TANTANGAN PENGEMBANGAN TENAGA KESEHATAN DI

INDONESIA

Sutopo Patria JatiFKM UNDIP

Siapa tenaga kesehatan ?

• Tenaga kesehatan adalah setiap orang yang mengabdikan diri dalam bidang kesehatan serta memiliki pengetahuan dan/atau keterampilan melalui pendidikan di bidang kesehatan yang untuk jenis tertentu memerlukan kewenangan untuk melakukan upaya kesehatan. (UU No 36 2009 ttg Kesehatan == > digunakan juga utk Draft RUU Tenaga Kesehatan 2011)

Evaluasi tentang Nakes • Terbatasnya tenaga kesehatan dan distribusi tidak merata. Indonesia

mengalami kekurangan pada hampir semua jenis tenaga kesehatan yang diperlukan. Pada tahun 2001, diperkirakan per 100.000 penduduk baru dapat dilayani oleh 7,7 dokter umum, 2,7 dokter gigi, 3,0 dokter spesialis, dan 8,0 bidan. Untuk tenaga kesehatan masyarakat, per 100.000 penduduk baru dilayani oleh 0,5 Sarjana Kesehatan Masyarakat, 1,7 apoteker, 6,6 ahli gizi, 0,1 tenaga epidemiologi dan 4,7 tenaga sanitasi (sanitarian).

• Banyak puskesmas belum memiliki dokter dan tenaga kesehatan masyarakat. Keterbatasan ini diperburuk oleh distribusi tenaga kesehatan yang tidak merata. Misalnya, lebih dari dua per tiga dokter spesialis berada di Jawa dan Bali. Disparitas rasio dokter umum per 100.000 penduduk antar wilayah juga masih tinggi dan berkisar dari 2,3 di Lampung hingga 28,0 di DI Yogyakarta. (Depkes, 2008)

• (i) there is a shortage and inequitable distribution of medical doctors and specialists;

• (ii) the education of health professionals is of poor quality and the accreditation and certification system is weak;

• (iii) health workforce policy development and planning are not based on evidence or demand, but rather on standard norms that do not reflect real need or take into account the contribution of the private health sector; nor have they adapted to a decentralized paradigm, and finally;

• (iv) the growing and changing demand for health care• due to demographic and epidemiological changes will increase

the burden on the already ineffective heal (WB, 2009)

PROYEKSI KEBUTUHAN NAKES ?

PROYEKSI KEBUTUHAN NAKES ?

FAKTOR PENYULIT DALAM PENGELOLAAN NAKES

• TRANSISI DEMOGRAFI DAN EPIDEMIOLOGI YG MENGUBAH DEMAND DARI YANKES;

• PENINGKATAN DEMAND TERJADI PADA KELOMPOK USILA YG SEMAKIN BANYAK; SERTA DEMAND UTK PELAYANAN YG LEBIH MODERN & LENGKAP KHUSUSNYA RANAP.

• POLA PERENCANAAN NAKES DI INDONESIA SUDAH SANGAT LAMA MENGGUNAKAN MODEL RASIO DIBANDINGKAN MODEL DEMAND DAN NEED .

Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.

10

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

Population in Thousands 2000

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

MalesFemales

Population In Thousands 2025

Source: BPS 2005.

Utara-Selatan(Biosecurity/Ideoscape)

“The Bottom Billions”(Pemiskinan/Finanscape)

Communicated dis.(Mediascape)

Disaster(Environscape)

Mobilisasi & Pandemi(Ethnoscape)

Peny berbasis perilaku:Napza-HIV & Kes Jiwa

(Socioscape)

Industrialisasi & efek GRK(Technoscape)

GLOBALISASI RISIKO KESEHATAN

KOMPETENSI SPESIFIK, JUGA KOMPREHENSIF:

HDI

Sumber: FA Moeloek, 2010

Figure 1

Source: The Lancet 2011; 378:1139-1165 (D p

Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis

Rafael Lozano, MD, Haidong Wang, PhD, Kyle J Foreman, MPH, Julie Knoll Rajaratnam, PhD, Mohsen Naghavi, MD, Jake R Marcus, MPH, Laura Dwyer-Lindgren, BA, Katherine T Lofgren, BA, David Phillips, BS, Charles Atkinson, BS, Alan D Lopez, PhD and Christopher JL Murray, MD

Figure 4

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)

Terms and Conditions

Figure 5

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)

Terms and Conditions

Figure 6

Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)

Terms and Conditions

Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008*0%

1%

2%

3%

4%

5%

6%

7%

Agriculture

Education

Health

Govt Apparatus National Defense

Infrastructure

Subsidies

Interest payments

% o

f G

DP

With subsidies declining again (in 2009) there might be increased space for the

health sector

17World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.

18World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.

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Health Center Ratio bed per 10,000 Health center ratio per 100,000

# He

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Ratio

TANTANGAN PENINGKATAN ASPEK KUANTITAS (PENYEBARAN NAKES)

The ratio of physicians to population also masks significant inequities among urban and rural areas.

Source: KKI 2008. 20

Distribution of Physicians in Indonesia, 1996-2006

Table 3-1: Distribution of Physicians in Indonesia, 1996-2006 Per 100K Residents 1996 2006 % changeNational 15.65 18.36 17.4Urban 40.24 36.18 -10.1Rural 5.39 5.96 10.6

Java & Bali 16.18 18.53 14.5Urban 38.97 34.06 -12.6Rural 4.37 4.49 2.8

Sumatera 14.62 18.72 28.1Urban 41.98 41.16 -1.9Rural 5.85 7.63 30.4

Other Provinces 15.09 17.44 15.6Urban 44.76 40.63 -9.2Rural 7.59 7.66 0.9 Source: PODES 1996 and 2006.

PTT Scheme Helps to Increase Recruitment to Rural Areas

PTT Doctors Recruited and location classification

Ordinary Remote Very Remote Total

1992-2002 19,549 7,042 3,270 29,861

Average per year 1,955 704 327 2,986

2003-2006 3,826 2,517 1,885 8,228

Average per year 957 629 471 2,057

2006-2007 995 1,489 1,700 4,184

Average per year 498 745 850 2,092

Source: Ruswendi, D., 2007

…even though midwives are almost everywhere and are equally distributed.

Note: All types of midwives included. Source: Indonesia Health Profile 2008.

Government target is 100 midwives per 100,000 population by 2010.

23

Distribution of Midwives in Indonesia, 1996-2006

Table 3-3: Distribution of Midwifes in Indonesia, 1996 & 2006Per 100K Residents

1996 2006 % changeNational 35.22 36.86 4.64Urban 30.26 31.36 3.63Rural 37.29 40.69 9.12

Java & Bali 27.55 26.12 -5.19Urban 23.84 25.08 5.21Rural 29.47 27.06 -8.19

Sumatera 53.73 54.09 0.67Urban 46.45 48.05 3.45Rural 56.06 57.07 1.80

Other Provinces 39.07 51.45 31.67Urban 43.25 42.23 -2.36Rural 38.02 55.34 45.55 Source: PODES 1996 & 2006

Facility Staffing of Puskesmas and Pustu, 1997-2007

Table 3-4: Facility Staffing of Puskesmas and Pustu, 1997-2007National Urban Rural

1997 2007 1997 2007 1997 2007Puskesmas

Number of MDs 1.51 1.90 1.63 2.04 1.29 1.58

No MD (%) 3.4 7.0 2.44 6.18 5.08 8.65

Number of Midwives 5.85 3.69 4.99 3.78 7.30 3.51

Number of Nurses 5.05 6.14 4.88 6.02 5.34 6.42

Pustu

Number of Midwives 0.98 0.81 1.14 1.06 0.84 0.50

Number of Nurses 1.08 1.06 1.21 1.19 0.99 0.86

Distribution of Physicians Providing Private Health Services

Per 100 k of population 1996 2006 % changeNational 9.90 13.71 38.45

Urban 26.50 27.65 4.33Rural 2.98 4.01 34.65

Java & Bali 10.98 15.44 40.54Urban 25.98 28.06 7.98Rural 3.21 4.03 25.43

Sumatera 9.15 11.91 30.08Urban 28.53 26.59 -6.79Rural 2.95 4.65 57.80

Other provinces 7.27 10.31 41.69Urban 26.57 26.90 1.26Rural 2.40 3.30 37.78

Distribution of Midwives providing private health services, 1996-2006

per 100 k of population 1996 2006 % changeNational 8.57 20.64 140.84

Urban 1.66 21.07 1169.28Rural 11.45 20.34 77.64

Java & Bali 6.97 20.95 200.57Urban 1.77 20.58 1062.71Rural 9.66 21.28 120.29

Sumatera 14.24 27.55 93.47Urban 1.81 29.15 1510.50Rural 18.22 26.76 46.87

Other provinces 7.33 12.07 64.67Urban 0.86 13.56 1476.74Rural 8.96 11.43 27.57

Midwife availability has increased significantly, however, TBA remains the preferred choice of provider for childbirth.

World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.

28

DIY

WJ

CJ

DKI

EJ

DKI

WJ

CJ

DIY

EJ

40

60

80

100

120

% D

eliv

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by h

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rofe

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nal

20 40 60 80100Ratio midwife per 100000 pop

SBA VS Ratio midwife, 2007

DKI DIY

EJ

WJ

CJ

DKI

WJ

CJ

DIY

EJ

40

60

80

100

120

% D

eliv

ery

by h

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rofe

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nal

200 400600Ratio TBA per 100000 pop

SBA VS Ratio TBA, 2007

Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007)Ratio Traditional Birth Attendant (TBA) (PODES, 2008)Note Abbreviation: DKI=DKI Jakarta, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java

There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.

30

TANTANGAN PENINGKATAN ASPEK KUALITAS PELAYANAN OLEH NAKES ?

Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.

32World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.

Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers

Ob-Gyns provide the most comprehensive services but reach only a limited population.

33

Antenatal Care Services by Type of Assistance in West Java (DHS 2007)

World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.

BAGAIMANA DENGAN TENAGA KESEHATAN MASYARAKAT ?

PERTUMBUHAN PROGRAM STUDI YANG LUAR BIASA

NO PRODI JENJANG JML KODE1 Ilmu Kesehatan Masyarakat S-3 2 13-0012 Epidemiologi S-3 1 13-0023 Ilmu Kesehatan Masyarakat S-2 20 13-1014 Epidemiologi S-2 2 13-1025 Ilmu Kesehatan Masyarakat S-1 143 13-2016 Kesehatan dan Keselamatan Kerja D-IV 2 13-3017 Analis Kesehatan D-IV 4 13-3028 Gizi D-III 6 13-4019 Kesehatan Lingkungan D-III 12 13-402

10 Epidemiologi D-III - 13-40311 Promosi dan Perilaku Kesehatan D-III - 13-40412 Kesehatan Ibu dan Anak D-III - 13-40513 Analis Lingkungan D-III - 13-40614 Hiperkes dan Keselamatan Kerja D-III 6 13-40715 Analis Kesehatan D-III 40 13-408

Sumber : Data EPSBED Tgl 03 Maret 2010

Modifikasi Penyajian DR.Arsitawati 2010

142

202

38647

245742 0

50001000015000200002500030000350004000045000

020406080

100120140160

S1 S2 S3

jum

lah

inst

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si k

ese

ha

tan

jenjang pendidikan

Jumlah Perguruan Tinggi Jumlah Mahasiswa

jumlah M

ahasiswa

Modifikasi dari:ARUM_BAPPENAS_MARET

2010

Jumlah Progam Studi & Mhsw Kesmas

=250-350mhsw/PS

GAMBARAN KONDISI AWAL

Region

S1 S2 S3

TotalA B C

Tdk Ada Data

A B CTdk Ada Data

A B CTdk Ada Data

Sumatera - 10 10 24 - - - 7 - - - - 51Jawa 3 20 9 23 2 1 2 3 - 1 - 1 65Bali, NTT - 2 1 - - - 1 - - - - - 4Kalimantan - 2 2 5 - - - - - - - - 9Sulawesi, Maluku - 5 12 13 - 1 3 - - - - - 34

Papua - 1 - 1 - - - - - - - - 2

JUMLAH 3 40 34 66 2 2 6 10 0 1 - 1 165

Sumber : Data BAN – PT tgl 03 Maret 2010

70% S1= Kategori C + Blm terakreditasi80% S2= Kategori C + Blm terakreditasi

Modifikasi Penyajian DR.Arsitawati/Staf khusus Wamendiknas 2010

PERKIRAAN KEBUTUHAN “SKM”

Institusi/ Jumlah

Kebutuhan Total Sarana per institusi Kebutuhan

Pusat 69 20 1,380

Dinkes Provinsi 33 20 660

Dinkes Kab/Kota 495 20 9,900

RS 1,372 5 6,860

Puskesmas 8,548 4 34,192

52,992

Modifikasi dari: ARUM_BAPPENAS_MARET 2010

OP menetapkan standar profesi dan kode etik nya serta menerapkan dengan segala sangsi

OP melaks advokasi & sosialisasi keprofesian dg customernya

OP yang menerima mandat untuk pengemb anggota & profesinya

Konsep yang ditawarkan oleh IAKMI Pusat?

Masing-2 unit pelayanan menetapkan peraturan, sop, compliance profesi kesmas berdasarkan kebutuhan setempatMasyarakat & industri kesehatan tidak perduli (ignore) dan tidak terlibat (involve with trust) thd profesi kesmasMisconduct & “SKM” yg dibiarkan dan ditangani bawah tangan shg tdk memuaskan masy

Pengembangan profesi kesmas terutama tanggung jwb pemerintah & masy bukan profesi itu sendiri

Orgn Profesi menentukan kriteria akreditasi, profesi

& sertifikasi

Kepercayaan masy thd “SKM”

Akreditasi, kualifikasi & sertifikasi belum berkembang

HARI INI

?

Upaya yg perlu MASA DEPAN

Norma Baru Profesi Agenda

PerubahanKeprofesia

n

Survei & analisissituasi

KesadaranKolektif profesi

SosialisasiKebijakan

&Program

Aktivasi Kelompo

kPenekan Diskursus

Politik

Implementasi &

Lessons-Learned

UNTUK BERUBAH MEMERLUKAN

Modifikasi dari Tarlov, 1999

TERIMA KASIH