1. TANTANGAN PENGEMBANGAN
TENAGA KESEHATAN DI INDONESIA
Sutopo Patria Jati
FKM UNDIP

2. 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)

3. 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)

4. • (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)

7. PROYEKSI KEBUTUHAN NAKES ?

8. PROYEKSI KEBUTUHAN NAKES ?

9. 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 .

10. Indonesia’s population is growing: by 2025 there will be 273 million people and
the elderly population will almost double to 23 million.
75+
75+
Males
70-74
70-74 Females
65-69
65-69
60-64
60-64
55-59
55-59
50-54
50-54
45-49
45-49
40-44
40-44
35-39
35-39
30-34
30-34
25-29
25-29
20-24
20-24
15-19
15-19
10-14
10-14
5-9
5-9
0-4 0-4
-15,000 -10,000 -5,000 0 5,000 10,000 15,000 -15,000 -10,000 -5,000 0 5,000 10,000 15,000
Population in Thousands 2000 Population In Thousands 2025
Source: BPS 2005. 10

11. Utara-Selatan
(Biosecurity/Ideoscape)
Peny berbasis perilaku: Industrialisasi & efek GRK
Napza-HIV & Kes Jiwa (Technoscape)
(Socioscape)
Communicated dis. “The Bottom Billions”
(Mediascape) (Pemiskinan/
Finanscape)
Disaster Mobilisasi & Pandemi
(Environscape) (Ethnoscape)

12. KOMPETENSI SPESIFIK, JUGA KOMPREHENSIF:
HDI
Sumber: FA Moeloek, 2010

13. 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

14. Figure 4
Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)
Terms and Conditions

15. Figure 5
Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)
Terms and Conditions

16. Figure 6
Source: The Lancet 2011; 378:1139-1165 (DOI:10.1016/S0140-6736(11)61337-8)
Terms and Conditions

17. Given current low levels of spending for health compared to other sectors, a
good case can be made for reprioritizing in favor of health.
With subsidies declining again (in 2009) there might be increased space for the health sector
7%
6%
5%
Subsidies
4%
% of GDP
3%
Interest payments
2%
Education
Infrastructure
1% National Defense
Govt Apparatus
Agriculture
0% Health
1994 1996 1998 2000 2002 2004 2006 2008*
World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia. 17

18. # Health center
1,000
1,200
200
400
600
800
0
West Papua
North Sulawesi
Maluku
Papua
Bali
East Kalimantan
West Sumatra
D I Yogyakarta
DKI Jakarta
Gorontalo
North Maluku
Health Center
Nanggroe Aceh Darussalam
South Sulawesi
South Kalimantan
serious inequities among provinces.
Central Sulawesi
Central Kalimantan
East Nusa Tenggara
Bengkulu
West Kalimantan
Ratio bed per 10,000
Bangka Belitung Island
Jambi
Central Java
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
North Sumatra
South East Sulawesi
South Sumatra
Riau
East Java
West Nusa Tenggara
Lampung
Health center ratio per 100,000
West Java
There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6
Banten
hospitals per 1,000,000 Indonesians, however, on average, there are
Indonesia
0
2
6
8
4
10
18
Ratio

19. TANTANGAN PENINGKATAN ASPEK
KUANTITAS (PENYEBARAN NAKES)

20. The ratio of physicians to population also masks significant inequities
among urban and rural areas.
Source: KKI 2008. 20

21. Distribution of Physicians in Indonesia, 1996-2006
Table 3-1: Distribution of Physicians in Indonesia, 1996-2006
Per 100K Residents
1996 2006 % change
National 15.65 18.36 17.4
Urban 40.24 36.18 -10.1
Rural 5.39 5.96 10.6
Java & Bali 16.18 18.53 14.5
Urban 38.97 34.06 -12.6
Rural 4.37 4.49 2.8
Sumatera 14.62 18.72 28.1
Urban 41.98 41.16 -1.9
Rural 5.85 7.63 30.4
Other Provinces 15.09 17.44 15.6
Urban 44.76 40.63 -9.2
Rural 7.59 7.66 0.9
Source: PODES 1996 and 2006.

22. 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

23. …even though midwives are almost everywhere and are equally
distributed.
Government target is 100 midwives per 100,000 population by 2010.
Note: All types of midwives included. Source: Indonesia Health Profile 2008. 23

24. Distribution of Midwives in Indonesia, 1996-2006
Table 3-3: Distribution of Midwifes in Indonesia, 1996 & 2006
Per 100K Residents
1996 2006 % change
National 35.22 36.86 4.64
Urban 30.26 31.36 3.63
Rural 37.29 40.69 9.12
Java & Bali 27.55 26.12 -5.19
Urban 23.84 25.08 5.21
Rural 29.47 27.06 -8.19
Sumatera 53.73 54.09 0.67
Urban 46.45 48.05 3.45
Rural 56.06 57.07 1.80
Other Provinces 39.07 51.45 31.67
Urban 43.25 42.23 -2.36
Rural 38.02 55.34 45.55
Source: PODES 1996 & 2006

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

26. Distribution of Physicians Providing Private Health Services
Per 100 k of population
1996 2006 % change
National 9.90 13.71 38.45
Urban 26.50 27.65 4.33
Rural 2.98 4.01 34.65
Java & Bali 10.98 15.44 40.54
Urban 25.98 28.06 7.98
Rural 3.21 4.03 25.43
Sumatera 9.15 11.91 30.08
Urban 28.53 26.59 -6.79
Rural 2.95 4.65 57.80
Other provinces 7.27 10.31 41.69
Urban 26.57 26.90 1.26
Rural 2.40 3.30 37.78

27. Distribution of Midwives providing private health services,
1996-2006
per 100 k of population
1996 2006 % change
National 8.57 20.64 140.84
Urban 1.66 21.07 1169.28
Rural 11.45 20.34 77.64
Java & Bali 6.97 20.95 200.57
Urban 1.77 20.58 1062.71
Rural 9.66 21.28 120.29
Sumatera 14.24 27.55 93.47
Urban 1.81 29.15 1510.50
Rural 18.22 26.76 46.87
Other provinces 7.33 12.07 64.67
Urban 0.86 13.56 1476.74
Rural 8.96 11.43 27.57

28. Midwife availability has increased significantly, however, TBA remains
the preferred choice of provider for childbirth.
28
SBA VS Ratio midwife, 2007 SBA VS Ratio TBA, 2007
120
120
% Delivery by health professional
100
100
DKI DKI
DIY DIY
CJ CJ
80
80
EJ EJ
WJ WJ
60
60
40
40
20 40 60 80100 200 400600
Ratio midwife per 100000 pop Ratio TBA per 100000 pop
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, W J=W est java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java
World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.

30. There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster
in richer urban areas.
30

31. TANTANGAN PENINGKATAN ASPEK
KUALITAS PELAYANAN OLEH NAKES ?

32. Although more than 70 percent of pregnant women receive antenatal
care by skilled providers, the quality of care varies widely.
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
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment. 32

33. Ob-Gyns provide the most comprehensive services but reach only a
limited population.
Antenatal Care Services by Type of Assistance in West Java (DHS 2007)
World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment. 33

34. BAGAIMANA DENGAN TENAGA
KESEHATAN MASYARAKAT ?

35. NO PRODI JENJANG JML KODE
1 Ilmu Kesehatan Masyarakat S-3 2 13-001
2 Epidemiologi S-3 1 13-002
3 Ilmu Kesehatan Masyarakat S-2 20 13-101
4 Epidemiologi S-2 2 13-102
5 Ilmu Kesehatan Masyarakat S-1 143 13-201
6 Kesehatan dan Keselamatan Kerja D-IV 2 13-301
7 Analis Kesehatan D-IV 4 13-302
8 Gizi D-III 6 13-401
9 Kesehatan Lingkungan D-III 12 13-402
10 Epidemiologi D-III - 13-403
11 Promosi dan Perilaku Kesehatan D-III - 13-404
12 Kesehatan Ibu dan Anak D-III - 13-405
13 Analis Lingkungan D-III - 13-406
14 Hiperkes dan Keselamatan Kerja D-III 6 13-407
15 Analis Kesehatan D-III 40 13-408
Sumber : Data EPSBED Tgl 03 Maret 2010
Modifikasi Penyajian DR.Arsitawati 2010

36. Jumlah Progam Studi & Mhsw Kesmas
160 142 =250-350mhsw/PS 45000
140 40000
jumlah institusi kesehatan
120 35000
100 30000
jumlah Mahasiswa
25000
80 38647 20000
60 15000
40 20 10000
20 2 5000
2457
0 42 0
S1 S2 S3
jenjang pendidikan
Jumlah Perguruan Tinggi Jumlah Mahasiswa
Modifikasi dari:ARUM_BAPPENAS_MARET 2010

37. S1 S2 S3
Region Tdk Tdk Tdk Total
A B C Ada A B C Ada A B C Ada
Data Data Data
Sumatera - 10 10 24 - - - 7 - - - - 51
Jawa 3 20 9 23 2 1 2 3 - 1 - 1 65
Bali, NTT - 2 1 - - - 1 - - - - - 4
Kalimantan - 2 2 5 - - - - - - - - 9
Sulawesi,
- 5 12 13 - 1 3 - - - - - 34
Maluku
Papua - 1 - 1 - - - - - - - - 2
JUMLAH 3 40 34 66 2 2 6 10 0 1 - 1 165
70% S1= Kategori C + Blm terakreditasi
80% S2= Kategori C + Blm terakreditasi
Sumber : Data BAN – PT tgl 03 Maret 2010
Modifikasi Penyajian DR.Arsitawati/Staf khusus Wamendiknas 2010

38. PERKIRAAN KEBUTUHAN “SKM”
Institusi/ Kebutuhan Total
Sarana Jumlah 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

39. Konsep yang ditawarkan oleh IAKMI Pusat?
HARI INI Upaya yg perlu MASA DEPAN
Akreditasi, kualifikasi & Orgn Profesi menentukan
kriteria akreditasi, profesi
sertifikasi belum berkembang & sertifikasi
Masing-2 unit pelayanan
menetapkan peraturan, sop, OP menetapkan standar
profesi dan kode etik nya
compliance profesi kesmas serta menerapkan dengan
berdasarkan kebutuhan setempat segala sangsi
Masyarakat & industri
?
kesehatan tidak perduli OP melaks advokasi &
sosialisasi keprofesian dg
(ignore) dan tidak terlibat customernya
(involve with trust) thd
profesi kesmas
Misconduct & “SKM” yg dibiarkan Kepercayaan masy thd
dan ditangani bawah tangan shg “SKM”
tdk memuaskan masy
Pengembangan profesi kesmas OP yang menerima
terutama tanggung jwb mandat untuk pengemb
anggota & profesinya
pemerintah & masy bukan
profesi itu sendiri

40. UNTUK BERUBAH MEMERLUKAN
Norma Baru
Profesi Agenda
Implementasi & Perubahan
Lessons- Keprofesian
Learned
Survei &
Sosialisasi analisis
Kebijakan & situasi
Program
Kesadaran
Aktivasi
Kolektif profesi
Kelompok
Penekan
Diskursus Politik Modifikasi dari Tarlov, 1999

41. TERIMA KASIH