Since early 2014, the Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS) has been helping selected districts in East Nusa Tengarra (NTT) and East Java to develop their District Health Accounts (DHAs). DHA is an activity which involves recording, analysing and reporting health expenditures. It describes how health is being financed; who is managing the funds; who is implementing the health services; the types of services and programs being provided; and who the beneficiaries are.
DHA is not new to Indonesia. Since 2008 a National Ministerial Decree stipulated that Health Accounts needs to be developed every year at the district, provincial and national levels. However, this also requires a decree from the local government to be effectively implemented. AIPHSS is helping those districts that have lagged behind others in establishing their health accounts.
North Central Timor (TTU) is a district in the NTT province where per capita income is currently $US35 a month. That is just over a dollar a day per person, however, fresh food is plentiful and cheap, and basic health and education services are provided by the government. Given the low revenue base of the government, prudent use of available resources is critical to provide adequate health services to the people. Knowing how money is spent across government and on health, and where it is allocated, is key to planning each annual budget so resources can be targeted to those social services and the people in in need.
Prior to AIPHSS, TTU didn’t even have a documented financial profile, or any clear indication of how the health budget should be spent according to local demand for services. Every year, stakeholders based annual budgets on the previous year’s budget without regard to emerging demands or key community priorities. The expenses were not closely analysed to look at how money is being spent to serve the best interests of the community. When Beato Yosef Fren Oenunu, Head of the Social and Culture subdivision at the Regional Planning Bureau began looking into the health accounts he noted where money was being spent:
“… I observed that the district health office budget has a lot of travel expenses, and so far we did not know about this…and it just meets obligatory functions”
At the beginning of 2014, the AIPHSS pioneered a DHA calculation in selected districts in East Nusa Tenggara (NTT) and East Java. The program trained 95 people from government areas, establishing DHA teams in each district. The ultimate purpose was to improve access to health care by the poor and near poor through better financing of local health services by reallocating money from areas of lesser priority.
Roland, a staff member from the Ngada District, who attended the training, noted the positive change:
“…I feel that this work is very valuable, as we get to know where the previous year’s budget was allocated , so that budgeting in the future will be better.”
Roland further explained that in the Ngada District, since the DHA calculation was undertaken, there was a shift in the allocation the following year. More money was allocated for health education and promotion for the community and less was spent on the purchase of laptops.
In some other AIPHSS districts, the results of DHA now clearly describe government’s expenditures on health and are beginning to affect the way resources are mobilised for more effective and efficient health services. The DHA results provide those preparing budgets with an improved understanding of how the budget should be structured and how to align with other supporting services in government. In TTU, for example, there is a new work culture among government officials who realise that the health sector needs to work across government and not just with the district health office. It involves building relationships with areas such as the educational office, regional planning, and other social services. They believe that the DHA process has reduced the tendency for government agencies to work in silos, and now each party understands that efficient and effective health services can only be achieved by working together; and that improvements start from the proper allocation of funds.
DHA production is neither a complicated nor complex process, but it requires strong political support . The approach AIPHSS has taken is to work with government systems while using political lobbying to gain support for DHA implementation. Socialization is done to raise awareness and gain commitment from government officials.
The training undertaken by the DHA Team is a five day course providing skills in calculating regional financial expenditure for various sectors. As a post-training follow-up, districts conduct a collection and analysis of DHA data. The collection of data is conducted across the government sectors which spend funds on health such as: Planning, Family Planning Board, Community Development Bureau, Prisons and Detention Centres, Hospitals, Police, Indonesian Red Cross (PMI), and others.
In the last two years, DHA has been successfully institutionalised in 8 AIPHSS districts with emerging positive results. There is continuing optimism amongst those involved that there will be an increase in health budgets and that this will improve the reach of health services to the poor and disadvantaged. The Secretary of the District Health Office in TTU shares this optimism for the work of AIPHSS:
“…AIPHSS program is very positive. The real evidence we can obtain from AIPHSS are: improvements of primary health care, and strengthening of puskesmas’ institutional capacity through the reform and accreditation of puskesmas. There are 7 puskesmas supported with 3 of them enjoy a regional cost sharing. …”
Most importantly, the key lessons learnt by AIPHSS will be the value for advocating and replicating DHA implementation in other districts.