New Burden of Disease:

New Burden of Disease in IndonesiaNew Challenge for Health Workforce in Indonesia

Mary S. Maryam13/10/20081Mary- Indonesia

The main health problems of Indonesia High infant mortality, child mortality and maternal mortality Child malnutrition High mortality or morbidity of infectious diseases. Lifestyle-related diseases increase,

13/10/2008Mary- Indonesia2Demograhic transition in IndonesiaUnequal access to quality health services among regions and among socio-economical statusContribute to the low health status HDI <

Crisis now13/10/20083Mary- Indonesia

The impacts of malnutrition and previously known health problems, create extra burdens of disease (become triple burden) i.e. 1) infectious (re-emerging and new emerging diseases), 2) chronic or life-style-related diseases, and 3) the growing burden of decreasing peoples brain learning capacity or the health of peoples intelligence. The above health problems are considered as lower the ability of Indonesias human resources in global competition.3

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Comparison between Height and Age of Children in Indonesia, 0 to 50 months** Menggambarkan pertumbuhan rata-rata anak Indonesia sejak lahir - 50 bulan pertumbuhan rata-rata anak Indonesia dibawah normal pd saat kelahiran ini mencerminkan buruknya pertumbuhan selama dalam kandungan. Pertumbuhan menurun cepat sejak lahir sampai dua tahun pertama kehidupan masa pertumbuhan otak tercepat (potensi terbesar) yang hilang (Dikutip dari IFLS 1993, dari 13 propinsi yang mewakili 83 persen populasi. Pertumbuhan direpresentasikan oleh tinggi badan berbanding usia sebagai standard deviation units, atau z-scores, untuk jenis kelamin dan usia).13/10/2008Mary- Indonesia

Based on the data of 1993, in 50 months of the early lifes, the average of childrens growth in Indonesia was below normal since births, which was then slowering down rapidly during the early two years of life. Although the data was about 5 years before the crisis, it represented 13 provinces or 83 % of Indonesias population, and we could expect that the figure would still be useful to see nutrition problems during pregnancy and soon after) and associated learning capacity during and after the crisis (IFLS 1993).4

Demographic and Epidemiologic TransitionThe health status of Indonesia has improved, however, the health status is not as good as expected.Increased life expectacy at birth: 65,8 years (National Health Survey or Susenas of 1999) improved to 69,2 years (Susenas of 2005). increases the proportion of aging population as much as 7,6% of total pop. or 16 M people)Prone to age-related diseases or disabilities, especially non-communicable diseases and some memory-related problems13/10/20085Mary- Indonesia

New ChallengePreviously known health problemsinfectious (re-emerging and new emerging diseases)chronic or life-style-related diseasesthe growing burden of new disease: decreasing peoples brain learning capacity or the health of peoples intelligence affecting all ages

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Increased budget for educational programs may not achieve maximum results, if the health of the peoples brain (human learning potential) is not optimally preparedThe premise that the capacity of the brain can be improved with effective and efficient interventions, even until the very old of age13/10/2008Mary- Indonesia7

Center for Maintenance, Improvement and Restoration of the Health of Intelligence (CMIRHI) in early 2008New Challenge

The establishment of CMIRHI is a breakthrough to address the wellness of Indonesias HR intelligence. But, the shortage of health workforce and lack of knowledge to deal with the new problem create a new challenge to the management of HRH (in addition to inequality in number, distribution, skills mix and quality of HRH among areas and socio-economic levels).The shortage of HRH worsens after decentralization, resulting in the mal-distribution among areas13/10/2008Mary- Indonesia8New Challenge

HRH Condition in Indonesia13/10/2008Mary- Indonesia9Non-obligatory PTT for doctors & midwivesDecentralization: especially for new districts w/ limited staff capacityNon medical & midwives personnel

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The Distribution of Nutritionists in the Health Centers in Indonesia (Source: MoHRI, 2006)

The figure shows only the distribution and relative quantity of HRH to the available health facility at the lowest level (community health center). Whereas, we still need adequate quality (competence, responsiveness, motivation) of health workers, so that they can productively work using available -but limited - resources in the field10

What is Needed to Cope with New Challenge? Adequate number of health professionalsBetter health professionals education Empowered HRHCollaborative actions with other ministries (e.g. Ministry of National Education, Ministry of Labor and Ministry of Social Affairs) and with NGOs , e.g. those concerned with pre-school age education, stroke or diabetic patients)13/10/2008Mary- Indonesia11

StrategiesCommunity Empowerment: endeavours to improve the health of intelligence must start fromHealth Workforce Education and Training: doctors (neurologists, psikiatrists, etc.) and other health care providers (physiotherapists, nurses, nutritionists, psychologist, etc.) Task Shifting: from doctors to nurses or midwives e.g. In remote areasCollaborative Work: Horizontally and VerticallyBreakthrough Efforts: health policy at all levels of service or programs health workforce education, on-the-job training of health workers, in education system, and in health services in general. The challenge also needs a paradigm shift in seeing intelligence problems 13/10/2008Mary- Indonesia12

StrategiesShort-Term Intervention: Policies and corresponding guidelines, norms, standards, procedures, and criteria or instruments for case detection and early interventionLong-Term Intervention:Need paradigm shift (fundamental change in health services, professional care, insurance system, and education system ) as to accomodate efforts to cope with the declining capacity of human resource intelligenceChange must also be added into curriculum of formal health professional education and on-the-job training HRH13/10/2008Mary- Indonesia13

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Some Forms of Interventions

Stimulation of brain learning functionOptimalization of brain learning functionRevitalization of brain learning function13/10/2008Mary- Indonesia15

The Lessons Learnt (1)Challenge 1: Paradigm shift will need political will from decision makers of all levelsChallenge 2: Need clear national policy on task shifting of health workforceNeed advocacy on the importance of paying attention and coping with the new burden of disease (i.e. decreasing peoples brain learning capacity or brain wasting), and hence creating more comprehensive health workforce management and patient care approach

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The Lessons Learnt (2)Challenge 2: Need advocacy to improve the awareness and commitment of central and local governments to provide adequate training, especially for the lower level of HRH, to provide financial and technical assistance, to ensure the continuity and quality of health servicesChallenge 3: Task shifting should be done after a careful planningRoles and tasks of each level of HRH are defined clearly for better implementation of comprehensive and integrated programs

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There is a difference between:Human resources for health developmentHealth (of intelligence) for human resources development

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Proposal for Regional or Global Actions (1)It is important to pay attention and cope with the new burden of decreasing peoples brain learning capacity or brain wasting: costsCommitment of policy makers: political (clear policy and the implementation plan), budget for HRH education and training, distribution (recruitment and retention), and health services and its referral system, and community empowerment at the grassroot level.Structural/organizational change if needed: coordinate more freely with any relevant institutions

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Task shifting: Empowerment of the community and the lower level of health care workers is the key to successful implementation or interventionsTechnical assistance for local health offices, monitoring and evaluationProper remuneration arrangement for health care providers linked to health insurance13/10/2008Mary- Indonesia20Proposal for Regional or Global Actions (2)

Thank youTerima kasih

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