Friday, November 5, 2010

Global Health System

First and foremost, I have to be honest that I actually have trouble to talk about this topic. It seems like this topic is too wide and have a great continuum ahead of which I feel pretty small to even dipping my toe into. So I take the lecture of "Globalization in Health" by Dr Yodi Mahendradhata as the main guideline for me to point- to- point talking about this topic. His slide- show are quite simple but he presented us a very interesting lecture bringing us to explore about Health System going back to history till today's world:) I read more on those he told us and I truly appreciate any suggestions and advises if there is any other thing I should find out.

Now lets' have a story- telling time with me:)



In my very first post; F.O.R.E.W.O.R.D, I told you honestly that the first thing which flashes in my mind when it comes to Health System is WHO.Indeed anyway, WHO is a big character in the Global Health so I'll start the story with WHO itself, and directly moving on to other points related.

The embryo of WHO is OIHP, stands for L'Office International d'Hygiene Publique which was established in France. OIHP was created in December 1907, while, the League of Nations (UN) established the Health Organization of the League of Nations in Geneva in 1919.

Right after World War II (1945), the UN Conference on International Organizations in San Francisco voted to establish a new international health organization. The International Health Conference in New York approved the Constitution of the World Health Organization a year later, which would carry on the functions previously performed by the League and the OIHP.

WHO did not come into existence until 7 April 1948, when its constitution was ratified by the required 26 UN member states. And as we can see today, Baby WHO is now a Big- guy in Health System:)


The Cold War began with the end of the World War II. It was a period of tension and hostility between the US and the Soviet Union (1945 - 1960). To quote from Dr. Yodi Mahendradhata, it was the event of the splitting of Europe and US. It was called the Cold War because there was no active war between the two nations, which was probably due to the fear of nuclear escalation.

WHO and UN were somewhat at the same side of which US was going against to. At that time, malaria matter was such a big black dirt on a piece of white cloth. Malaria cases were so high that it caused the decrease of economy so the principle was that, the economy would be better as the malaria cased being managed.

The real agenda behind malaria matter were actually the political and economic reasons. The ability to handle critical problem of the world indirectly shows strength and power. US insisted that they could eliminate malaria. WHO and UN backed off so US held the global malaria eradication which was merely based on DDT spray. It was indeed a total failure..

There was also malaria eradication in Indonesia. In 1959, during the period of which President Sukarno was in charge in the country, Malaria Eradication Commando was formed under Ministry of Health. Yes, it also based on DDT spray. It was something truly positive about the effort made:)

"HEALTH FOR ALL by the YEAR 2000"

"Health for all by the year 2000" is the WHO slogan fruited from the Declaration of Alma-Ata in 1978, referring to the access to the basic health services as part of the fundamental human right.
"The Conference strongly reaffirms that health, which is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector."
Alma-Ata Declaration, 1978

Personally, if you ask me, I give two thumbs up upon this idea. I somewhat see this as a generous gift to EVERYONE with not much terms and conditions to meet with. I believe we all agree that this is a perfect example of a socialist figure.

This so- called socialist idea however, was strongly disagreed by the capitalist figures. World Bank, USAID (United States Agency for International Development), UNICEF, Rockefeller and Ford Foundation challenged the Alma- Ata Declaration in Bellagio conference, 1979. In 1982, UNICEF launched "The Children revolution" to compete with WHO.

Specifically, the Child Survival and Development Revolution, was launched by UNICEF as a drive which was said to save the lives of millions of children each year.  The ‘revolution’ is based on 4 simple, low-cost techniques:
  • Growth monitoring
  • Oral rehydration therapy
  • Breastfeeding
  • Immunization
Well.. I never think that those had been made or formed are bad. Those had actually been providing us for a beneficial living ever since, I admit. But the fact that there are quite not so clean reasons of why this and that were actually given to us make me pretty aggrieved, by heart....

World slowly crawling into the Neo- liberal Era, an era which filled with economic crisis and many country collapsing or even collapsed, especially when there was a petrol crisis in 1970s. So many countries reached to point where they have to borrow money.. This condition was a jackpot to Big Power with Big Money group as they could make a benefit out of the neediness of other pathetic countries. World Bank , IMF (International Monetary Fund), and US Treasury offered a "solution" for the money problem which was called as "Washington Consensus".


The basic principle of this consensus is the lending of money for any country to borrow but as a compulsory change, the country have to implement the 3 principal recipes which they made:
  1. Drastic cuts in public spending, including health to reduce inflation and public debt.
  2. Privatization in all sectors
  3. Decentralization
These may seem to be an ideal methods of problem- solving, but definitely won't goes well to every matter. But that's the must- take terms and conditions for any country who make loan from them. The analogy is like, 

"I don't care what's your disease or illness but this is the drugs you must take."

So with this, over time, World Bank gets bigger and bigger especially in the aspect of their power as more and more countries clinging on to and take their policies. The influence of World Bank becoming more and more huge, greater than that of the WHO.


One of the many things which had my interest dragged into is The Bill and Melinda Gates Foundation, a foundation named after Bill Gates himself and his wife.

We all are somewhat well introduced to who Bill Gates is: The world's richest man. Even in the field of health, this man has power which is bigger (and dollars which is lots thicker..) than the World Bank and even WHO. He is by far, the biggest single payer in Global Health.

His approaches are technically what we can expect from a very intelligent, Microsoft founder: TECHNOLOGY as the most important fundamental principle to solutions in Global Health.

It's a good thing to have a generous rich man who care for others but it's certainly not a good thing to have a rich man who spend in any way as he wishes without any control. And yes- no one, nothing deserve to control him of which this can lead to imbalance be it in the management of Global Health or in the expenditures or funding mechanism.

To me anyway, I vote for his effort:) I hope though, that he has people with the most appropriate credibility to work with him in sailing the foundation and he is truly sincere to bring good to the people:)

Take a tour:)


    Thursday, November 4, 2010

    The Stairs: District- Provincial- National

    As I mentioned in my previous posts, health system are being set up thoroughly through the region of the country. There are management to administer and conduct the health system in every level of the country of which yes- to provide care:)

    For today's post, I would like to discuss on the organization of the health system in 3 levels: National, provincial, and district.

    Generally, each sub-district in Indonesia has at least one public health center (PUSKESMAS: Pusat Kesihatan Masyarakat) headed by a doctor, usually supported by two or three sub-centres, the majority of which are headed by nurses. Most of the health centres are equipped with four-wheel drive vehicles (or even motorboats) to serve as mobile health centres and provide services to underserved populations in urban and remote rural areas.

    At the village level, the integrated Family Health Post provides preventive and promotive services. These health posts are established and managed by the community with the assistance of health canter staff. To improve maternal and child health, midwives are being deployed to the villages.

    Regional government has the authority of “support". This has an implication that regional development has to be performed by District/City, while the development at Province level is limited only to those, which have not been covered by District/City, and Inter-district/Inter-city.  Meanwhile, the Central government has to perform the role of policy formulation, standards and providing guidance to Province and District/City government levels.

    The chart below will help to clarify the organizational structure of health system in Indonesia:

    • "Governance and Regulation", Panel Discussion 
    • "Medical Doctors and Specialist Distribution in Indonesia", GROUP 8 TUTORIAL SESSIONS (Week 1)



    The health care system consists of all personal medical care services; prevention, diagnosis, treatment, and rehabilitation. Plus, the institutions and personnel that provide these services and the government, public, and private organizations and also the agencies that finance service delivery.

    Therefore,  basically, I can conclude that human resources, information, financing, governance, and service provision are part of the systemic concept and components in health system.

    I would like to put Health System as a complex consists of 3 interrelated components:

    People in need of health care services
    Health care consumers
    People who deliver health care services and the systematic arrangements for delivering health care
    The professionals and practitioners called health care providers
    The public and private agencies that organize, plan, regulate, finance, and coordinate services
    The institutions or organizations of the health care system
    *The institutional component includes hospitals, clinics, and also the insurance companies.

    Other institutions are the professional schools that train students for careers in medical, public health, dental, and allied health professions, such as nursing.

    Also included are agencies and associations that research and monitor the quality of health care services; license and accreditation providers and institutions; local, state, and national professional societies; and the companies that produce medical technology, equipment, and pharmaceuticals.

    These are the examples of 2 independent institutions being formed to put into practice the Medical Practice Acts:

    • Protect patients against malpractice.
    • Encourage doctors to increase their knowledge and enhance their service quality.
    • Regulate medical practice.
    • Guide medical practitioners in keeping their professionalism.
    • Issue certificates of medical registry for doctors.

    • Enforce doctor's discipline in their medical practice
    • Warn doctors who have conducted a malpractice

    2. THE GOALS

    The goals of health system in any country are generally almost similar upon their basic target: to create, improve, and maintain a good care (services).

    I found it useful to have a specific reference to state the goals of health system in Indonesia which based on "The Healthy Indonesia 2010’ goals:
    • To initiate and lead a health orientation of the national development
    • To maintain and enhance individual, family, and public health along with improving the environment
    • To maintain and enhance quality, accessible, and affordable health services
    • To promote public self-reliance in achieving government health


    A good health system delivers quality services to all people;  No matter when or where they need them.

    Proposed Ultimate Health System Outcomes (Harvard)
    • Health status
    • Citizen satisfaction
    • Financial risk protection
    The obstacles I able to captured so far are:


    At the first place, decentralization are part of the pillars in setting up the Strategy for National Health Development which is based on the new Vision and Mission of National Health Development. However, much of its disadvantages causing it to be one of the most significant obstacles in yielding good outcomes of the Health System.

    Some of those are the fact that it causes more doctors moving to urban area and eventually most cases reported that it's hard to get specialist in the remote area. As decentralization causing focus of management pointing in the higher level of administration, it causes heaps of career and development targeting at the area so limiting those in the district and province area.
      Precautions, principally good governance are necessary to prevent any adverse effects of decentralization.


      Low utilization may be due to poor quality of services; limited health insurance coverage; and the blurred distinction between private and public health care. Most health personnel are also private providers after office hours. This creates a conflict of interest which adversely affects the performance of the public health facilities.


      One of the best examples of this problem is the fact that many health personnel are reluctant to work in rural areas. It’s becoming a key issue in the decentralized health system if health personnel are directly recruited and paid by district governments.