In the decade before decentralization, Indonesia was on a path toward better health and survival rates for children under five and their mothers. Modern family planning methods had reduced the total fertility rate. Increased immunization of pregnant women and infants and better treatment of diarrheal diseases and acute respiratory infections had reduced newborn deaths.

But progress has been uneven. Health surveys in Indonesia in 2002-2003 indicated that only 51 per cent of children under 12 months of age are fully immunized. There are many deaths among newborns. Wide geographic and demographic disparities persist in the survival and health of young children and new mothers. And while access to modern family planning methods has increased, there is still a large unmet need for contraception.

Assessments by the Management & Leadership Program (M&L) in 2002 and 2003 suggest that the changes wrought by decentralization, which have often led to insufficent local budgets and gaps in oversight, have undermined the availability and quality of family planning and other basic health services, especially services for the poor.

Summary of Work

Since 2001, M&L has been working with managers to address Indonesia's most urgent health challenges by strengthening the nation's decentralized public health infrastructure. We are providing technical assistance to the Ministry of Health (MOH) and National Family Planning Coordinating Board (BKKBN) to ensure the delivery of basic health services, including family planning. This is one of M&L's most comprehensive programs, with dozens of partners in addition to USAID.

The M&L program, which is working at the central, provincial, and district levels of the health system, has these key objectives:

• define and establish a legal framework for essential public health services and functions (EPHSF), and minimum service standards;
   
• build the capabilities of district and municipal health teams to improve performance of high-priority health services, including family planning, and strengthen district and municipal management skills and systems;
   
• improve management of essential drugs by national programs and the districts and municipalities;
   
• foster the use of data by district managers to improve program performance and to advocate for public health funding.
   

Results

Legal framework for essential public health services and functions established
M&L's support helped the MOH examine health laws in other countries and issue a Ministerial Decree (October 2003) that established obligatory authorities, basic health services, and minimum service standards for districts and municipalities. The BKKBN established obligatory functions, basic services for family planning and family welfare, and minimum service standards for districts and municipalities, provinces, and the central structure.

Health planning teams improve performance
Analysis of data, effective planning and budgeting, and monitoring and evaluation of implementation are keys to improving the performance of public health teams that manage and deliver essential health services. M&L developed a Performance Assessment and Implementation process, available in English and Bahasa Indonesia, which allowed district health and municipal teams to use existing evidence and data to assess and compare health facilities, prepare plans and budgets for essential (obligatory) public health services, and identify the most urgent priorities—family planning, antenatal care, child birth management, neonatal care, immunization, TB and malaria control.

M&L is continuing to build an infrastructure to support the district health teams by training local facilitators to conduct this Performance Assessment and Implementation process.

Management of essential drugs improved
M&L technical assistance has improved the distribution of essential drugs. The tracer drug list was refined (from 32 to 22); the list now includes critical drugs (such as drugs for tuberculosis), vaccines, contraceptives, and related medical- surgical commodities. M&L developed manuals and guidelines for procurement, distribution, warehouse management, treatment protocols, and training.

A District Level Assessment Tool (DLAT) was developed by M&L in early 2003. It has been used to assess drug management and availability at warehouses and health centers. Survey results showed that 70 percent of the 22 essential drugs were available, although stock-outs were observed for vaccines and contraceptives at the district level. Managers are now able to use such survey findings to formulate district plans and budgets.

District managers use data to strengthen surveillance programs
M&L technical assistance is helping Indonesia strengthen its disease surveillance, which had been weakened by decentralization in many districts, according to the MOH's Infectious Disease Surveillance Unit.

The MOH and M&L are collaborating with provincial health offices and districts to put new epidemiology guidelines for communicable and non-communicable diseases into practice. Surveillance and outbreak control practices were added to the process for health planning and budgeting. The evidence-based plans developed by the teams in two districts led to their success in advocating for additional funding to manage pneumonia, control TB, and promote safer childbirth.