MATERNAL NEONATAL CHILD HEALTH BUDGET: Looking for the ownership Case Study on 4 districts (Merauke, Sikka, Tasikmalaya, and Pontianak) Trisnantoro, L. Kurniawan, F. Harbianto, D. Abstract Background The relatively slow progress in maternal and neonatal health indicates that a more robust health system is required. Geographical disparities highlight the different conditions and constraints under which health interventions are delivered in the country. This situation is in sharp contrast with the centrallydriven approach to MNCH policy that still persists today, in which MNCH plans and policies are not directly linked to sound implementation and health financing strategies. Such an approach in a diverse and decentralized country like Indonesia has failed to translate policies into effective implementation. Decentralization, if well managed, could offer the opportunity for locally-driven solutions that respond to the diversity of problems and strategies to scale-up MNCH interventions faced by provinces and districts in Indonesia. On the other hand, an ill-designed and poorly implemented decentralization program could seriously hinder the delivery of health services as it has been observed during the last decade in Indonesia. The key policy challenge is how to improve ownership of MNCH by the local government and mobilize local financing support for MNCH. So far, local governments have not been mobilized to support priorities and fund the MNCH agenda. The central government budget has limited capacity for financing the provision of MNCH services along the continuum of MNCH care program. One key challenge for policymakers on the ground is to develop plans and budgets that set implementation and funding priorities based on evidence. There is no report available on national infant and mortality data at district level and rates are extrapolated. There are no data available for costeffectiveness analysis in MNCH. Another gap is the lack of costing data for MNCH interventions to inform central and local government budgeting processes. There is limited research on family oriented, population oriented and individual clinical services and the scarce information available is not used for MNCH budgeting at the central, provincial or district government level. There is no analysis on the allocation of available funding to MNCH. Formidable problems exist in the use of evidence for government budgeting and planning. Although geographical and socio-economic disparities have been extensively documented, there is no comprehensive analysis of the distribution of MNCH related variables. These gaps reflect the problem for estimating the additional funding required to effectively address the constraints and bottlenecks and to scale-up the “best-buy range of interventions” to achieve such equitable progress on MDGs 4 and 5. MNCH is centralized-funded program on health. The biggest share of financial sources is come from Central government (APBN). The local (district-municipality) share is relativity low. For last 4 years, MNCH was became the central government responsibility. Central Government budget has concerned in achieving the MDG target. Based on that reason, local government has no responsibility to budgeted more money to MNCH (low local commitment). Method The study applied descriptive on quantitative data method. The analyzed units were central budget, district budget, and decentralizations/de-concentrated budget, assisting tasks, and sector budget. The research subjects were the Ministry of Health, National Development Planning Board (BAPPENAS), and Districts Health Offices. The research settings were the Ministry of Health, Sikka district, Merauke district, Pontianak city and Tasikmalaya city. The analyzed units were the budget/expenditure data of health-decentralizations/de-concentrated fund, other health-assisting fund on Maternal Neonatal and Child Health, in the last 2 budget years 2008-2009 Objective Analyzed and described the share of district health budget on MNCH as an indicator of local commitment on achieving MDG 4 and 5. This local budget commitment is also describe “the ownership” of the program that answered the questions; does the district concern on the achieving MDG 4 and 5? Or has a political thought that it should be central government responsibility. Results One of the key challenges for policymakers and planners is to ensure adequate financing resources for priority interventions such as MNCH. The prominent place of MNCH in the strategic plans and documents of both the Presidential Office and the Ministry of Health has not guaranteed that MNCH is given a priority during budget negotiations. In theory, the national budget should be developed in line with these strategic plans. However, the national health budget has not followed the core recommendations of the strategic plan. In the last five years, the allocated resources for health program other than the health insurance for the poor have been reduced in order to meet the increasing funding requirements of Jamkesmas. Notwithstanding the well documented problems with central funding, after excluding curative care financed through Jamkesmas, it can be seen that MNCH program rely heavily on central government funds. A preliminary assessment of available data shows that the largest share of MNCH funding comes from Central Government (ABPN), whereas the proportion funded from local sources, District Municipality, (ABPD) is relativity low. In average, the source of funds share are; APBN (MNCHImmunizations program) 57%, APBN (DAK) 13%, APBD (Counterpart budget) 7%, APBD (MNCH-local initiative program) 14%, Donor program 9%. It also shows that, there are the big share of the local budget is used for counterpart budget to certain central budget such as Dana Alokasi Khusus (DAK) or de-concentrated budget/special autonomy fund in Papua. Comparing with own local health budget (APBD Kesehatan), it’s only 2% from the budget are used for MNCH program (in estimate, include salary, or 18% exclude salary). The current health financing arrangements pose serious challenges to the effective implementation of MNCH policies and strategies. According to the regulatory framework for decentralization, the central budget uses a de-concentration mechanism to fund the implementation of health services. Resources from the de-concentration fund are first directed from the central government to the provinces. The provincial government redirects the funding to the district/municipality or to the program activities. This flow of funds from central to provincial to districts/program often encounters several problems, including: insufficient time to spend the resources and report on their use; improper use of central budget by provincial government officers; and mismatch between allocation and local needs. Conclusion While the reliance of MNCH program on the central government fund poses serious problems to the scale-up of priority interventions, insufficient funding from local governments is allocated to MNCH. It shown by the comparison of total government budget (APBD), total regional government health budget (APBD-KES), and total regional government MNCH budget (APBD-KIA), the share of local budget is relatively low. In absolute terms most local governments allocate insufficient funding for MNCH, although regional disparities can be observed. This insufficient district budget allocation to MNCH shows the lack of ownership by the local government. This is particularly problematic in the current decentralized system under which local governments are responsible for the delivery of health services, including MNCH. Keyword: health financing, local commitment, budget allocation
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