Responding to the health needs of internally displaced persons : an analysis of the Indonesian health system

摘要

Since 1998, several provinces in Indonesia have suffered a number of violent conflicts causing massive destruction, several thousand deaths and creating over a million displaced people. This happened in North Maluku and Central Kalimantan Provinces. In 1999 the displaced people from North Maluku took flight to Manado municipality and in 2001 those from Central Kalimantan fled to Sampang District. These recipient areas were selected for this study because of their differing characteristics, including presence of IDPs; urban/rural; and levels of development. While the central government was initially responsible for providing adequate support in the first two -three years of their displacement in both areas, this changed at the end of 2003 when the central government terminated their support for the IDPs. During this period, authority for developing health programmes and services had been devolved to local government by central government through the health decentralisation policy in 2001, which created additional challenges to their meeting the needs of the incoming IDP population and particularly after the removal of government support for IDPs in 2003. This research was designed to contribute to a policy or model to be developed by the Indonesian health authorities to provide services for IDPs. The research questions were: what are the key health needs of the displaced population in the two selected recipient areas in Indonesia; what are the problems experienced by services in the municipality and district in seeking to meet these needs; to what extent has the public sector identified and responded to the health needs of the IDPs in the context of the health decentralisation policy that was currently being implemented in these two areas; on the basis of the preceding analysis, what are appropriate recommendations for the provision of health services to the displaced populations of Indonesia? The research employed mixed methods in handling the above questions. It was conducted through direct observation, surveys and focus group discussions (FGD) with IDPs. Semi-structured interviews were conducted with the Heads of the Municipal/District Health Offices and Heads of selected puskesmas in the recipient IDP areas. Respondents for surveys were selected by using a formula for estimating statistical proportions. 71 respondents in Manado and 116 respondents in Sampang were selected and respondents for FGD were selected through purposive sampling. This thesis presents the effect of the reception of IDPs on the local health systems and the responses of the areas that received them. It argues that IDPs, trapped in complex emergency situations with consequent increased health needs, added a burden to the health systems in the recipient areas The findings indicated that the local health authorities were unable to fully meet the health needs of the IDPs and therefore suggested that local health systems need to be improved at the same time as the implementation of the health decentralisation policy. This thesis provides recommendations for the public health sector capacity in the areas that received the IDPs. These are intended to enable the national health system to fill the gap between the health needs of the IDPs and the local authority health system. Recommendations include: redefinition of functions of local health institutions, ensuring a better quality of health service and strengthening the referral system.