District‐level impacts of health system decentralization in Indonesia: A systematic review

Abstract

Summary The local‐level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty‐nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post‐decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.

Untapped Potential: A Qualitative Study of a Hospital-Based Dengue Surveillance System

“…32 From a helicopter view, most of the components of a wellperforming dengue surveillance system were indeed already available, although not in all hospitals. In line with a recent review of the decentralized Indonesian health system, 33 our study found issues in several of the building blocks of a wellperforming health system as defined by the WHO. 34 First, it was found that the regulatory frameworks used to support the staff in diagnostics and reporting were inconsistent.…”

Ensuring Sustainability of Polio Immunization in Health System Transition: Lessons from the Polio Eradication Initiative in Indonesia

“…East Java (Trenggalek, Jombang, Ngawi, Sampang, Pamekasan) was below 51%, with the lowest level at 9% in Sampang district, East Java (12).…”

“…During transition from a centralized to decentralized system, maternal and child immunization coverage and availability remained pressing issues at the district level in Indonesia. Complete child immunization in most districts in Indonesia was below the WHO recommendation threshold of 80% (12). In 2002, complete child immunization coverage in central java (Cilacap, Rembang, Jepara, Pemalang, Brebes) and…”

“…The district government is not under the provincial government. Each level has its own mandates and areas of authority (11,12).…”

“…However, in both poor and rich local governments, the health budget from the general allocation fund (Dana Alokasi Umum/DAU) and APBD was not enough to fund the healthcare services. In several districts, budget constraints were more common after decentralization due to public health budget reduction (12).…”