68976 Senior Policy Seminar on Health Systems Strengthening Bandung, Indonesia Summary 1. Background At the request of the Government of Indonesia to provide more support on policy development in the health sector, the World Bank organized a Senior Policy Seminar (SPS) with senior officials of the Ministries of Planning (Bappenas) and Health (DEPKES), Provincial and District planning and health officials, and noted academics. The seminar focused on health systems strengthening and disseminating the policy messages of the second Disease Control Priorities Project (DCPP2) volumes with particular attention on the impact of Indonesia’s underlying demographic, epidemiological, and nutrition transitions on future health system needs; global health financing experiences related to sustainability, coverage of informal sector workers, benefit package design; and, a range of health manpower issues including numbers, mix, deployment, incentives, productivity, and quality. The Seminar was organized by the Jakarta-based Health team, Claudia Rokx, Puti Marzoeki and Pandu Harimurti with support from Vic Paqueo, HD Coordinator. Washington DC participants included Ed Bos, Lead Demographer, HDHNE, George Schieber, Consultant, Health Financing Expert, HDHNE, Jed Friedman and John Giles, Senior Economists, DEC, experts on labor markets/human resources for health (HRH) and health planning models and Jups Kluyskens, consultant in public sector management. The agenda, participants list, and presentations are attached as Annexes 1-3, respectively. The seminar was co-financed with a grant from the DCPP2 program. The seminar was requested by the Indonesian government with the objective to provide them with global experience and the underlying analytics in a variety of key health systems reform areas in which the GOI has undertaken major and complex reforms. In particular, the GOI in 2004 passed a law to implement universal health insurance coverage under a social health insurance model by 2009. Interacting with this effort is the “big bang� decentralization law passed in 2001, delegating responsibility for virtually all service delivery to district levels with a complex amalgam of intergovernmental fiscal arrangements. The decentralization reform is still evolving with lack of clarity of governmental roles and major questions about the appropriateness and adequacy of the various intergovernmental fiscal formulae. An additional objective of the seminar was to gather views and inputs from the Indonesian counterparts for the Bank’s future analytical and policy work in the health sector in Indonesia. 2. Seminar Content The seminar was divided into four main sessions. The first session’s objective was to provide an overview of Indonesia’s health system and the underlying demographic and epidemiological dynamics. This first session laid out the context for the second and third sessions in which the implications of changes in the context for financing and workforce in the health sector were discussed. The fourth and last session’s objective was to agree, come to a consensus, on the main issues and challenges and a process how to address these challenges in a future analytical agenda, and how the World Bank could assist GOI in this process. 3. Session 1: Setting the context The first session focused on the demographic, epidemiological and nutrition transitions. GOI officials, academics, and Bank staff all presented a situation analysis of Indonesia’s health system and its current reforms, the unfinished agenda, and the global evidence base in the specific requested reform areas. The presentations and discussions set the stage for the needed changes in:  public health program foci,  Indonesia’s future health system needs, and  future delivery system configurations, health worker deployment and financing policies The session also highlighted the enormous disparities in terms of disease prevalence and health outcomes in the various parts of this country. While there was a strong focus on the overarching non-communicable disease (NCD) burden, there was also a good deal of discussion of Indonesia’s persistent problems with malnutrition and maternal mortality. The extensive NCD discussion focused on the high incidence of tobacco use, poor diet, and the challenges in such a diverse country to deal with NCDs. A needs-based planning model for future manpower and facility ‘needs’ based on the evolving epidemiology developed by the Bank in 2005 in collaboration with Indonesian GOI officials and academics was also presented and discussed. 4. Session 2: Health Financing The second session on health care financing focused on global and Indonesian health expenditure patterns, revenue raising and sustainability concerns, and overall macroeconomic issues; the various health financing functions, objectives, and models and how Indonesia fares in these regards; and, the global evidence base and experiences from other developing and developed countries concerning the enabling conditions for successful implementation of universal coverage. Indonesian presenters and panelists focused on the many unresolved issues in Indonesia’s current reform effort including:  limited success with national health accounts;  the many unresolved issues in the SHI expansion to universal coverage including: the design of the basic benefit package (BBP), how to cover and finance informal sector workers, coordination of Askeskin with Askes and Jamsostek, and the overall financial sustainability of these systems; and,  basic outstanding issues with the intergovernmental fiscal structure including: potential mismatches of funding flows, needs, and equity concerns, basic services requirements which are heavily focused on public health, the affordability of such, and the potential mismatch between the SHI BBP and the minimal service standards. The discussion also highlighted the neglected provider payment/contracting issue and the many unresolved SHI issues facing reformers, both institutional and economic, despite a reasonably favorable medium term fiscal situation. 5. Session 3: Indonesia’s Health Work Force: Issues and Challenges The third session focused on human resources for health (HRH). The presentations focused besides the current status on questions that could be analyzed in future research; an initial discussion on the effectiveness questions surrounding the long-standing health HR policy, the PTT-program and an example of the Yogyakarta Health Care Quality Council experience with licensing and accreditation at the province level. During the discussion and reactions to the presentations, the following issues were raised:  numbers and mix, deployment, pay and incentives,  the public and private mix,  restrictive medical practice standards precluding midwives and other non- physician personnel from legally performing many of the functions that they actually do and need to perform as part of their jobs, particularly in remote areas, and,  issues of quality, licensure and accreditation. Lack of clarity of roles among governmental levels, the importance of the private sector and the issues with the current dual practice arrangements, and the problems with the current incentive structures were all discussed in detail. The special problems of rural areas were repeatedly discussed and the severe shortage of specialists was a continual theme. 6. Session 4: Moving ahead with Indonesia’s Health Agenda The fourth session was a free ranging discussion of Indonesia’s reform needs and a possible joint GOI – Bank led collaboration to assist the GOI in resolving some of the many issues it is facing. Ten major areas of reform resulting from the 2-day discussions were highlighted: 1. Non-communicable diseases (NCDs) including tobacco, diet, and exercise 2. Basic public health functions 3. Health care demand projection model 4. SHI phase-in including the BBP, informal sector employees, Askeskin implementation and financing, actuarial costing and sustainability 5. Provider payment/contracting issues 6. Decentralization including the various intergovernmental fiscal revenue sharing formulae, the minimal service standards, and roles and responsibilities of all stakeholders 7. Pharmaceuticals 8. Health information system and monitoring and evaluation 9. Human resources for health including local and provincial government roles, numbers, mix, incentives, deployment/underserved areas, licensing/accreditation/legal protections, specialist shortages, training and education, and dual practice 10. Physical infrastructure and medical equipment A democratic process to identify the 3 biggest challenges on which to focus in future work was applied. Not surprisingly, Indonesian participants identified the SHI phase- in/financing, decentralization and HRH as the three most important areas for immediate collaboration. However, it was also recognized that, given the interactions across almost all these areas, that some focus on the other seven areas is needed as well. In fact it was recognized that very little intensive work has been done in key areas such as pharmaceuticals and provider payment, while other areas such as NCDs and tobacco were also front and center on the GOI’s policy agenda. 7. Next Steps GOI officials requested that the Bank coordinate an effort with other donors to assist the government in an overall health system’s strengthening effort focused primarily on SHI, decentralization, and HRH but also addressing the other important interactive and sometimes neglected issues raised above. The Ministry of Health will send a formal request through the Minister of Planning to the World Bank. Both an inter-ministerial policy level steering committee and technical focal points will be established. Key ministries mentioned to be represented on the committee are Health, Planning, Finance, Education and Home Affairs. In particular follow up with Finance was agreed upon as a key next step. The Bank will collaborate with the other key donors in the identified areas and, once the official request from the GOI is received, will develop in collaboration with the GOI and key donor partners a detailed outline of the proposed activities and a draft work plan to take the effort forward for discussion. Simultaneously, the Bank and other key donors will allocate the necessary resources for undertaking the necessary studies and activities. These efforts will focus on capacity building as well as the development of a health systems strengthening plan with the ultimate goal to feed into the 2009-2015 five year development plan for Indonesia. Indonesian officials will undertake the necessary GOI steps for the official request. Bank staff will inform its senior management and meet with the other key donors. It is anticipated that a preliminary work plan will be developed by end-August and that the plan will be finalized shortly after the tentatively planned WBI Capacity Building Course for Ministers, provincial, and district health leaders and other stakeholders at the end of August 2007.