Building Bridges to Strengthen Primary Health Care Governance: Indonesia
Workshop Report
An international workshop on Primary Health Care Governance in Indonesia,
organised by Professor Stephanie Short and Dr Kirsten Harley from the Health
Systems and Global Populations group in the University of Sydney’s Faculty of
Health Sciences, has brought together researchers, health professionals, policy-makers
and development agencies from Indonesia, Australia, the United Kingdom and South
Africa. The workshop was held in Bali, Indonesia, on 23-24 May 2011. Over two
days of presentations and intensive discussion we identified some key challenges and
opportunities to contribute to primary health care governance in Indonesia, developed
a framework for ongoing comparative international work on primary health care
governance, and strengthened collaboration between the university partners, the
Ministry of Health and AusAID. The workshop was supported by a University of
Sydney International Program Development Fund grant and matched funding from
the Faculty of Health Sciences, as an activity of the Worldwide Universities Network
(WUN) Shaping Health Systems research group.
From left: Prof. Hasbullah Thabrany, Dr Ede Surya Darmawan, Dr
Halimatussadiah, Dr Gianluca Veronesi, Prof Stephanie Short, Helen McFarlane, Dr
Kirsten Harley, Dr Gita Maya, Prof. Ian Kirkpatrick, Dr Poppy, Ria Arief, Dr
Shadrick Mazaza, Dr Pujiyanto, Valentin Hadjiev. Also in attendance on Tuesday:
Prof. Laksono Trisnantoro.
Workshop participants included senior and early career researchers from three WUN
(World University Network) Universities – The University of Sydney’s Faculty of
Health Sciences (Professor Stephanie Short, Dr Kirsten Harley), Leeds University
Business School (Professor Ian Kirkpatrick, Dr Gianluca Veronesi) and the University
of Cape Town’s Graduate School of Business (Dr Shadrick Mazaza) – along with
University of Indonesia’s Center of Health Economics and Policy (Professor
Hasbullah Thabrany, Dr Ede Surya Darmawan, Dr Pujiyanto), Center for Health
Service Management, Gadjah Madu University (Professor Laksono Trisnantoro), and
Queensland University of Technology’s Law and Justice Research Centre (Valentin
Hadjiev). On the first day we also enjoyed the participation of representatives from
the Ministry of Health’s Bureau of Planning (Dr Gita Maya, Dr. Halimatussadiah and
Dr Poppy) and the Jakarta office of AusAID (Helen McFarlane and Ria Arief).
Professor Stephanie Short opened the workshop with the presentation ‘Building
Bridges to Strengthen Health Workforce Governance and Management in Indonesia’,
including key challenges and the plan of action developed in a current AusAID Public
Sector Linkages Program (PSLP) funded project on health workforce governance in
Indonesia. She emphasised the role of academics in building bridges between
Australia and Indonesia and the importance of collaboration – through international
partnerships and networks, between policy makers and academics, and involving
senior and early career researchers and health professionals – in sharing expertise and
building capacity to address primary health care governance.
In his presentation on ‘Indonesia’s health system’, Professor Hasbullah Thabrany
provided a valuable analysis of the past three decades of health reform in Indonesia,
measures of health achievements and outcomes, prospects for health reform and
financing, and particular challenges for public and private primary health care.
Helen McFarlane, Counsellor Health, Gender and Disaster Response, AusAID
Jakarta, and Dr Gita Maya, Head of the Division of Health Strategic Planning and
Program in the Ministry of Health, presented together on AusAID’s programs in
Indonesia, including recent developments and broad goals of the Health Systems
Strengthening program currently being finalised between AusAID and the Ministry.
These presentations and discussion groups generated lively discussion in which
participants focused on key challenges, identified relevant experiences and knowledge
from other health care systems and suggested projects.
Key challenges and problems include:
 the dynamic context of decentralisation, with governance responsibilities and
financing spread over multiple levels and uneven levels of local government
commitment and health outcomes in different provinces and districts;
 overall low levels of health financing (internationally, and compared to e.g.
tobacco tax revenue and petrol subsidies);
 health financing system does not provide incentives to focus on primary care or
health promotion in either public or private practice;
 there has been some progress with implementation of health insurance schemes,
but variable coverage and exclusions remain, financing is not always available to
cover costs of care, and a planned National Health Insurance scheme remains to
be implemented;
 lack of quality control of medical training, particularly with rapid expansion of
private medical schools, and variable/poor quality of doctors;
 an ageing population, and growing demand for geriatric care and incidence of
cardio-vascular disease (CVD);
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poor perceptions of primary care quality (and sometimes pricing) restricts
utilisation;
overproduction and maldistribution of GPs based on free-market mechanism, with
overconcentration in large cities;
prioritisation of hospitals over community health centres, which are better placed
to deliver primary care, particularly in relation to political voice and health
expenditure targeted at health care for the poor;
poor career paths for GPs;
lack of specialists, particularly outside of big cities; and
availability and quality of data to provide evidence-base for policy and solutions.
Workshop participants agreed to continue this international collaboration to
strengthen primary care governance in Indonesia, and on a set of objectives, timelines,
roles and responsibilities. The group will be represented as a new Primary Health
Care section within the Indonesia Health Policy Network at the AusAID and Ministry
supported National Forum II in Makassar, in Indonesia’s South Sulawesi province, in
September 2011.