Decentralization and Its Negative Impact

The Indonesian government has imposed Law no. 22/2002 to decentralize government functions and authorities to regional administrations, including healthcare.

It was a brilliant idea with good intention to increase the quality of public health services delivery. However, surveys and studies on basic health indicators and accessibility to health care services proved otherwise.

So, here I would like to share the negative impacts and challenges of the implementation of decentralization in health sector. What have gone wrong? What problems were faced by the provincial authorities in implementing the health decentralization system?

First of all, decentralization has considerably weakened the unified national health system including the once established disease surveillance system as well as public health programs. The communicable diseases that were supposed to be eliminated are reemerging, for example polio and leprosy.

Besides that, animal-borne disease including avian influenza and rabies were also spreading. For instance, before 1997, only 5 provinces were affected by rabies but after decentralization, the outbreak of rabies has affected 24 of the country’s 34 provinces, and claimed 143 lives a year on average.

It was difficult to address the epidemic and implement measures to track Rabies since it first emerged in Bali in November 2007. It was due to lack of coordination between provincial and regional health officers. The weak health policies and unclear prevention and eradication concepts have worsened the problems.

Secondly, decentralization has widened the gap of availability of healthcare services and facilities in urban and rural areas. The essential public health services such as maternal and child health, immunization, health promotion, disease surveillance, disease prevention and control including response to epidemic have become less accessible.

Thirdly, it has also further widened the existing huge gaps in the distribution of human and financial resources across provinces and across cities and districts within each province. The deployment of medical professionals lies in the hands of provincial and regional authorities. This affected the number of medical professionals working in the regencies. For example, in the remote area of Ende of East Nusa Tenggara, the 28 community center Puskesmas shared just 4 doctors.

Last but not least, many elected heads of provinces and regencies as well as legislators were lack of knowledge and understanding about health issues. For example, the community center was run by a former lurah, or subdistrict village head, instead of health professionals in the village. Under these circumstances, it is difficult to expect basic public health function such as disease control and combating malnutrition.

In a nutshell, the Health Ministry should develop clear guidelines on the roles of central, provincial and district health authorities. They should open a wide network with international agencies and donors to support health services in provinces and districts. At the same time, provincial and district authorities must improve their human resources, technical and financial capacity in handling health issues in their respective areas.

References:

1. Impact of Decentralization on Universal Coverage: a case study in Bali, Indonesia

2. International Health and Decentralization, dr. Yodi Mahendradhata.