosy), locally epidemic and endemic diseases and environmental health risks. The Organization has further defined the functions of the Secretariat within the pertaining areas of work. The SEAR will emphasize the following functions: - Articulating and advocating evidence-based policies and strategies - Maintaining high level technical expertise for catalyzing change - Enhancing partnerships In addition, the Region will sustain national and regional health development capability, and emphasis will be put on: - managing information; setting and validating norms and standards; developing and testing new technologies, tool and guidelines. Section 6: Strategic Agenda for Indonesia: The Next Five Years Overall Goals The overall goal of the World Health Organization in Indonesia is to improve the health of the people of Indonesia by supporting health development, advocating health promoting policies and providing technical leadership in collaboration with the government, donor partners and other actors in health. This will be accomplished by advocating and influencing health-related policies in line with WHOs core list of goals for health development. WHO support will focus on the development and adoption of standards and norms, implemented through technically sound health interventions. WHO will work towards a more equitable and efficient health system. These goals will only be achieved through an optimal mix of partnerships in health. In addition, WHO will also contribute its experiences to other countries, regionally as well as globally.

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Key Strategic Directions and Functions The objective of WHOs strategy is to improve the process of developing health policy, planning, regulation and financing leading to a more equitable, responsive and fair financing of a decentralized health system. WHO will work with other developmental partners towards improving health systems and to make health policies more pro-poor. While initiatives to improve the health system affect all activities in WHO during this period, there are some technical areas that deserve high priority during 2001 through 2005. WHOs strategic direction focuses on six priority areas (components) for the period of 2001 through 2005: 1. Health Policy and System Development 2. Communicable Disease Control 3. The Health of Women and Children 4. Promoting Healthy Environment and Lifestyles 5. Emergency Preparedness and Response 6. Partnerships and coordination As the governments own funding for health has increased and the MoH has received major support from the development banks (ADB and the World Bank), WHOs direct support for implementation has become much less significant. Large fellowship programmes of the development banks have also meant that WHO has become a minor actor in this area. Nonetheless, WHO continues to play an influential role in the MoH because of the presence of a large number of technical staff and consultants and its influence in setting standards and developing guidelines. In additional, the flexibility of WHO funding procedures make it possible for WHO to move quickly to support key strategic activities. Thus WHO will move away from supporting large fellowship programmes and large local cost activities towards providing more technical support and expertise. WHOs past support has focused on the Ministry of Health (MoH) and has consisted of technical assistance, training, fellowships, guidelines and support for international standards. This was through small projects with limited scope but covered a large number of health areas, with special attention on communicable disease control. Staff and consultants were assigned to specific MoH units with the main task of assisting in WHO project implementation. Up until the last ten years, WHO sponsored international fellowships and trained key MoH and university personnel. During the last decade, fellowships were for local degrees in public health for district health officers in remote areas. WHO also provided funds for MoH staff to attend international meetings and conferences, as well as to procure key health reference materials. In general, although some staff were involved with projects of other development partners and the MoHs own projects, most staff and consultant were confined to WHO supported activities and projects. Following the severe economic crisis, Indonesia is engaged in a reform of the government system. These fundamental changes strongly affect the health sector. During the next five years, the key role of WHO is to support the health sector in developing responses and taking pro-active stances on issues of decentralization, privatisation, civil service reform, poverty reduction and other elements of overall reform. This will involve such areas as health financing, corporatisation of health facilities, new institutional arrangements and changes in employment conditions of health personnel. WHO will attempt to narrow the gap between policy intentions and policy implementation. For example, while decentralization is clearly supported as a major element in this reform process, there is no clear design of how health institutions will change to ensure increased effectiveness and community support. WHOs strategy to improve the health system demands close links with its development partners. The recently formed Partners for Health will provide a forum of major donor and technical agencies to coordinate and focus their efforts to improve the health sector. This groups first efforts have facilitated the establishment of the Minister of Healths Policy Advisory Group which is supported by two technical staff from WHO, to advise the minister on policy issues and options for health system changes

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With the development of the WHO Corporate Strategy and a reevaluation of the comparative advantages of WHO, the Country Cooperation Strategy intends to take a more strategic approach in its support of the MoH. Rather than support limited implementation of health activities, WHO can have a greater impact by a more strategic selection of activities. This involves five functions that emphasize modes of assistance that are can be best carried out by WHO. These five functions are: F1 - Catalysing adoption of technical strategies and innovation; country-specific adaptation of guidelines; seeding large-scale implementation F2 - Supporting research and development; policy experimentation; simulating; monitoring health and health sector performance; trends assessment and anticipation F3 - Providing information, sharing knowledge (global, inter-regional, inter-country); advocacy; generic policy options and positions; cases studies, standards and guidelines F4 - Providing specific high-level policy and technical advice; serving as a broker and arbiter; exercising influence on policy, action and spending of governments and development partners. F5 - Supporting limited essential routine implementation It is recognized that the implementation of these five functions is not necessarily the same in all six of the components of Indonesias Country Cooperation Strategy. Therefore, after an assessment by WHO staff, relative emphasis for each of the five functions are estimated for the 2001-2005 period. These were arrived at in an assessment carried out jointly by the WHO country team, taking into account the current status of the health situation and the health programmes. These are presented in the following table: *Component 1A. Health Policy and System Development 2. Communicable Disease Control 3. Health of Women and Children 4. Promoting Healthy Environment and Lifestyles 5. Emergency Preparedness & Response 6. Partnerships and coordination F1 (catalysing) + +++ +++ ++ ++ F2 (R & D) + ++ + + F3 (advocacy) +++ ++ + +++ ++ +++++ F4 (policy) ++++ ++ +++ +++ + ++++ F5 (implement) + ++++ -

*( minus(-) denotes no role in that function, while plus(+) denotes relative importance of each function in each component)

In general, WHO will give most attention to functions F4 (policy) and F3 (advocacy). While direct implementation will be severely restricted (except in the case of emergency activities), more attention will be on catalysing the implementation of standards and guidelines to meet conditions in Indonesia. These functions are reflected in the detailed discussion of components presented below. Component 1: Health Policy and System Development Decentralization and other changes in the health system are likely to have an extensive impact on all aspects of the health system. Due to the immense changes taking place, there is an urgent need to redefine the roles and functions of the health system at different levels of government and to determine appropriate institutional arrangements. It is important to determine appropriate institutional arrangements, emphasizing civil service reforms. A broader sector wide approach will be advocated as opposed to project oriented interventions.

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Key changes in direction 1. Assist the development of the new roles and functions of the MoH to support a decentralized health system. 2. Change from provision of services to policy formulation focusing on the district health system. 3. Emphasize health financing issues, including monitoring of health expenditures and service utilization, and promotion of pre-paid health service schemes. 4. Re-direct fellowships to address policy issues on human resources development and personnel management. 5. Improve district-level management of drugs and rational drug use. 6. Improve the quality and use of information to better manage district health systems. 7. Assist in the development of an integrated surveillance system for the district 8. Promote epidemiological approach in health planning 9. Encourage reorientation of medical and allied health education to better address public health problems and the needs of the patients. 10. Improving quality assurance in service provision Component 2: Communicable Disease Control During the next five years, WHO will continue to support the MoH in designing and implementing effective communicable disease control programs to reduce excess mortality, morbidity and disability, especially in populations with limited access to health services. Vertical strategies will be revisited to adjust to a decentralized health system approach building a rapid response to epidemics and newly emerging communicable diseases. Key changes in direction 1. Strengthen communicable disease control programmes, including EPI, at the district level 2. Increase support to control of tuberculosis 3. Increase emphasis on control of vector borne diseases, especially malaria, dengue, and filariasis 4. Strengthen surveillance and outbreak response to emerging and re-emerging diseases 5. Strengthen health laboratory services 6. Provide assistance to model central CDC institutions to support a decentralized health system Component 3: The Health of Women and Children The strategy for the coming period is to solve some of the major health systems problems affecting Reproductive Health and to strengthen initiatives to improve comprehensive health services for women and children. Key changes in direction 1. Support the development of national policies, strategies and action plans that will be applied at the district and provincial levels on nutrition, child health, reproductive health and MPS 2. Concentrate on promoting an effective referral system from the family upwards 3. Scaling up and expanding the IMCI approach, especially focusing on nutrition, and include interventions at the community and family levels. 4. Support to programmes improving the health of women, including actions to reduce violence against women Component 4: Promoting Healthy Environment and Lifestyles Currently many health promotion activities have limited impact due to lack of targeting. The strategic agenda for this sub-component will concentrate on integrating health promotion into key health programs in Indonesia. WHO will play a more strategic role in environmental health developing clear policies and priorities for a healthy environment. Key changes in direction 1. Promote selective approaches to environmental health risk management.

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2. 3. 4. 5. 6.

Assist development of National Policy and Strategic Plan for Non Communicable Diseases. Assist development of National Mental Health Policy and Strategic Plan. Undertake activities to support Tobacco Free Initiative. Foster advocacy in dealing with substance abuse. Facilitate integration of health promotion into disease control programmes.

Component 5 - Emergency Preparedness and Response The Government of Indonesia has been challenged by needs of traumatized and internally displaced persons from civil unrest and natural disasters in several provinces of Indonesia. Indonesia has only recently experienced complex disasters, and the institutional experience with them is limited The strategic direction of WHO in this area will be to foster development of a national capacity for emergency preparedness and response to emergent public health needs. Key Changes in Direction 1. Encourage adoption of international best practices and minimum standards in emergency management. 2. Support the development of emergency management capacity in government ministries. 3. Emphasize emergency mitigation and preparedness including better hazard and vulnerability assessments. 4. Increase extra budgetary resources to emergency relief activities in support of disaster affected populations. Component 6: Partnerships and coordination WHO has a major role in coordinating donor assistance in the health sector. WHO acts as a broker and arbiter exercising influence on developmental partners and government agencies. Key Changes in Direction 1. Increased role in coordinating donor assistance 2. Increased role in mobilizing resources from donor agencies 3. Promote inter-country cooperation in health development 4. Emphasize advocacy for putting health in the development agenda 5. Mobilize WHO support from the Headquarter, Regional and other Country offices. 6. Reorganize the WRs office to implement the new country strategy

Section 7:
Supporting and Implementing the CCS Introduction In general, the WHO strategy is to move from an operational support and supplementation of the MoH budget. This move will require more technical resources from all levels of WHO. For example, the emphasis on health system will require extensive technical assistance and local workshops to determine appropriate changes for Indonesia. Since field implementation will be limited, travel and supervision expenses will be limited. In addition, a move from fewer fellowships to the forming of a human resource development plan and strategy will also demand a change in expenditure patterns. Finally, the component on health promotion and healthy environment will work more on assessments and strategies, again requiring more intensive technical assistance and less operational support. All these changes are likely to mean substantial changes in WHO Office in Indonesia as well as the support required from the Regional Office and Headquarters. The shift in the emphasis of the working of WHO in Indonesia was discussed in a staff retreat. Taking into account the current staffing pattern as well as other technical assistance

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being provided by the country office in Indonesia, the change in WHO technical assistance and working within the country was then quantified. The pie chart below may please be seen in regard, which shows the position pre and post CCS.

P 11%

HS 24%

P 11% EHA 12% HE 10% HS 35%

EHA 20%

HE 11%

CDC 23% W+C 11%

W+C 12%

CDC 20%

Current WHO Technical Assistance

WHO Technical Assistance in CCS Legend

HS Health System CDC Communicable Disseases W+C Women and Child Health

HE Healthy Environment EHA Emergency Health P Partnership

Staffing and other resources WHO Indonesia currently has 35 full-time professional staff, although this includes some shortterm consultants assigned to Indonesia for six months or more. Of these staff, 20 are international staff while 15 are nationals hired on long-term contracts. It should be noted that two international positions are currently vacant (Monitoring and Evaluation and EPI Medical Officers) as are two national staff positions (NPO and Surveillance Specialist). The largest number of positions is involved with CDC programs, especially TB. This includes about eight positions funded by an extra budgetary project. In addition, all five positions involving Component 5 (EHA) are funded from extra budgetary resources. The following bar graph contrasts the total number of person years technical assistance in each component in the country office currently and proposed assistance under the country cooperation strategy.

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10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 Health system CDC Women & Children Healthy environment EPR Partnership

No. of Person Years

current ccs

Components

Based on the Strategic Agenda for 2001-2003, it is anticipated that there will be some changes in staffing and resource allocation to implement this agenda. Based on the special projects and appeals, it is anticipated that there will continue to be extra funds from outside the country budget. Component 1 (Health Systems) will require considerable strengthening in health organizations, decentralization, human resource development, health financing and health regulations. Component 2 (CDC) will continue to require large resources, especially for the tuberculosis control program. It is likely that the current support to leprosy be reduced depending on the status of the programme during 2001 to 2005. Support will be needed for malaria and other vector borne diseases. More resources should be put on surveillance, a key element of the strategic agenda. Also tied to surveillance is support for health laboratories. No major changes are anticipated in Component 3 (Health of Women and Children). Some of the resources used for developing IMCI can be moved to other areas of the strategic agenda. Additional resources are needed to provide more attention to nutrition. Component 4 (Promoting Healthy Environment and Lifestyles) will be sustained and strengthened in the area of assessment and strategic reviews. Component 5 (Emergency Preparedness and Response) will require sustained resources.. Finally, Component 6 (Partnerships and Coordination) will require a re-evaluation of the operations of the WRs office. The likely increases in extra budgetary projects and personnel will mean an increased administrative and management burden for this office. In addition, capacity to be involved with partnerships (both in the United Nations and with donor partners) will demand more personnel and other resources. The following table gives a rough estimation of technical assistance required over the next five years in the country. This assistance could be in the form of long term posts in the country office, short term consultants, support from the regional office or headquarters as well as technical expertise available within the county.

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Component

HEALTH SYSTEM

CDC

Women & Children

Estimation of Technical Assistance 2001-2005 Expertise Quantity(person months) Organization Development 24 District Health System 90 Health Financing 60 Human Resource Development 60 Drugs 60 Surveillance \ Epidemiology 60 Quality Assurance 48 Management Information System 60 Planning 60 Subtotal 522 EPI 36 Tuberculosis /HIV-STD 180 Vector borne diseases 60 Laboratory Services 12 Subtotal 288 Reproductive Health \ MPS 90 Child Health \ IMCI 60 Nutrition 24 Community Involvement \ 6 Subtotal 180 Mental Health \ Substance Abuse Tobacco Environmental Health Promotion Non Communicable Diseases Subtotal Emergency Public Health Disaster Management Subtotal Advocacy Leadership Administration + Management Resource mobilization Subtotal TOTAL Average Person Months per Year 12 24 36 60 12 144 120 60 180 30 60 60 12 162 1476 295.2

Healthy Environment

EHR

Partnership

HQ and Regional Support There are several key areas requiring special support from the regional level and headquarters. With the heavy focus on strengthening health systems during the period of the strategic plan, technical support will be essential. Similarly, decentralization will require experiences from other countries and experts who have faced similar situations in other countries. It is important for these experts to visit the country from time-to-time to assess the situation and to specify further technical needs. In addition, efforts of identifying and sending relevant reports and technical papers can help provide necessary inputs for local technical work. This will require active attention from WHO resources outside the country.

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Another area requiring technical support is in the area of the environment and health promotion. These are broad areas with a major need of special assessments to determine local strategies and priorities. Periodic reviews also need to consider the extensive work of other donor partners who often have a much large role than WHO. It is essential to identify where WHO can make a key contribution in these areas without being the major player. Major donor-funded projects, such as tuberculosis control and various projects in emergency and humanitarian assistance, will require periodic external reviews from outside the country. These must be done on a regular basis to provide timely inputs and modifications of local work. Materials and guidelines developed in other parts of WHO must be immediately brought into these local activities. It some cases, special materials and procedures can be developed from outside the country itself. Financing the Strategic Agenda The budgetary implications of the strategic agenda of the country imply an overall increase in financial resources, mainly due to increased country staff and STCs required for technical support. At the same time, it is likely that the WHO country budget will continue to fall. Nonetheless, it is likely that there will be adequate resources available from extra budgetary resources. This included donor support to WHO at the country level, donor support to WHO at the regional or Headquarters levels and indirect support for technical assistance through World Bank and ADB projects to the Indonesian government. While the scenario of increased extra budgetary resource is likely to be good in Indonesia, there are implications for the country strategy. Appealing for money means that more technical resources will be needed to hold discussions with possible funding agencies and to prepare proposals to the donors. In addition, the donors expect accountability if they are providing specific funds for various projects. Dependency on extra budgetary support will always involve the fine line between technical support as opposed to actual implementation. The country office must be able to limit its support for operational activities as these are likely to require extensive staff and administrative inputs. Finally, the greater use of extra budgetary funding must consider the smooth execution of administrative procedures. Issues of staff hiring and procurement are often result in major implementing delays and require that extensive involvement of technical staff. The regional office and Headquarters must be assessed to improve administrative support to the country office.

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