HUMAN RESOURCES FOR HEALTH AT THE DISTRICT IN INDONESIA
As outlined by Bossert, the underlying notion of decentralization, …….implies the expansion of choice at the local level. “ Using a principal / agent approach, Bossert describes this expansions as “decision space” the range of effective choice that is allowed by the central authorities (the principal) to be utilized by local authorities (the agents).” The nation of decision space can then be used to asses the situation for the various functions and activities of local authorities. Viewed in this way, decentralization is process, the outcome of which may vary across functions and over time.
Consistent with this approach, the radical and rapid change in intergovermmental relations in Indonesia was expected to lead to many changes at the district level, especially to improved public sector performance. These expectations were based on the view that although districts would remain heavily dependent on transfers of funds from central goverment for their revenue, the tight specification of the way in which funds would be used, which characterized the highly centralized government of the Suharto era, would be greatly relaxed and the districts would now decide how funds would be spent – this increased autonomy at the local level was then expected to result in decisions more suited to the local setting and improved outcomes.
Like other government services, the health sector has also been affected by these changes. One of the areas in the health sector more affected is human resources. Prior to decentralization, the central Ministry of Health had complete responsbility for the health sector, including human resources, and decided how resources were to be allocated in the districts. Although in principle the districts now have control of their public sector health workforce (Hence the statement in one important analysis of decentralization in Indonesia that ‘Over 2 million civil servants, or almost tho thirds of the central government workforce were transferred to the regions’), the central government still controls all permanent civil servants (Pegawai Negeri Sipil – PNS) working at the district level, these staff are paid directly from the centre and the centre effectively controls hiring, firing and the conditions of employment of this category of staff. The centre also controls hiring, firing and the conditions of employment of a category of contract staff known as PTT (Pegawai Tidak Tetap).
However, there are, in addition, many public sector staff members contracted at the district level who are neither PNS or PTT. These locally contracted staff have been crucial to allowing districts to develop flexibility in total numbers and skills mix in their staffing plans. The central government has little, if any, information about this category of staff – their qualifications, how many there are, where they work or the conditions of their employment.
Before decentralization, districts were obliged to respond to demands from the central government for information about use of resources, health status, the deliveryof services and human resources for health. Although there were inaccuracies in the data and delays in receipt at the cancer, it was possible for the central government, through their representives in the provinces and districts, provincial and national levels. With decentralization the districts no longer feel as obliged to maintain these records or to respond to requests for information from the center. In addition, there is increasing number of private sector health care providers who do not work for the government at all, and the central has little information for the sector as a whole about its most critical asset, human resources, than it did before. And this is occuring at a time when the there is great concern about the lack of attention to human resources in the health sector globally, especially that many governments do not have even basic information about their most important resource : how many health professionals, theis age and sex, or how they are distributed. At the same time, there are clear indications that the health system and the health needs of the population are changing and that government must modify policies in response to these changes and shape a health system that can cope with the future. Reliable information about human resources for health is vital to envisioning a health system that can respond to the health challenges facing Indonesia.
The work reported here is part of an attempt to understand what is happening at the district level in the health sector, starting with a basic enumeration of the human resources and the health facilities in which they work and deliver services. Our aim, in a sample of 15 districts in Java, is to : (1) enumerate the stock of health facilities (public and private) in the health sector in 2006; (2) enumerate the stock of human resources (public and private) in the health sector in 2006 trained to provide care and treatment for illness – in Indonesia this means doctors, nurses and midwives; and (3) estimate the funds (public and private) spent on health care in the course of 2006. The results will be reported in separate papers. This paper address the following questions :
What is the stock of human resources for health trained to provide care and treatment for illness (doctors, nurses, and midwives) at the district level, by professional group ?
What is the service status of these health care providers at the district level ?
What is the primary place of work of these health care providers at the district level ?
What was the effect of decentralization on human resources for health at the district level ?
What are the implications of the results for future delopment of the health sector?