Menzies Centre for Health Policy, University of Sydney, NSW, Australia.
BMC Int Health Hum Rights. 2010 Mar 5;10:3. doi: 10.1186/1472-698X-10-3.
Assessments over the last two decades have showed an overall low level of performance of the health system in Indonesia with wide variation between districts. The reasons advanced for these low levels of performance include the low level of public funding for health and the lack of discretion for health system managers at the district level. When, in 2001, Indonesia implemented a radical decentralization and significantly increased the central transfer of funds to district governments it was widely expected that the performance of the health system would improve. This paper assesses the extent to which the performance of the health system has improved since decentralization.
We measured a set of indicators relevant to assessing changes in performance of the health system between two surveys in three areas: utilization of maternal antenatal and delivery care; immunization coverage; and contraceptive source and use. We also measured respondents' demographic characteristics and their living circumstances. These measurements were made in population-based surveys in 10 districts in 2002-03 and repeated in 2007 in the same 10 districts using the same instruments and sampling methods.
The dominant providers of maternal and child health in these 10 districts are in the private sector. There was a significant decrease in birth deliveries at home, and a corresponding increase in deliveries in health facilities in 5 of the 10 districts, largely due to increased use of private facilities with little change in the already low use of public facilities. Overall, there was no improvement in vaccination of mothers and their children. Of those using modern contraceptive methods, the majority obtained them from the private sector in all districts.
There has been little improvement in the performance of the health system since decentralization occurred in 2001 even though there have also been significant increases in public funding for health. In fact, the decentralization has been limited in extent and structural problems make management of the system as a whole difficult. At the national level there has been no real attempt to envision the health system that Indonesia will need for the next 20 to 30 years or how the substantial public subsidy to this lightly regulated private system could be used in creative ways to stimulate innovation, mitigate market failures, improve equity and quality, and to enhance the performance of the system as a whole.
过去二十年的评估显示，印度尼西亚的卫生系统整体绩效水平较低，各地区差异较大。绩效水平低的原因包括公共卫生资金水平低，以及地区一级卫生系统管理者缺乏酌处权。2001 年，印度尼西亚实施了彻底的权力下放，并大幅增加了中央向地方政府的资金转移，人们普遍预计卫生系统的绩效将会提高。本文评估了自权力下放以来卫生系统绩效提高的程度。
我们测量了一套与评估卫生系统绩效变化相关的指标，这些指标在三个方面进行了比较：孕产妇产前和分娩护理的利用情况；免疫接种覆盖率；以及避孕药具的来源和使用情况。我们还测量了受访者的人口统计学特征及其生活环境。这些测量是在 2002-03 年的三次人口普查中进行的，然后在 2007 年在相同的十个地区重复进行，使用相同的工具和抽样方法。
这十个地区妇幼保健的主要提供者是私营部门。在家分娩的人数显著减少，而在其中五个地区，在卫生设施分娩的人数相应增加，这主要是由于私人设施的使用增加，而公共设施的使用已经很低，几乎没有变化。总体而言，母亲和儿童的疫苗接种情况并没有改善。在使用现代避孕方法的人中，大多数人在所有地区都从私营部门获得这些方法。
尽管公共卫生资金大幅增加，但自 2001 年权力下放以来，卫生系统的绩效几乎没有改善。事实上，权力下放的程度有限，结构问题使得整个系统的管理变得困难。在国家层面，印尼没有真正试图设想未来 20 到 30 年所需的卫生系统，也没有试图设想如何以创造性的方式利用对这个监管宽松的私营系统的大量公共补贴，以刺激创新、减轻市场失灵、提高公平性和质量，并提高整个系统的绩效。
