Prof. Achir Yani S.

Hamid, MN, DNSc

Universal Health Coverage & SDGs
people-centered
integrated health care
Access to health care Financial support

Health Care Health Political Will Global

Facilities Professionals
Trends
Regulation
• Renewed attention on frontline services and
associated health workers.
• Universal Health Coverage a regional and
global priority
• UHC central to achieving the Sustainable
Development Goal for Health (SDG3)
• Universal health coverage is when all
people receive the care they need, without
incurring financial hardship
• Progress on UHC is ‘everybody’s business’
UHC central to the Sustainable Development Agenda’s
ambition to ‘leave no-one behind’

Despite progress, in the

South-East Asia Region
• At least 130 million
people still lack access
to one or more
essential services
• At least 65 million
people are pushed
into poverty because
of health care costs
Source: Monitoring health in the Sustainable Development Goals 2017, WHO/SEARO
HWF DENSITY
2- DENSITY

22.8/10,000
World Health
Report 2006
 To achieve UHC, front line services remain key. Fresh
thinking needed on service delivery models and on
associated health workforce. Services need health
workers – but remember they are a means to an end,
not an end in themselves.
 Rethinking HRH – have to think about numbers;
distribution; individual competencies; appropriate team
skill-mix, to meet changing needs; available resources;
best use of resources.
 To track progress, need better indicators and better
data
Attention to HRH not new, but intensified in recent years
2016 SEAR
- First report of
Decade of HRH
2014 SEAR - Consultation on
Health, the SDGs and
Launch of the role of UHC
Decade of health
2010 workforce
- WHO Code on strengthening
international 2015-2024
2017
recruitment/migra
WHA resolution on
tion 2016 Global
HRH and
- WHO - Global HRH implementation of
recommendations strategy outcomes of UN
2013
on retention in - UN High-Level High-Level
- Third Global Commission
rural/remote areas Forum on HRH, Commission on
2006 Recife “A Universal Health
World Health Truth: No Health Employment and
Report on Without a Workforce” Economic Growth
Health - Recommendations
workforce on Transformative
education
Decade of Strengthening HRH in SEAR 2015-24.

• Focus on rural retention and ‘transformative’

education.
• First review of progress for Decade of HRH was
in 2016.
• Second review of progress is due in 2018.
• Will have Regional consultation to discuss
progress in April 2018.
• Will report to Regional Committee in
September 2018
 Decade is exactly that – ten years. It shows that
politicians recognise change can take time. But
they also need to see progress.
 First review of Decade asked
◦ Are we on track?
◦ Do we need to rethink what we are doing – or
how?
◦ How can we best make use of this commitment to
HRH?
◦ How can we use the momentum around the SDGs
and UHC to accelerate progress on HRH in SEAR,
to develop the health workforce we need?
1. HRH strategies and actions must be linked to
service delivery, UHC, SDG reforms to address
changing needs; focus on those being left behind.
2. The SDGs put new attention and momentum behind
HRH. So do initiatives such as the global HRH
Strategy; Commission on Health Employment,
SEAR’s Decade on HRH. Important to use them.
3. The commitment to a Decade of HRH in SEAR is
unusual and valuable. It gives time to align short
term actions with long term vision. Two year
reporting cycle will help maintain attention.
4. More HRH change is happening in SEAR countries
than realised.
5. To improve frontline services, the HRH debate
needs to go beyond doctors and nurses - to other
health workers.
6. In many SEAR countries, the private sector’s role
in HRH is too big to be ignored: it is a major
producer and employer of health workers, and
attracts health workers from the public sector.
7. Stronger linkages within the health sector and
beyond the health sector are essential for
significant, sustained change. We heard good
examples but also how hard it is.
8. So far, no countries have reported any systematic
assessment of impact. Demonstrating impact
takes time, and active monitoring of progress is
essential: to show politicians and paymasters that
change is happening; to make adaptations to
policies as needed. Some simple ‘tracer indicators’
would be useful.
 1. Optimize the existing workforce in
pursuit of the Sustainable
Development Goals and universal
health coverage (e.g. education,
employment, retention)

2. Anticipate and align investment in

future workforce requirements and
plan the necessary changes (e.g. a
fit for purpose, needs-based
SDG 3c workforce)

3. Strengthen individual and

institutional capacity to manage
HRH policy, planning and
implementation (e.g. migration and
regulation)

4. Strengthen data, evidence and

knowledge for cost-effective policy
decisions (e.g. National Health
Workforce Accounts)
One vision: Accelerate progress towards universal health coverage and
the 2030 Agenda for Sustainable Development by ensuring
equitable access to health workers within strengthened
health systems
Two goals: Invest in both the expansion and transformation of the
global health and social workforce

To facilitate the implementation of intersectoral approaches

Five and country-driven action and catalyse sustainable
workstreams: investments, capacity-building and policy action: (1)
advocacy, social dialogue and policy dialogue; (2) data,
evidence and accountability; (3) education, skills and
jobs; (4) financing and investments; and (5) international
 Existing Nursing Issues of SEAR Member States
NO ISSUES COUNTRY
BAN BHU PRK IND INO MDV MMR NEP SRL THA TLS

1. Deployment and Utilization of Nurses

1.1 Shortage of Nurses X X X X X X X X
1.2 From inadequate number till no X X X X X

Nursing Professionals at Primary Care

Level
1.3 No clear job description among Nurses X X X

1.4 Mismatch of competences/ X X X X X X X X

qualification with the scope of practice
of different category/level of
education/training
1.5 Nurses with lower education have more X X X X X X

scope of work at Primary Care Level, in

contrast with the higher educated
nurses mostly work at Secondary and
Tertiary Care Level
1.6 Midwives only focus on RMNCH X X
Programme implementation
1.7 General Nurse Midwife (GNM) in X X X
addition to RMNCH Programme also
perform other health programmes

2 Education/Training

2.1 Many categories of nursing education/ X X

training led to fragmentations of
competences and scope of works
2.2 Family Welfare Visitor with limited X
training is considered as part of health
professionals and authorized to
perform some nursing and midwifery
interventions
2.3 No education higher than Bachelor X X x X x
2.4 Curriculum is not regularly reviewed X X
2.5 No supporting policy for quality of X X X X X X

education
2.6 No mechanism to recognize the X X X

education institutions (Accreditation) 14

3 CPD (Continuous Professional
Development/PCD (Professional Career
Development)
CPD (Continuous Professional
Development
3.1 No national policy and mechanism for X X X X X

CPD
3.2
No standard of CPD X X X X

3.3 No regulation to support the X X X

implementation of CPD’s Standard

3.4
No National Training Center X

3.5
No accreditation of Training Center X X X X

3.6 No annual calendar for in-service X X X X

training program
3.7
No data base on the training staffs X X X X

3.8 No coordination between National X

RMNCH Programmes and Training

Institution
PCD (Professional Career Development)
3.9 Limited opportunities for career X X X

development in public and private

sector, which adversely affect
motivation
3.10 PCD is not used for remuneration and X X X X

career mobility
3.11 Lack of policy to support the X X X X X

recruitment, deployment and retention

system for nurses and midwives
4 Lack of Evidence and Information System
on Nursing and Midwifery Workforce
4.1 No data on number of graduates to X X X X X X

measure the annual capacity of

production, particularly at private sector
4.2 No data at all on number of deployed X X X X

and utilized nurses and midwives

4.3 Limited data on number of deployed X X X X X X X
X
and utilized nurses and midwives,
particularly at private sector
4.4 Lack of data on staffing norms. Only the X x X X X X X 15
 The availability,
accessibility, and quality of
the nursing workforce

The vital role of the nursing

and workforce in building
the resilience of
communities to respond to
diverse health conditions

Notable achievements
have been made
16
 As the sustainable expansion and
reform of health professionals’
education and training to increase
the quantity, quality and relevance
of health professionals, and in so
doing strengthen the country
health systems and improve
population health outcomes
17
 Global strategic Future
Global strategy on directions for Direction and
human resources strengthening
Nursing
for health: nursing and
Workforce 2030 midwifery 2016– Development
2020 of Indonesia

18
 Nasional:
1. Tuntutan masyarakat tentang yankes versus kualitas SDM dan
yankes
2. Yankes tidak sesuai dengan kompetensi dan kewenangan SDM
3. Geografis yang menyebar menimbulkan tidak meratanya dan tidak
rasionalnya yankes oleh tenaga kesehatan
4. Sistem penghargaan dan perlindungan kerja yang tidak mendukung
5. Sistem pendidikan belum mampu menyiapkan tenaga kesehatan
yang kompeten sesuai dengan kebutuhan masyarakat: skill mix
competences bagi tenaga kesehatan
6. Tidak terintegrasinya perencanaan, produksi dan utilisasi/distribusi
tenaga kesehatan
 Peraturan dan perundangan undangan:
1. memberikan perlindungan pada
masyarakat
2. profesionalisme dan arahan kerja perawat
mengatur uji kompetensi, sertifikasi,
registrasi dan lisensi
3. bekerja dalam lingkup kewenangan
berdasarkan kompetensi yang disiapkan dan
dijamin melalui sistem penataan keperawatan
secara utuh yang ditetapkan oleh UU
Keperawatan
 UU, PP dan Kepmenkes, kendala:
1. tidak mengikat daerah secara penuh,
karena desentralisasi, lebih mengacu pada
perda
 UU No. 36 Tentang Kesehatan, belum spesifik
diatur menjadi PP sementara Kepmenkes
kurang mengikat daerah.
 UU No 44 Tentang Perumahsakitan belum
membangun kerja tim multidisiplin, belum
pro masyarakat
 Konsil yang tidak kuat karena tidak secara
otonom mengatur secara utuh sistem
kredensial dan profesi keperawatan, di bawah
Konsil Tenaga Kesehatan Indonesia
 Sistem kredensial tidak mutlak menjadi
kewenangan konsil.
@ Uji kompetensi: PT, OP atau Lembaga
Terakreditasi
@ sertifikasi kompetensi: PT
@ registrasi: Konsil
@ lisensi: Dinkes Kab/Kota
 Kesetaraan peraturan dan perundang undangan, contoh:
MRA, dan MEA cross border nursing regulation (ICN)
berdampak
a) pengakuan terhadap kompetensi:
b) memfilter perawat asing masuk ke Indonesia; sehingga
Perawat Indonesia akan kehilangan lapangan kerja dan
tidak bisa memanfaatkan peluang kerja di luar dan bahkan
dideportasi bagi yang sudah bekerja di LN; masyarakat
Indonesia tidak mendapatkan pelayanan yang peka budaya,
melalui bahasa dan kompetensi terstandar.
 Devisa ekonomi meningkat dengan migrasi perawat,
meminimalkan pengangguran, meningkatkan
kesejahteraan, meningkatkan kompetensi/IPTEK
 Brain drain versus brain circulation/gain
 Pemanfaatan lulusan Ners dan Ners-Spesialis belum
optimal, jumlah lulusan Ners <10% yang bekerja di
pelayanan kesehatan (Informasi SDM Kesehatan, 2016)
Perencanaan SDM
Keperawatan belum
Pelaksanaan asuhan keperawatan mengacu kepada tuntutan
belum terlaksana sebagai asuhan perkembangan IPTEK,
keperawatan professional pelayanan yang bermutu,
dan akreditasi rumah sakit
(termasuk JCI)
Pendidikan D IV Keperawatan
yang semula sebagai crash
program masih berlangsung
 Konsisten terhadap kesepakatan Lokakarya
Keperawatan 1983 tentang sistem pendidikan
tinggi keperawatan ( DIII, Ners, Ners-Spesialis)

Peningkatan pemberdayaan lulusan Ners

(akademik-profesi) dan Ners-Spesialis dalam
fasilitas pelayanan kesehatan

Pendidikan D III Keperawatan berangsur-angsur

dikurangi sejalan dengan peningkatan jumlah Ners.
Setelah itu pendidikan D III keperawatan dapat ditutup
(seperti negara Malaysia, Thailand)
 Pendidikan D IV Keperawatan ditutup karena tidak
sesuai dengan kesepakatan (crash program) untuk
pembimbing klinik D III. Saat ini telah dipersyaratkan
minimal S2. Untuk meningkatkan kemahiran perawat,
PPNI telah menyiapkan program CPD

Lulusan Ners tidak hanya diberdayakan untuk duduk

sebagai staf struktural, namun lebih banyak
diberdayakan untuk pemberian asuhan keperawatan
professional. Oleh karena itu diperlukan penataan
utilisasi lulusan pendidikan tinggi keperawatan

Lulusan Ners-Spesialis harus diberdayakan sesuai

dengan bidang spesialisasi untuk meningkatkan
kualitas pelayanan keperawatan
Konsil Keperawatan agar segera dibentuk dan difungsikan
untuk menata credentialing system perawat Indonesia

Penataan Pola Ketenagaan Perawat di Penguatan fungsi

Fasyankes Primer dan Rujukan ketenagaan perawat
(staffing)

Program – Program
Pengembangan
pembinaan Sistem Jenjang karir
SIM Ketenagaan
kompetensi dan perawat dan
Perawat dan
profesionalisme penghargaan
Pelayanan
perawat
Keperawatan
 STRATA KETIGA
(TERTIER) Konsultan
YANKEP TERTIER
Ners Spesialis
Ners + Sertifikasi
Diploma III +
Sertifikasi

STRATA KEDUA
(SEKUNDER) Ners Spesialis
YANKEP SEKUNDER
Ners + Sertifikasi
STRATA PERTAMA Diploma III + Sertifikasi
(PRIMER)
YANKEP PRIMER
Ners Spesialis, Ners,
Diploma III 2
8
 Pyramid-Shaped

Ners Sp & S3
Ners Ners Sp 2 (K)
Sp/S3: Ners Sp 1
20%
Ners Sertifikasi Lanjutan
Ners Sertifikasi Dasar
Ners: 20% Ners Generalis

D3 Kep: 60%
 Ners Sp &
S3
Diamond-Shaped
Ners Sp 2
(K)
NersNers
Sertifikasi
Sp 1
Lanjutan
Ners Sertifikasi S3,Sp2,
Dasar Sp1: 20%
Ners Generalis

Ners: 45 % PMK 30/2019 (26

Sept): Klasifikasi dan
Perizinan RS:
65% Profesi dan
D3: 35 % 35% Vokasi
Ners di RS kelas A, B,
C, D.
Sehat Risiko Sakit
TARGET PELAYANAN & SAKIT DI
ASUHAN KEPERAWATAN RUMAH
LANSIA SAKIT

BUMIL
Dewasa Bayi
SAKIT DI
KELUARGA
SEHAT DI KOMUNITA
KELUARGA/ S
KOMUNITAS ANAK
Remaja
PRA SEK RISIKO DI
Anak KELUARGA/
Sekolah
Kanak2 KOMUNITAS
 PPNI

IKATAN/
HIMPUNAN KOLEGIUM

KONSIL KEPERAWATAN

UU KEPERAWATAN 33
 Meningkatkan Profesionalisme perawat
dlm melaksanakan praktik keperawatan

1. Kejelasan Pengaturan jumlah, rasio & komposisi perawat sesuai dgn

jenis pelayanan keperawatan/kesehatan:
2. Penguatan profesionalisme perawat dalam melaksanakan praktik
keperawatan
a. Perawat memiliki kompetensi (sertifikat kompetensi), diakui
terdaftar (STR)
b. Kejelasan tugas dan wewenang
c. Kejelasan hak dan kewajiban
d. Kejelasan Pola dan Jenjang Karir
e. Kejelasan Sistem Remunerasi perawat
3. Tersedia Program CPD sesuai Standar Pelayanan dan Standar Profesi
4. Dijamin Kesempatan perawat untuk mengembangkan diri
5. Pengaturan Praktik yang dilakukan oleh perawat asing
Pemerintah:
 Kejelasan dalam kesepakatan sistem kerjasama,
informasi seluas luasnya tentang konsekuensi,
sistem yang berlaku, kejelasan kontrak,
melibatkan organisasi profesi
 Kebijakan yang mengatur agar negara penerima
menginvestasi contoh: pengembangan sistem
pelatihan di RS yang terstandar; penyetaraan
kurikulum termasuk implementasi dan evaluasi
serta utilisasi
 Utilisasi maksimal setelah kembali dari LN dgn
memperhatikan sistem jenjang karir professional
PDF Version
 Setelah 40 tahun baru pada tahun 2001
resolution on strengthening nursing and
midwifery services was in the agenda of WHA
(World Health Assembly); Judith Oulton,CEO
ICN: Naema Algazeer; Nurse scientist WHO-
HQ)
 Each country delegation should report at WHA
meeting (May) on the activities done in
country in 2003, 2006, 2010.
 UN for Woman Affair
 Leadership of ICN and WHO Nurse Scientist
 ICN punya 138 anggota NNAs (PPNI/INNA
anggota 125, tahun 2003; network dengan
berbagai NNAs dan ICN)
 WHO punya Chief nurses (Directorate of
Nursing) di hampir semua negara anggota
 Health Professional Associations (ICN, WMA,
Pharmacist)
 Dr. Judith Shamian, President ICN sbg UN
High Level Commission on Health
Employment and Economic Growth
Together we can make a change:
 Each individual nurses should be well equipped
with leadership capacity (setiap individu perawat
dibekali dengan kemampuan kepemimpinan)
 Membentuk kelompok (critical mass of leaders)
 Membentuk focal points dari critical mass of
leaders (a.l: ikatan keilmuan, himpunan kajian,
OP, kolegium, AIPNI, DON, dll). DON sudah
dihapuskan di SO Kemkes
 Membina jejaring kerja dengan berbagai
pemangku kepentingan (di luar keperawatan:
PERSI, ARSADA, ARDINKES, OP Kesehatan (IDI, IBI,
ISFI, PDGI, IAKMI, dll)
 Membangun opini publik berdasarkan evidence
dengan cara publikasi, artikel, press conference,
seminar, workshop, road show, gerakan
simpatik, memanfaatkan pendukung untuk
menyuarakan tentang kepentingan masyarakat
keperawatan
 Mengesahkan regulasi turunan Undang Undang
keperawatan
 Mendorong perawat politisi untuk pengaruhi
kebijakan dan peraturan perundang-undangan
kesehatan
 Kaderisasi dan suksesi kepemimpinan
 Masuk dalam penjelasan UU Keperawatan tidak
tercantum di batang tubuh
 Membawahi Ikatan, Himpunan dan Kolegium
 Memerlukan kepemimpinan kolektif (collective
leadership)
 Membangun kerjasama dan networking nasional
dan internasional
 Membina kemitraan dengan penguasa
pemerintahan dan stakeholders lainnya
 Menyepakati position statements dan
mengkontribusi pada formulasi kebijakan
kesehatan nasional dan daeah
Persiapan:
 Pemahaman isu penting: merugikan masyarakat,
menghambat proses Peraturan dan perundang-
undangan, ……….
 Evidence base dihasilkan melalui telaah secondary
data atau hasil kajian/penelitian
 Menyusun proposal/masukan terkait dengan
perumusan kebijakan (policy brief) berdasarkan
evidence dan ditujukan untuk merespon isu
 Tidak boleh lebih dari 3 hal. Usahakan 1 hal besar
mempunyai banyak implikasi.
 Hanya 1 pembicara sbg wakil, kecuali
misalnya contoh nyata di daerah/kasus
 Executive summary: tidak lebih dari 2
halaman
 Fokus pada kepentingan publik yang
biasanya diampu melalui program kesehatan
 Pengkawalan usulan: langkah langkah tindak
lanjut yang perlu dilakukan secara spesifik
 Tulis notula rapat untuk di check recheck
dengan pendamping pejabat publik
 Pahami arah kebijakan partai untuk
mensinergikan perjuangan kita dengan
kebijakan partai
 Seni bermain dengan “kepentingan”
 Akademisi: “boleh salah tapi tidak boleh
bohong”
 Politisi: “tidak boleh salah tapi boleh bohong”
 Perawat Politisi: “tidak boleh salah dan tidak
boleh bohong”
 Program Indonesia Sehat dengan Pendekatan
Keluarga Sehat (UKK, UKBM: Posyandu,
Posbindu, PTM, Poskesdes) yang sangat sesuai
dengan keperawatan kesehatan keluarga dan
keperawatan komunitas
 Program Pelaksanaan Nusantara Sehat
 Pendekatan yang mengutamaan upaya promotif
dan preventif
 Penempatan perawat professional secara
rasional di semua tatanan yankes
45