Born in Cirebon, West JawaBorn in Cirebon, West JawaDokter from UNIVERSITAS INDONESIADokter from UNIVERSITAS INDONESIAMaster of Public Health: HARVARD-USAMaster of Public Health: HARVARD-USADoctor of Science: JOHNS HOPKINS-USADoctor of Science: JOHNS HOPKINS-USAPost Doc in Statistics: UNIV of MICHIGAN-USAPost Doc in Statistics: UNIV of MICHIGAN-USACurrent Activities:Current Activities:

Indonesian Public Health AssociationIndonesian Public Health Association,, PresidentPresidentGlobal Fund TB at Global Fund TB at FPHFPH-UI, -UI, DirectorDirectorHealth Professions Coalition for Anti Smoking,Health Professions Coalition for Anti Smoking, ChairmanChairmanNational Expert Panel on TB,National Expert Panel on TB, Health Policy SpesialistHealth Policy SpesialistIndonesian Healthcare HIV/AIDS Roadmap development,Indonesian Healthcare HIV/AIDS Roadmap development,

Head of TeamHead of TeamKomnas Penelitian & Pengkajian Penyakit Infeksi (PINERE) Komnas Penelitian & Pengkajian Penyakit Infeksi (PINERE)

Litbangkes Kemenkes, Litbangkes Kemenkes, Expert PanelExpert PanelIndonesian MCH-Nutrition Eval Team,Indonesian MCH-Nutrition Eval Team, Head of TeamHead of TeamDept of Health Policy & Administration, UI, Dept of Health Policy & Administration, UI, Past Chairman; Past Chairman;

Advice & examnine more than 150 PhD dissertationsAdvice & examnine more than 150 PhD dissertationsNational Health Research Committee,National Health Research Committee, Expert PanelExpert PanelResearch Committee in Hospital, Research Committee in Hospital, Expert PanelExpert Panel

PUBLIC H

EALT

H

PUBLIC H

EALT

H

GOOD

GOOD

GOVERNANCE

GOVERNANCE

THE ROLE OF PUBLIC HEALT

H PROFESSION

THE ROLE OF PUBLIC HEALT

H PROFESSION

adan

g@pos

t.har

vard

.edu -

2013

……the rule of law, predictable the rule of law, predictable administration, legitimate administration, legitimate

power and responsive power and responsive regulation …regulation …

Kofi Annan, UN Secr Gen

EFFORTS FOR GOOD GOVERNANCE (G-EFFORTS FOR GOOD GOVERNANCE (G-G)G)Health Sector Reform:Sustained, purposeful change to improve the efficiency, equity and

effectiveness of the health sector (Berman, 1995).

Financing of healthUser charges (Jampersal)Community financing schemes (Dana sehat) Insurance (Jamkesda, Jamkesmas, SJSN)Stimulating private sector growth (Hospital Law no 44/2011) Increase resources to health sector (5% APBN + 10% APBD, BOK,

DAK, Dekon, etc)

EFFORTS FOR GOOD GOVERNANCEEFFORTS FOR GOOD GOVERNANCE

Health Sector Reform:Sustained, purposeful change to improve the efficiency, equity and

effectiveness of the health sector.

Organization and ManagementDecentralization (Govt Reg no.38/2008, no.19/2010)Contracting out of services (PTT)Public-private mix (TB program)

EFFORTS FOR GOOD GOVERNANCEEFFORTS FOR GOOD GOVERNANCEHealth Sector Reform:Sustained, purposeful change to improve the efficiency, equity and

effectiveness of the health sector.

Good Governance / Public Sector ReformDownsizing public sector (Family Physician)HRH productivity improvement (MTKI/MTKP; Financial Audit) Introduction of competition and quality (Hospitals w global standard) Improving geographic coverage (Priority of DTPK, PTT program) Increasing of local governments (CCF of local govts)Targeting role of public sector through packages of essential

services (Puskesmas revitalization)

G-G FOR SUSTAINABLE DEVTG-G FOR SUSTAINABLE DEVT

““Good Governance and Good Governance and sustainable development sustainable development are are indivisibleindivisible… Without good … Without good governance – without the rule of governance – without the rule of law, predictable administration, law, predictable administration, legitimate power and responsive legitimate power and responsive regulation - no amount of regulation - no amount of funding, no amount of charity funding, no amount of charity will set us off the path to will set us off the path to prosperity”prosperity”

Kofi Annan, UN Secretary General

G-G FOR HEALTH STATUS ATTAINMENTG-G FOR HEALTH STATUS ATTAINMENT

Modified from: ECA Africa Governance Report, 2004

G-G PRINCIPLESG-G PRINCIPLES

Principles of Public Sector GovernanceAccountabilityTransparencyIntegrityStewardshipLeadershipEfficiency

ACCOUNTABILITYACCOUNTABILITYAbility to describe clearly and/or detailed justification of activity

plans with clear responsibility of any transaction and decision; its outcomes and further consequencies

Have strategic roles in public services

Ability to explain on budget plan-execution-and monitoring, use and implement the budget plans for and only for public health interventions

The aboves explicitly express public interest, above all individual interest, and abide to rules

Modified fr: www.records.nsw.gov.au

ACCOUNTABILITY LEVELINGACCOUNTABILITY LEVELING Individual

PH officers commitment; responsibility; and high professional skills and competencies

OrganizationalEach unit has objectively measurable otputs related to PH goals

Community at largeAssuring PH professional conduct in front of public

TRANSPARANCYTRANSPARANCY

Systematically develop public health information system for each

individual to be able to make decision for own’s health

STEWARDSHIP & STEWARDSHIP & PUBLIC HEALTH LEADERSHIPPUBLIC HEALTH LEADERSHIP

The indicators are

Ability for strategic thinkingEstablish productive working conditionsSoftskills-softskills-softskills (integrity)Output oriented

PUBLIC HEALTH PUBLIC HEALTH PROBLEMSPROBLEMS

IN INDONESIAIN INDONESIA

DECREASING QUALITY OF MIDWIVES

1.Weighing pregnant woman2.Fundus uteri height3.Blood pressure meas.4.Iron tablets5.Tibia sign for pre-eclampsia

Low Exclusive Breastfeeding

Catatan: SDKI 2007, 6-7 bulan 7,2%; 4-5 bulan 17,8%

0.0

20.0

40.0

60.0

80.0

100.0

120.0

0 1 2 3 4 5 6 7 8 9 10 11

Age of baby (in month)

Kuintil-1-2

Kuintil-3-4

Kuintil-5

Health centres limited accessibility, availability, effectivity

Difficulties in HRH

placement

Low ability in budget

advocacy

Low Financial accountability

system

Limited monev & superv

Health technology

assmt & use(-)

Inadequate HC need

assessment

Substandard health care

quality

Inadequate drug supplies and

logistics

Barrier to access for

poor people

Inadequate healthcare quality

climate

Bachtiar, 2008

USING BALDRIGE USING BALDRIGE FRAMEWORK:FRAMEWORK:

Low healthcare performance, related to:

Low healthcare leadership at healthcentreLimited HRH capacitation and management Ineffective health information system at health centreLimited community empowerment

Bachtiar et al, MCH & Nutr Midterm Ev , 2012

PROBLEMS #2:PROBLEMS #2:

HEALTH PROGRAMMING & HEALTH PROGRAMMING & POLICIESPOLICIES

Primary health care is neglected (2010 Health Facility Survey)

No maintenance for health devices and appliancesLimited procedures for clinical pathway/governance

Limited local government’s budget for operational and maintenance

Difficult HRH recruitment and placement

Chronic problems in drugs’ accessibility and availability

Inadequate Health information System, i.e. non-existence Knowledge Mgmt SystemData collection abilitiesData analysis capacity Information uses for decision making Information uses for capacity development

Mostly it’s related to limited financing health system

LOW PRIORITY TO HRH LOW PRIORITY TO HRH DEVTDEVT HRH contributes at leat 80% for the success of PH efforts

Anand S, Bärnighausen T. Health workers and vaccination coverage in developing countries: an econometric analysis. The Lancet, 2007, 369: 1277–1285.

Speybroeck N et al. Reassessing the relationship between human resources for health, intervention coverage and health outcomes. Background paper prepared for The world health report 2006. Geneva, World Health Organization, 2006 (http://www.who.int/hrh/documents/reassessing_relationship.pdf).

Weaknesses:HRH production system (Relevancy-Quality-Effectivity)HRH planning capacityRecruitment and deploymentPerformance monitoring and developmentIncentive and career mobilityHRH information system

INDONESIA – COUNTRY WITH HRH INDONESIA – COUNTRY WITH HRH CRISISCRISIS

LOW QUALITY WORKLow correlation b/w Immuniz & Measle Prev

Riskesdas, 2007

MDs in district area (log)

Poor

people

Pro

port

ion

GPS MOSTLY IN CITIESGPS MOSTLY IN CITIES

Doctors tend to open private practices in (big) cities, even in a (very) high competition. It is assumed relate to incomprehensive ability

Poor/rich district

32

MDNursePublic HealthNutritionist10.333

47.3176.480

18212.726

11.771

1.511516

4.05817.537

2.987

1.033

7224.922

837 284

20.443

113.0247.481

2.40394

3693

3.843181

Concentrated in Java-Bali

33

HRH TO PH INDEXHRH TO PH INDEX

No. Doctors at Health Center

PH

P I

nd

exDistrictCity

PHC PHC SUSTAINABILITYSUSTAINABILITY

LOCAL GOVT BUDGETING FOR HEALTHLOCAL GOVT BUDGETING FOR HEALTH Means (7 provs)

PR.1 Public Health Programs 6.58%PR 1.1 MCH 0.70%

PR 1.2 Nutrition 0.97%PR 1.3 Immunization 0.12%

PR 1.4 TBC 0.06%PR 1.5 Malaria 0.30%

PR 1.6 HIV/AIDS 0.03%PR 1.7 Diarea 0.00%

PR 1.8 Pneumonia 0.01%PR 1.9 Dengue 0.06%

PR 1.10 Other infectious diseases 0.15%PR 1.11 Non-infectious diseases 0.03%

PR 1.12 Family Planning 0.57%PR 1.13 School Health Programs 0.07%

PR 1.14 Reproductive Health 0.01%PR 1.15 Environmental Health 1.20%

PR 1.16 Health Promotion 0.41%PR 1.17 Disaster Program 0.02%

PR 1.18 Surveillance 0.05%PR 1.19 Other Public Health Programs 1.83%

Gani, 2011

LOCAL GOVT BUDGETING FOR HEALTHLOCAL GOVT BUDGETING FOR HEALTHMeans

(7 provs)PR 2 Personal healthcare 41.23%PR 2.1 Curative visits 1.50%PR 2.2 Hospitalisation program 0.89%PR 2.3 Referral program 0.15%PR 2.4 Others for personal healthcare 38.69%

PR 3 Management and Capacity Building 52.20%PR 3.1 Administration and health management 25.29%PR 3.2 Health information system 0.28%PR 3.3 Capacity Building 0.57%PR 3.4 Infrastructures provision 15.65%PR 3.5 Monitoring and supervision 0.54%PR 3.6 Drugs and health logistics 6.90%PR 3.7 Health insurance 3.24%PR 3.8 Other Capacity Building activities 0.11%

Grand Total 100.00%

IN CONCLUSION:IN CONCLUSION:

NON-PYRAMIDICAL “ENERGY” FOR NON-PYRAMIDICAL “ENERGY” FOR HEALTHHEALTH

PROBLEMS #3:PROBLEMS #3:

LOCAL GOVERNMENTLOCAL GOVERNMENT

Limited understanding of Human Development Index Approach, i.e. MDG targetsPoverty as health risk (vice versa), limitly understood Non synchronize sectors development to support HDI/MDG goals

Inappropriate, inadequate and delayed budget transaction implementation

Fragmented funding sources for health development

Limited budget accountability

Low priority HRH mgmt at local governments

WTP=Clean w/o restriciton WDP=Clean, but with some notes/restrictionDisclaimer=Couldn’t declare accountability Adverse=Non accountable

Patent

R&D and clinical trials

Manufacturing

Pricing

Distribution

Registration

Selection

Procurement & import

Promotion

Inspection

Conflict of interest

Overstated results

Substandard med

Tax fraud

Research falsification

Bribery

Regulatory breech

Falsify bills

Decision pressures

Unethical promotion

Stealing

Fraud

Med Cartel

Collusion

Unethical donation

CORRUPTION CHAIN IN DRUGS CORRUPTION CHAIN IN DRUGS AVAILABILITYAVAILABILITY

Research priority

WHO, 2007

CORRUPTION COUNTRYCORRUPTION COUNTRY

STEWARDSHIP & LEADERSHIP ??STEWARDSHIP & LEADERSHIP ??

INILAH INILAH ELITE BANGSA ELITE BANGSA INDONESIA..INDONESIA..Persoalan bangsa tidak berhasil dituntaskan secara substansial

bahkan bertendensi hanya memindahkan persoalanMelemahkan sendi-sendi berbangsaAkan tenggelam dalam krisis dimensi lebih luas, kompleks dan dalam

Salah satu penyebabnya adalah:Para pemimpinnya telah mati rasa..Tidak konsisten antara ucapan dan perilakuKalahnya keluhuran budiKerdilnya semangat kebangsaan Interaksi transaksional yang paling rakus

Ahmad Syafii Ma’arif, 2010

Health outcomes:Life expectancy at birth :67 IMR :31MMR :240

Health Inputs:Govt health expenditure : 6.2%Hospital beds (per 10,000) : 6# Doctor (per 10,000) :1.3# nurses & midwives (per 10,000) :8.2

IMPACT TO PH IMPACT TO PH ACHIEVEMENTSACHIEVEMENTS

MDG Progress(Peter Warr-ANU, 2010)

CONCLUSION: Inefficient Health System

Misdirected & Overheated Personal Care Neglected PHC prioritiesNeglected PHC priorities

Budget orientation for

curative

Educate for curative

only

Overloaded hospital care,

anger and critics

Limited ability for healthy life

style regulations

Soc Det of Health esp.

Poverty

Unhealthy life styles

Low capacity for PHC devt

Limited budget for

PHC

Non-vitalized PHC

infrastructures

Low ability in health politics

PHC considered not for profit

only

Limited synergy of Acad-Buss-Govt for Comm

EmpowermentFailure in gatekeeping PHC system Low

understanding of community

empowerment

Low non standardized health Low non standardized health profession’s competenciesprofession’s competenciesModif: Bachtiar, 2011. WHO Meeting for CHW at Srilanka

Part-3

Part-3

Visi:Zero-Tolerance

Designing PH progrDesigning PH progrAsesmen Risiko. Ulasan mutu

Kendali internal

Proactive preventionProactive preventionPemberdayaan masy sipil

utk akuntabilitas & transparansi,

Kapasitasi internal, Kontrak terbuka

Supervision systemSupervision systemVerifikasi on-site, Expert support

Siklus PDCAUlasan target periodik

PH capacitationPH capacitationKomitmen Pemr. Staf mumpuni

S.o.p kerja, Kapasitas auditKlausul perjanjian

Effective sactionEffective sactionPenundaan & pembatalan.

Kepatuhan thd ethical conduct.Merit based performance

Rules & Rules & regulationsregulations

Kebijakan KorupsiKlausul2 & perjanjian

FRAMEWORK-1:FRAMEWORK-1: ZERO TOLERANCE TO CORRUPTIONZERO TOLERANCE TO CORRUPTION

COMPREHENSIVE EFFORTSCOMPREHENSIVE EFFORTS

GLOBAL COOPERATIONGLOBAL COOPERATION

United Nations Office for Drugs & Crime (UNODC)Corruption prevention is an integral part of crime prevention policiesA culture of integrity and corruption prevention are shared

responsibilities for all sectors of society, including: the corporate communityProfessionals & civil societymediamembers of parliaments scientific and educational institutions

UNODC, 2009

Professional Professional CapacityCapacityInformational-Role Perception-PracticesSDM dg

kapasitas aktif anti korupsi

ProductiveInteractions

Supervisor & Pengawas

yang kompeten

Interaksi aktif melalui:.Supervisi & audit

.Continuing Learning.Program prevensi

.Pemulihan

Database kinerja SDM mudah diakses dan

ditransfer

OO - Output terukur

UU - Utamakan budaya pencegahan tindak koruptif & ancamannya

TT - Training menuju kemandirian pekerja dlm hadapi tindak koruptif

RR - Rancang mobilisasi sumberdaya lingkungan untuk anti koruptif

EE - Eratkan partisipasi semua

AA - Adopsi dan adaptasi rencana kerja sesuai kebutuhan

CC - Cerahkan stakeholders melalui komunikasi

HH – Himpun-pelajari sukses & tahapan2nya

FRAMEWORK-2FRAMEWORK-2: MILESTONES: MILESTONES

AdvocacyAdvocacy

BrokeringBrokeringKnowledgeKnowledge

Convening Convening StakeholderStakeholder

AdvocacyAdvocacy

BrokeringBrokeringKnowledgeKnowledge

Convening Convening StakeholderStakeholder

HRHHRHStewardship & Stewardship &

GovernanceGovernance

Costed Costed PlanPlan

Rule of Rule of LawLaw

Process Process ImprovmntImprovmnt

Stakeholder Stakeholder CapacitationCapacitation

PH HRH PH HRH PerformancesPerformances

FW-3:FW-3: STRATEGIC STRATEGIC COMPONENTSCOMPONENTS

HEALTH OUTCOMES

HEALTH SYSTEM TARGETS

Access& EquityEffectivity & Effciency

SustainabilityQuality

PH HRH MAPPING

PH HRH CONTROL &

EVALUATION

PH HRH EMPOWERMENT

POLITICS & POLICY

FISCAL CAPACITY

HRH MGMT SYST

OTHER HEALTH SYSTEM

COMPONENTS

DEVT PRIORITY(HDI)

PH HRH PLANNINGLEADERHIP

EDUC & TRAINING

ALLIANCES e.g., THRU CCF

FRAMEWORK-4:FRAMEWORK-4: DECENTRALIZED PROFESSIONAL DECENTRALIZED PROFESSIONAL DEVELOPMENTDEVELOPMENT

Part-4

Part-4

HEALTH PROFESIONALS HEALTH PROFESIONALS MUST HAVEMUST HAVE_1

Knowledge-driven modelAdequate knowledge and skills to understand health

problems, at all levels, ie, individual and community

Problem-solving modelAdequate professional skills to solve health problems

Interactive modelAdequate softskills for implementing public health

solutions within social economic development frameworks and perspectives

Enlightenment modelA comprehensive involvement in social cultural, poltical

and economic development for the sake of people’s health

HEALTH PROFESIONALS HEALTH PROFESIONALS MUST HAVEMUST HAVE_2

11STST DOMAIN: DOMAIN:

STRUCTURIZATION OF STRUCTURIZATION OF HEALTH COMPETENCIESHEALTH COMPETENCIES

1a.M

onito

ring

Health

Sta

tus

1b.Diagnose & Investigation

2a.Information,

Capacitation,

Empowerment

2b.Alliances

3a.H

ealth

Pol

icy &

Regul

atio

n3b.Rules

enforcement

4.Stdzed healthcare

5.Competenced HRH

6.Monev

22NDND DOMAIN: DOMAIN:

HEALTH PROFESSIONS HEALTH PROFESSIONS INVOLVEMENTINVOLVEMENT

4-Capacitation inHealth Knowledge

Development

1-Capacitation in Policy & Programming

3-Capacitation in“Health is

AlsoIndividual Responsibility”

2-Alliance Capacitation

1.Strong Health Profession Inst.

4.Sources for Health action

2.Health professions’Mobilization

3.Knowl & SkillsDevelopment

•SOLIDITY of the ProfessionsSOLIDITY of the Professions•Health Profession orgz existence•Continuous standardization •Accreditation•Continuing Education

•Health System Capacitation:Health System Capacitation:•Clinical governance•Health policy capacitation•Programming & monev facilitation

•Tacit KNOWLEDGE for:Tacit KNOWLEDGE for:•Innovation in Health Intervention•Innovation in Health-programming•Innovation in Healthy Life Styles

•Health is POLITICS:Health is POLITICS:•Fiscal capacitation•Resource mobilization•Embedded Health knowl•Healthy Public Policy

Adapted from Hughes-Tuohy 2003 & Hicks & Mishra 1993

33RDRD DOMAIN: DOMAIN:CLOSE ENCOUNTER WITH HEALTH CLOSE ENCOUNTER WITH HEALTH

USERSUSERS

Involvement of (end) Users

Health professions’ competency development

Stakeholders involvement in each step

Goals of HealthDevt

PlanningDevt

ProcessImplem &

MonevDirect

Outputs

HealthOutcomes(Indirect)

Expected benefits:-Health system capacitation

-Evidence based-Health Improvement

CLOSE ENCOUNTERS’ CLOSE ENCOUNTERS’ IMPACTIMPACTA Effective knowledge production – e.g. Publications

B Research targeting, capacity building and absorption(i) better targeting of future research;(ii) development of research skills, personnel and overall research capacity;(iii) critical capability to utilise appropriately existing research, including that from overseas;(iv) staff development and educational benefits.

C Informing policy and product development(i) improved information bases on which to take political and executive decisions;(ii) informing product development.

D Health and health sector benefits(i) cost reduction in the delivery of existing services;(ii) qualitative improvements in the process of service delivery;(iii) increased effectiveness of services e.g. increased health;(iv) equity e.g. improved alloc of resources at an area level, better targeting and accessibility;(v) revenues gained from intellectual property rights.

E Broader economic benefits(i) wider economic benefits from commercial exploitation of innovations arising from R&D;(ii) economic benefits from a healthy workforce and reduction in working days lost.

PEOPLE’S PEOPLE’S EXPECTATIOEXPECTATIO

N TO THE PH N TO THE PH PROFESSIONPROFESSION

Expectations From PH LeadersExpectations From PH Leaders

Competitive AdvantagesEV

IDEN

CE B

AS

ED

H

EA

LTH

CA

RE

GLO

BA

L C

ULTU

RA

L

CO

MP

ETEN

CE

HU

MA

N

RES

OU

RC

ES

FO

R H

EA

LTH

EFFECTIVE RESOURCE MOBILZATION

POLITICAL COMMITMENT “HEALTH IS RIGHTS”

HEA

LTH

P

RO

FES

SIO

NS

S

YN

ER

GIS

M

(ON

E H

EA

LTH

)

HEALTHOUTCOME

I have a dream!I have a dream!

Martin Luther King, Jr.August 28, 1963