Indonesia Needs Reforms on Health Care System, CISDI and AIPI Suggest

• The pandemic has exposed health policy gaps that have led to public health problems. It is needed to create data-and-science-driven policies to avoid similar mistakes
• Through scientific foresight methods, AIPI and CISDI recommend five fundamental reforms to strengthen primary health services

Jakarta, March 16, 2022 - The Indonesian Academy of Sciences (AIPI) together with the Center for Indonesia's Strategic Development Indonesia (CISDI) launched a study document entitled Foresight untuk Menata Masa Depan Layanan Kesehatan Primer Indonesia (Foresight to Manage the Future of Indonesia's Primary Health Services). This document provides recommendations and efforts to strengthen Indonesia's primary health services in the future.

"This activity is carried out as evidence of multi-actor collaboration in the health sector to determine policy breakthroughs based on evidence," said Prof. Satryo Soemantri Brodjonegoro, Chairman of AIPI.

Based on this study, the two institutions conveyed their aspirations to strengthen primary health care – or also known as primary health care (PHC) – through a structural and transformative change, not only to end the pandemic, but also to ensure that Indonesia has a stronger national health system after the plague passed.

Primary health services are systems that meet the health needs of individuals and families at the community and community level from upstream to downstream. As it is the community's first contact with the health care system, it must be affordable in terms of access, cost, location, or distance. It also includes public health functions, community involvement, and multi-stakeholder collaboration and action. 

According to the WHO report in 2019, PHC investment in low-and-middle-income countries can reach more than 90% of the world's population and increase life expectancy by 3.7 years in 2030. Thailand, which prioritizes on PHC strengthening, managed to reduce 44% of deaths of children in the lowest income society.

Learning from the COVID-19 pandemic, according to Prof. Satryo, there are still many gaps in primary health care policies that lead to population health problems. One of the key problems is the tendency of some stakeholders to ignore data and science in making policy.

“At the beginning of the pandemic, there was a debate about lockdown. Then there's the debate about quarantine and vaccinations. This all happens because we do not have good standards or references in making decisions, be it for individuals, community groups, or formulas for determining policies. Everything is sometimes responsive and assuming. Meanwhile, we are in debates, many people are passing. Even though Indonesia has more than 10,000 health centers with more than 67,000 doctors and nurses who can be relied on," he said.

Those past mistakes should not be repeated, countries must learn to be more sensitive to data and science. “To make policies that are right on target, realistic and can be implemented, policy makers need facts as the main element. This fact-based policy-making process is consistently used in many countries and should be used systematically and comprehensively by Indonesian stakeholders to accelerate the achievement of national health development targets," Prof. Satryo continued.

In line with Prof. Satryo, Prof. Akmal Taher, Faculty of Medicine University of Indonesia professor and member of the AIPIMedical Sciences Commission, said the pandemic was the best momentum to improve primary health services.

“Many countries such as Thailand and Brazil showed good primary health services before the pandemic had a positive impact on the resilience of the health system. However, this has not been reflected in the Indonesian government's spending on the health sector, which is only 3% of GDP with only 0.05% of GDP for primary health services. In fact, for the health sector, Thailand and Brazil have spent up to 7% of GDP."

"Indeed, there have been several initiatives to strengthen primary health services through Pencerah Nusantara or Nusantara Sehat or the PUSPA Program in West Java. The government is also implementing the Program Indonesia Sehat dengan Pendekatan Keluarga (PIS-PK) (Healthy Indonesia Program with a Family Approach) and Healthy Living Community Movement (GERMAS). I believe there are many other health innovations at the local government level. However, it seems that the government itself has not made any special efforts to inform and involve the public in this matter.”

Despite the commitment to strengthen primary health services, many concrete steps have not been taken. “The policy direction to strengthen PHC has actually been included in the 2020-2024 National Medium-Term Development Plan (RPJMN). Our national health system has only depended on presidential regulations. It is time for the legislature and executive to draft laws on the National Health System that prioritizes PHC. Regulation at a higher level is needed because strengthening PHC requires a long time with a commitment to a sustainable budget,” she said.

To make a fact-based and targeted PHC strengthening recommendation, AIPI and CISDI decided to use the foresight method. Diah S. Saminarsih, Senior Adviser on Gender and Youth for WHO Director General and Founder of CISDI, explains its advantages.

“The foresight method is strategic, inclusive and objective. AIPI and CISDI accommodated the input of dozens of expert sources in the health and non-health fields through discussions using the Delphi method, and synthesized various actual conditions of primary health services in Indonesia. We also examine the social, technological, economic, environmental, political, and value dimensions surrounding primary health care," she said.

"CISDI also conducted a horizon scan and managed to collect 740 online media articles, 1.5 million tweets about health centers and 6.8 million tweets about hospitals on Twitter. All inputs are then processed and synthesized into four scenario options, all of which have the same probability of occurring.” Diah added.

From this in-depth study, it is known that there are various challenges to strengthening the position of primary health services in the Indonesian health system, as well as the solutions. "If these efforts are carried out carefully and adequately, this will be one of the most strategic contributions and inputs from AIPI and CISDI, both to the current and future governments," said Diah.

AIPI and CISDI concluded that there are three shifts to create easily accessible and quality health services, namely:

1. Shift from the point of view of fulfilling access to fulfilling access and quality

Transformative PHC ideally provides health services without access restrictions, quality, equipped with the latest health technology but still economical.

2. Shift from fragmentation to integration

The future PHC must be able to integrate promotive-preventive services with curative services, and equal services in government and private facilities.

3. Shift from a short-term and reactive perspective to a long-term and sustainable perspective

PHC should no longer be considered a burden on the budget, but a long-term investment. This paradigm shift will ensure that the costs incurred to treat people's morbidity are much lower.

To have them implemented, five fundamental reforms must take place:

1. Leadership and governance reforms

Considering that national health system reform and PHC transformation require a long time and budgetary commitment, regulations for national health systems must be higher level and binding like laws.

2. Public policy reform

Policy reform is also needed on social, economic, commercial and environmental policies that have an indirect link with the health sector.

3. Service quality reform

Public can get quality services from primary health facilities. This level of service quality can be guaranteed through improvements to the accreditation system.

4. Health insurance reform

Redistribution of membership so that National Health Insurance (JKN) participants are not concentrated in the public health centers (puskesmas) only.

5. Health Human Resource Reform

Countries that have a strong PHC system do not only rely on health workers but also have many empowered health cadres with high capacity. The standard for primary care doctors who work in the PHC system must also be on par with specialist doctors.

About AIPI

The Indonesian Academy of Sciences (AIPI) is an independent institution that brings together Indonesia's leading scientists. AIPI was established based on Law No. 8 of 1990 as an independent institution to provide opinions, suggestions and considerations on matters related to science and technology to the government and the public. AIPI also contributes to the development of science and excellence through scientific conferences and policy discussion forums, publications, as well as national and international relations.

About CISDI

The Center for Indonesia's Strategic Development Initiatives (CISDI) is a non-profit organization that encourages the implementation of scientific evidence-based health policies to create an empowered, equal and prosperous Indonesian society with a healthy paradigm. CISDI carries out advocacy, research and program management to achieve transparent, adequate and equitable governance, financing, human resources and health services.