Sunday, November 28, 2010

Disaster~ 3) the cycle...


.......السلام عليكم ورحمة الله وبركاته

What is disaster management? What are the various stages that it involves? The terminology may differ depending on where you are. In New Zealand, for example, you would be talking of the 4R’s, namely Readiness, Response, Recovery and Reduction. In other places, such as Indonesia, it could be as outlined in the graphic below:


(Disaster management: click to enlarge)

There are no standardized rules defining the different phases of the disaster management cycle. Different agencies use different cycles depending upon their objectives. However, while approaches vary, it is agreed that disaster management activities should be carried out in a cycle. Some of the terms used in disaster management are described as follows:

  • Mitigation: any activity that reduces either the chance of a hazard taking place or a hazard turning into disaster.
  • Risk reduction: anticipatory measures and actions that seek to avoid future risks as a result of a disaster.
  • Prevention: avoiding and reduce the chances of disaster, usually the impact and damage of disaster.
  • Preparedness: plans or preparations made to save lives or property, and help the response and rescue service operations. This phase covers implementation/operation, early warning systems and capacity building so the population will react appropriately when an early warning is issued.
  • Response: includes actions taken to save lives and prevent property damage, and to preserve the environment during emergencies or disasters. The response phase is the implementation of action plans.
  • Recovery: includes actions that assist a community to return to a sense of normalcy after a disaster.

Disaster management (also called disaster risk management) is the discipline that involves preparing, warning, supporting and rebuilding societies when natural or man-made disasters occur. It is the continuous process by which all individuals, groups and communities manage hazards in an effort to avoid or minimize the impact of disasters resulting from hazards. Effective disaster management relies on thorough integration of emergency plans at all levels of government and non-government involvement. Activities at each level (individual, group, community) affect the other levels.

Whatever the terminology used, today it is an undeniable truth that the need of the hour is effective disaster management and preparation for a growing incidence, worldwide, of different forms of natural disasters.

Resources:
1)Lecture note on Conceptual Frame work of Disaster and Disaster Management by dr. Hendro Wartatmo

2)http://globalvoicesonline.org/2009/10/27/disaster-management-and-the-role-of-icts/


Saturday, November 27, 2010

Decentralization~ 2) Pros & Cons!


.......السلام عليكم ورحمة الله وبركاته

The general decentralization process has had many impacts on the health system, even though it was not designed specifically with the health sector in mind. Under decentralization, responsibility for health care provision is largely in the hands of regional governments.


i) Human Resources


The human resource situation in health has major deficiencies in numbers and quality of the health workforce.

Decentralization is one of many factors exacerbating long-standing problems with mal distribution and reportedly low productivity and quality of health workers.

Limited number of health workers affected health service in Indonesia. In 2006, ratio of general practitioners was 19.9 per 100,000 populations while ratio of midwife per 100,000 populations was 35.4.

ii) Health Information System


Decentralization resulted in a partial breakdown of health information systems and led to an unclear division of reporting responsibilities.

As a result, no comprehensive data exist that cover the entire nation. The disruption of the information flow makes it difficult to develop strategies and monitor health programmes in provinces and districts.

Exceptions do exist in some vertical programmes (tuberculosis, malaria or HIV-AIDS) where the Central Government retains the responsibility as the principal recipient of GFATM grants to the country

iii) Health Financing


Indonesia spends relatively little on health services. Estimated total expenditure on health (per capita, in 2003) was $ 33.

The overall health financing situation in Indonesia is complex and incompletely documented. In 2003, around 34% of total health expenditure is undertaken by public sector agencies, while 66% is private. By far the largest single source of private expenditure is direct out-of-pocket payments by households, accounting for nearly half of the total expenditure.

Privately provided services are largely financed by out-of-pocket payments, with some insurance and employer-financed expenditure benefiting a minority of formal sector employees. Publicly provided services are financed by a mix of public budgets and user fees, in turn financed by a combination of households, employers and insurers.

Until the advent of the new social insurance scheme for the poor, insurance coverage of the population was low, at well under 10%.

iv) Health Services


At primary health care level, Indonesia is generally regarded as having relatively adequate levels of provision, one public health centre for every 30 000 people on average.

In addition to public facilities, private practices are operated by doctors, nurses and midwives, in many cases by the same personnel as are employed in public facilities.

At the hospital level, Indonesia has low levels of bed provision at 62, 5 beds per 100,000 populations. Paradoxically, the utilization is also low, with bed occupancy rates in the vicinity of 56.2 % in both public and private facilities.

The private sector is increasingly important in the provision of health care in Indonesia, especially in big cities, with wide variations in quality of care. Furthermore, since there is no regulation of pricing or quality of service in place, users are vulnerable to excessive treatment and expenses.

The role of non-governmental organizations (NGOs) in Indonesia has been growing during the last two decades but the exact number of NGOs providing health care services remains unknown.

Despite the presence of a strong Drug Regulatory Authority, responsible for the registration of medicines as well as quality control and inspection, counterfeit drugs remain a big problem.

At the same time, the use of traditional medicines (such as ‘jamu’) is popular and widespread in Indonesia. Yet procedures for quality control of traditional medicines are limited in scope, and difficult to implement, also because large numbers of small-scale manufacturers exist.

When it comes to decentralization, many people see it negatively. It is true that decentralization has negative impacts, but do not forget that it also bring some good. Decentralization can be beneficial in the fact that it:

  • allows for experts to take control of specific functions of an organization
  • easily convey information back and forth
  • allows for direct contact and relationships with managers
  • allows managers to participate in planning.

Unfortunately, there are disadvantages of decentralization as well. For example:

  1. Some managers will find that they have too much work to do and other will have too little.
  2. It will also become difficult to have managers take on different tasks or projects if needed because of overspecialization.
  3. Also, if one manager leaves, there will not be anyone to pick up his place with quite the same knowledge and expertise.

Centralization is another method which has its pros and cons. A positive aspect is the fact that the corporate decision maker has full control over the organization and the decisions that the organization must follow. The organization may also benefit from the fact that all information is reported to the corporate decision maker; he or she listens to all comments and concerns and is able to infer from all information received.

There are disadvantages to centralization as well. The larger an organization becomes, the more information that one manager has to comprehend and consider; eventually he/she will need help. Tasks will have to be divided or else the organization will become disorganized and at times, seem chaotic. What happens if the manager is away for whatever reason? Timely corporate decisions are impossible when no one is around to make them.

Whether an organization chooses centralization or decentralization is completely a matter of choice. One system may work better than the other depending on the situation or the type of organization. It is an important choice and should be carefully and wisely considered.


Friday, November 26, 2010

Decentralization~ 1) what it is about?

.......السلام عليكم ورحمة الله وبركاته


For 30 years from 1967, Indonesia made remarkable progress. A period of economic growth raised per capita income from US$50 in 1968 to US$ 1,124 in 1996, despite an increase in population from 147 million in 1980 to 179 million in 1990, with a forecast of 210 million in the year 2000. Between 1980-1990 the annual population growth rate was 1.9%, 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 femalesinfant mortality rate declined from 142 per 1000 in 1968 to 50 per 1000 in 1998. The proportion of the 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. By 1997 the literacy rate for those aged 10 years or more was 89%.

However, 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 long droughts and extensive forest fires. This sudden crisis resulted in political turmoil and, in 1998, a change of government. The ensuing political instability has had a direct impact on economic recovery. The proportion of population living in poverty increased from the estimated 11-13 % (1996) to 24.2%(1998).

Triggered by the financial crisis of 1997, the resignation of the Soeharto government, and the weak public support for the Habibie government, demands for political and fiscal decentralization increased in 1998.

The new policy of decentralization is outlined in Law No. 22, 1999 concerning “Local Government”1 and Law No. 25, 1999 concerning “The Fiscal Balance Between the Central Government and the Regions”. Both these laws are based on five principles:

  1. democracy,
  2. community participation and empowerment,
  3. equity and justice,
  4. recognition of the potential and the diversity within regions and
  5. the need to strengthen local legislatures.

*** One aim of the policy of decentralization and regional autonomy is to bring the governments closer to their constituents so that government services can be delivered more effectively and efficiently. This is based on the assumption that district and municipal governments have a better understanding of the needs and aspirations of their communities than the central government.


The territory of Indonesia is divided into districts (kabupaten) and municipalities (kota). They are technically the same level of government but differ in its location. If located in a rural area (district) or if an urban area (municipality). Within districts and municipalities there are sub-districts (kecamatan) which are smaller administrative government units. Each sub-district is further divided into villages. Villages in rural areas are called desa, while in an urban areas there are referred to as kelurahan.

Law No. 22, 1999 transfers functions, personnel and assets from the central government to the provincial governments. This means that additional powers and responsibilities are being devolved to district and municipal governments, establishing a far more decentralized system compared to the deconcentrated and co-administrated systems of the past. The bupati (district head) and walikota (municipal head) as the head of the autonomous local government will be directly responsible to the local assembly (Dewan Perwakilan Rakyat Daerah, DPRD), while the deconcentrated agencies for devolved functions will be abolished and the civil servants of these agencies will be placed under the authority of the regional governments.

The two new decentralization laws cover all major aspects of fiscal and administrative decentralization. Under the laws, all public service delivery functions except defense, foreign affairs, monetary and trade policy, and legal systems will be decentralized to subnational governments. Most public services, including education, health, and infrastructure, will be delivered by districts and cities, with provinces performing only the role of coordinator. The previous hierarchical relation between provinces and districts or cities will be abolished. Any task not specified in the law will fall to districts or cities. The subnational share of government spending will reach more than 40 percent, up from 19 percent in fiscal 2000.


Risks of the new laws !!!

IMF and World Bank experts found that Indonesia’s decentralization process, as structured by the two laws, contained serious risks:

• The Law on Regional Governance is too general in assigning spending responsibilities—and so threatens effective service delivery. Rather than clarifying responsibilities, the implementing regulations for the law have confused regional governments, because the regulations specify only the center’s remaining responsibilities. Because of this lack of clarity in the assignment of functions, the decentralization of revenue under the Law on Fiscal Balance could exacerbate macroeconomic imbalances.

• Decentralizing most functions of public service provision to districts may not be compatible with government capacities, or in line with economic principles of scale and spillover.

• Political decentralization is incomplete. Although regional parliaments were elected in July 1999, many regional heads were appointed by the old government and will be replaced by elected heads only when their terms expire. As a result the key element of local government accountability may be missing for years to come.

• The proposed sharing of oil and gas revenues would distribute significant revenue, most of which is not from royalties or taxes on resource rents, to a small number of provinces and districts. This arrangement would exacerbate regional disparities in revenue and is inconsistent with the objective of equalizing transfers. In addition, highly volatile oil and gas revenues are not ideal sources of local revenue, and would create considerable uncertainty for local budgeting.

• The coincidence of administrative and fiscal decentralization renders nearly impossible the design of an objective equalization scheme. Cost differences among regions cannot be determined because most functions were financed through the central budget. Moreover, information is not available on current costs for each function, impeding the determination of the aggregate transfers needed to finance the decentralized functions.

• The Law on Fiscal Balance does not provide regional governments with new taxing powers. Regions have only limited autonomy over small taxes such as water use taxes and street lighting taxes. Thus local governments cannot cover additional local spending through taxes on local residents— compromising local accountability.

• The timetable for implementing the new laws is extremely tight. International experience indicates that at least two years are needed to prepare detailed regulations for functional devolution of major services and to establish a system for administering grants. Hasty implementation could interrupt important local public services.



RESOURCES
1) http://www.ino.searo.who.int/en/Section3_24.htm
2) http://www.who.or.id/eng/strategy.asp?id=cs2

3) http://www.mekonginfo.org/HDP/Lib.nsf/0/7C32092FE86174C847256D8F0019DDA1/$FILE/Q%201.2%20-%20World%20Bank%20-%20PremNote43_DecInd.pdf
4) http://www.smeru.or.id/report/workpaper/euroseasdecentral/euroseasexperience.pdf




Thursday, November 25, 2010

A key to a success door!


.......السلام عليكم ورحمة الله وبركاته



To organize a system is not easy especially in a big system like a HEALTH SYSTEM. Like in my previous post, I already mentioned about the main health services provided basically in Indonesia.

Here, are some Key Components of a well functioning health system:

1) Leadership and governance

· Ensuring that the health authorities responsible for directing the health sector as a whole (not just the public service sector), and to meet the challenges of the future (including unexpected events or disasters) as well as current challenges

· Defining, transparently and inclusively the national health policies, strategy and plan that set a clear direction for the health sector by:

  • A formulation of the country’s commitment to high level policy goals (health equity, people-centeredness, sound public health polices, effective and accountable governance)
  • A strategy for translating these policy goals into its implications for financing, human resources, pharmaceuticals, technology, infrastructure and service delivery, with relevant guidelines, plans and targets
  • Mechanisms for accountability and adaptation to evolving needs
  • Effective regulation through a combination of guidelines, mandates, and incentives, backed up by legal measures and enforcement mechanisms;
  • Effective policy dialogue with other sectors
  • Mechanisms and institutional arrangements to channel donor funding and align it to country priorities
2) Health information systems

Good governance is only possible with good information on health challenges, on the broader environment in which the health system operates, and on the performance of the health system. This specifically includes timely intelligence on:

  • Progress in meeting health challenges and social objectives (particularly equity), including but not limited to household surveys, civil registration systems and epidemiological surveillance
  • Health financing, including through national health accounts and an analysis of financial catastrophes and of financial and other barriers to health services for the poor and vulnerable
  • Trends and needs for HRH; on consumption of and access to pharmaceuticals; on appropriateness and cost of technology; on distribution and adequacy of infrastructure
  • Access to care and on the quality of services provided.

3) Health financing

Health financing can be a key policy instrument to improve health and reduce health inequalities if its primary objective is to facilitate universal coverage by removing financial barriers to access and preventing financial hardship and catastrophic expenditure. The following can facilitate these outcomes:

  • A system to raise sufficient funds for health fairly
  • A system to pool financial resources across population groups to share financial risks
  • A financing governance system supported by relevant legislation, financial audit and public expenditure reviews, and clear operational rules to ensure efficient use of funds

4) Human resources for health

The health workforce is central to achieving health. A well performing workforce is one that is responsive to the needs and expectations of people, is fair and efficient to achieve the best outcomes possible given available resources and circumstances. Countries are at different stages of development of their health workforce but common concerns include improving recruitment, education, training and distribution; enhancing productivity and performance; and improving retention. This requires:

  • Arrangements for achieving sufficient numbers of the right mix (numbers, diversity and competencies)
  • Payment systems that produce the right kind of incentives
  • Regulatory mechanisms to ensure system wide deployment and distribution in accordance with needs
  • Establishment of job related norms, deployment of support systems and enabling work environments
  • Mechanisms to ensure cooperation of all stakeholders ( such as health worker advisory groups, donor coordination groups, private sector, professional associations, communities, client/consumer groups).

5) Essential medical products and technologies

Universal access to health care is heavily dependent on access to affordable essential medicines, vaccines, diagnostics and health technologies of assured quality, which are used in a scientifically sound and cost-effective way. Economically, medical products are the second largest component of most health budgets (after salaries) and the largest component of private health expenditure in low and middle income countries. Key components of a functioning system are:

  • A medical products regulatory system for marketing authorization and safety monitoring, supported by relevant legislation, enforcement mechanisms, an inspectorate and access to a medical products quality control laboratory
  • National lists of essential medical products, national diagnostic and treatment protocols, and standardized equipment per levels of care, to guide procurement, reimbursement and training
  • A supply and distribution system to ensure universal access to essential medical products and health technologies through public and private channels, with focus on the poor and disadvantaged
  • A national medical products availability and price monitoring system
  • A national programme to promote rational prescribing.

6) Service delivery

Health systems are only as effective as the services they provide. These critically depend on:

  • Networks of close-to-client primary care, organized as health districts or local area networks with the back-up of specialized and hospital services, responsible for defined populations
  • Provision of a package of benefits with a comprehensive and integrated range of clinical and public health interventions, that respond to the full range of health problems of their populations, including those targeted by the Millennium Development Goals
  • Standards, norms and guidance to ensure access and essential dimensions of quality: safety, effectiveness, integration, continuity, and people -centeredness
  • Mechanisms to hold providers accountable for access and quality and to ensure consumer voice.

To conclude;
Without strong policies and leadership, health systems do not spontaneously provide balanced responses to these challenges, nor do they make the most efficient use of their resources. The leaders of an organization need to be smart in conducting his/her group.


RESOURCES:

1) http://www.who.int/healthsystems/EN_HSSkeycomponents.pdf

2) http://www.who.int/healthsystems/en/

3) http://cpds.fep.um.edu.my/events/2009/workshop/29042009/PPT%20&%20full%20paper/session%202/03%20-%20Components%20of%20a%20Health%20System.pdf



An insight of the Health Care System


.......السلام عليكم ورحمة الله وبركاته

First, let us define the words.

Health care:
The act of taking preventative or necessary medical procedures to improve
a person’s well-being. This may be done with surgery, the administering of medicine,
or other alterations in
a person's lifestyle.

System :
Organized, purposeful structure regarded as a 'whole' consisting of
interrelated and interdependent elements (comp
onents, entities, factors, members, parts etc.).
These elements continually influence one another (directly or indirectly) to maintain
their activity and the
existence of the system,
in order to ACHIEVE the COMMON purpose or GOAL of the system.

(a) Inputs, outputs, and feedback mechanism

(b) Every system is a part of a larger system, is composed of sub-systems, and shares common properties with other systems that help in transferring understanding and solutions from one system to another. Systems stop functioning (or malfunction) when an element is removed or altered significantly.

Healthcare system:
Designed to meet the health care needs of target populations.
There are a wide variety of health care systems around the world.
Complex of facilities, organization, and trained personnel engaged
in providing health care within a geographical area.

National Health System (Sistem Kesihatan Nasional, SKN) is an institution that collects the various efforts of Indonesia to ensure the health status as the highest manifestation of the general welfare as defined in the Pembukaan UUD 1945.

The sub-system in SKN are:

• Service delivery (Upaya Kesehatan)
• Health Financing
(Pembiayaan Kesehatan)
• Human Resources for Health (
Sumber Daya Manusia Kesehatan)
•Essential Medical Products and Technologies
(Farmasi,Alkes,Makanan & Minuman)
• Health Information and Management
(Manajemen & Informasi Kesehatan)
• Community empowerment
(Pemberdayaan Masyarakat)

***2 elements of Service delivery (Upaya kesehatan):
• PUBLIC HEALTH SERVICE (Upaya Kesehatan Masyarakat, UKM)
• PERSONAL HEALTH SERVICE (Upaya Kesehatan Perorangan, UKP)

1) PUBLIC HEALTH (UKM)

- Every activity of government and /or community, to maintain and increase the health, preventing & overcoming the problem of cases in the community

- Involve the promotion of health, eradication of communicable & non-communicable diseases, environmental health & supply basic sanitation, community’s nutrition improvement, securing the use of addictive substances in food & beverage, security of narcotics, psychotropic substances, addictive substances and hazardous materials, as well as disaster relief & humanitarian aid

2) PERSONAL HEALTH (UKP)

- Every activity of government and /or community, to maintain and increase the health, preventing & overcoming the individual problems

- Involving the promotion of health, disease prevention, medical care, hospitalization, disability & rehabilitation restrictions on individuals.

Health care system generally involves the Medical Health Service and Community Health Services. In Indonesia, Hospital (Rumah Sakit) known as medical health service while Primary Health Center (Pusat Kesehatan Masyarakat, Puskesmas) consist of both medical health service and community health services. It also has PUSTU (PUSKESMAS pembantu) and PUSLING(PUSKESMAS keliling) to help in delivering its services to the community.

> subsytem of health services (click to enlarge)

Functions of the HOSPITAL

• To provide and organize:
• Medical Services
• Medical Support services
• Rehabilitative services
• Prevention and health improvement
• As a place of education and training of medical staff.

Functions of PUSKESMAS:
-Public health development center
-Building community participation to promote healthy life behaviors
-Provide Comprehensive and integrated health care services
-As a technical institution, it shall have a managerial capabilities and long-term vision to improve the quality of health services
-Planning, managing and evaluating
-Using update related information and techniques to improve the comprehensive and integrated health services
-Administration, as a technical unit of the district government office via the district health office
-Hierarchical health service, as a primary health service facility


> example of Health System in Malaysia .

Source: Sirajoon Noor Ghani & Hematram Yadav (2008) Health Care in
Malaysia. KL: UM Press. p.38


Resources:
1) http://www.businessdictionary.com
2) http://staff.ui.ac.id/internal/140102741/material/Puskesmas.pdf
3) http://www.scribd.com/doc/21462956/Sistem-Pelayanan-Kesehatan

4)http://www.businessdictionary.com/definition/system.html#ixzz16OYYQ9DQ