The general objective of the National Health Development Program in Indonesia as stipulated in the National Health System is to provide

a healthy life for all Indonesians. The specific objectives of the National Health Development Program in Indonesia are:
To enable people to maintain their own health and

live a healthy and productive life To promote an environment conducive to the health of the people To promote good nutrition among the people To decrease morbidity and mortality To promote a healthy and prosperous family life

To achieve these objectives, various healthcare efforts have been implemented, including among others, the strengthening of the healthcare delivery system as part of an overall health development program. This is being carried out both by government and the private sector.

Due perhaps to the fact that Indonesia is still a developing country, the present condition of Indonesian healthcare remains unsatisfactory although there have been major improvements compared to two decades ago. The primary cause of death in Indonesia since 1995 is cardiovascular diseases that now overtake predominant infectious diseases, reflecting the double burden faced today.

The pattern of death in Indonesia is still strongly related to general poverty, low income per capita, high rates of illiteracy and various socio-cultural factors. According to Household Health Surveys, the 10 leading diseases in the country are: acute respiratory tract infection, diseases of skin, diseases of teeth, mouth and gastro-intestinal tract, other infectious diseases, bronchitisasthma and other disease of respiratory tract, malaria, nerve disorders, cardiovascular disorders, diarrhoea and tuberculosis.

INDICATOR/VARIABLE Infant mortality rate per 1000 live births Under five mortality rate per 1000 Maternal mortality rate per 100.000 live births Crude death rate per 1000 Life expectancy : male - female Low birth weight (%) Protein Calorie Deficiency per 100 Underfives

YEAR 1993 1993 1993 1994 1993 1993 1993 1993

FIGURES 58.0 81.0 425 6.0 60.8 64, 6 15.0 40.0

Clean water supply per 100 population Latrines per 100 population Percentage EPI coverage

1986 1986 1993

30.0 37.9 93.6

The responsiblility for dealing with public health problem in Indonesia lies with the government. Following the basic principle of sound public health, public health services provision in Indonesia strongly encourages community participation through primary health care services.
The main health body entrusted with carrying out public health services in Indonesia is the Community Health Center (Puskesmas), situated at sub-district level serving a population of about 30,000-40,000. There are over 7,000 such centers in the country by the year 2000.

The basic services are health promotion, Family planning, Nutrition, Environmental sanitation, Curative care and various developmental services according to local areas need. In most instances, a doctor, with a staffing between 8-32, consisting of nurses, midwives and other auxiliary personnel, heads each Puskesmas. In densely populated areas, there are SubCommunity Health Centers (Puskesmas Pembantu) at the village level, generally headed by a senior nurse or midwife, and operated under the supervision of, and linked to, the Community Health Center. At present, the total number of Puskesmas Pembantu in Indonesia is 19,977

To serve people who live in very remote areas, there are Mobile Community Health Center (Puskesmas Keliling), operated by and based at the local Puskesmas. The staff of Puskesmas Keliling consist of one doctor, assisted by two or three personnel, including nurses/midwives and a driver. At present, there are about 6,024 Puskesmas Keliling serving villages within the sub-district.

To support the activities of the Puskesmas, the community health effort is organized in the form of the Integrated Services Post (Posyandu), located at the hamlet level. The responsible community institution to Posyandu is the village community resilience committee. The activities of each Posyandu, assisted and supervised by local Puskesmas staff, consist of five basic types of health services. These are: (i) MCH Services, (ii) Nutrition Services, (iii) Family Planning Services, (iv) Diarrhoeal Disease Control and (v) Immunization Services. At present, there are about 251,459 Posyandu registered in Indonesia.

To guarantee successful operation of the Puskesmas, a referral system has been introduced. Any public health problem that cannot be overcome by the Puskesmas will be referred to higher health institutions/offices at the district, provincial or even the national level. In accordance with the principle of devolved autonomy, there are District Health Offices at the district level and the Provincial Health Office at the provincial level.

The Ministry of Interior and the Ministry of Health at the national level coordinate the health offices that are directly under the coordination of the local government.

The general rule is that the main function of the Ministry of Health is to provide conceptual guidance, technical guidance and material, as well as financial contribution and assistance to the local government district and provincial health offices.

The healthcare delivery system that is responsible for medical problems in Indonesia, in general can be divided into three categories:
(i) primary medical care facilities, (ii) secondary medical care, and (iii) tertiary medical care facilities.

In contrast to public health concerns which are under the government, the responsibility of the government is to encourage medical care services in Indonesia to have a considerable private sector involvement. Management of medical care services in Indonesia is therefore a shared responsibility between the public and private sectors.

The primary level personal/medical care facility managed by the government is the Puskesmas assisted by the Puskesmas Pembantu and Puskesmas Keliling. Besides the provision of medical personal care, the Puskesmas also makes provision for public healthcare services in the community medical care facilities.

The primary medical care facilities managed by the private sector vary. There are private midwives practitioners and private medical practitioners found in almost every part of the country. The number of private midwives practitioners in Indonesia is estimated to be approximately 34,000. Around 20% of the private medical practitioners are specialists, while the rest are general practitioners.

Since most of the midwives and doctors are government employees, their private practice is usually conducted in the afternoon after the closing of government offices. In some places, although it is illegal, paramedics also have their own private practices. Most private medical practitioners in Indonesia operate their practices as a sole practice, although in the big cities there is now an increasing trend for group practices that become more popular.

Other types of primary medical care facilities managed by the private sector in Indonesia are the MCH clinic and the polyclinic. These types of medical facilities are usually managed by midwives or nurses, although the responsible person for these facilities is still the doctor.

Unfortunately, the actual number of private MCH clinics and private polyclinics in Indonesia is not available.

The secondary and tertiary medical care facilities in Indonesia are located at hospitals. There are around 1,200 hospitals registered in the country, of which 404 hospitals are government or local government hospitals. The total number of beds available in all hospital is 111,460, which means that for every 100,000 people there are around 59.8 hospital beds available.

Government hospitals are divided into five categories, namely the A, B, C, D and E type. Type D (with 25-100 beds) and type C (with 100-400 beds) government hospitals are considered to be secondary level medical care facilities in Indonesia.

These hospitals are situated in the district capitals, of which there are 305 in the country.

Type D hospitals are in transitional period and ought to be promoted to a type C hospital.

Type C hospital are expected to be able to provide at least six major specialty services, namely internal medicine, pediatrics, obstetric and gynecology, surgery, radiology and clinical pathology.

Type B (with 200-500 beds) and the type A (with 100-400 beds) government hospitals are considered as secondary level medical facilities in Indonesia. Type B hospitals are located in the provincial capitals and are expected to be capable of providing a broad spectrum of specialist services, while type A hospitals are expected to provide a broad spectrum of sub-specialist services. At present, the total number of type B government hospitals is 23 and the total number type A government hospitals is 4.

Type E hospitals are specialized hospitals, numbering 72 throughout the country. The specialized hospitals operated by government are predominantly for specific diseases commonly found in the community, such as leprosy, TBC and mental illness.

Health Services in Indonesia are operated under a fee for service system.
The number of people covered by health insurance schemes is still limited mainly to civil servants and some private employees.

Annual health expenditure in Indonesia is still very low. It is estimated to be around 2.5% of GNP or about US$18 per capita, a level far under the WHO recommended expenditure level of at least 5% GNP. A big portion of total health expenditure in Indonesia comes from the people, whereas the contribution of government is only around 30%. The small contribution of government are utilized for all-line subsidy that creates unfair health financing for the poor.

Most of private spending on health care is out-ofpocket, because only around 20% are protected by various types of prepaid care.

Indonesia still faces various health problems. To overcome these challenges, Indonesia has implemented, since 1969, a series of Five Year National Development Programs, including the National Health Development program. Significant progress has been achieved in health care sector, both in public health services as well as in medical services. The management of the healthcare delivery system in Indonesia is carried out both by government and the private sector, including some forms of public-private mix.

The low level of health spending, the misdirection of government subsidies, and the big portion of population with out-of-pocket spending indicating low proportion of people protected by prepaid care, are challenges in that needs to be reformed gradually towards more fairness in health financing.