Indonesia’s Health Sector
Review
1
OVERVIEW
DATA, GRAPHS AND TABLES
UPDATED DECEMBER 2010
Next Update foreseen in
March 2011 adding the
Actuarial Estimates and
Jamkesmas Review
Background
2
 The WB received requests for electronic copies of the various charts, tables and
graphs included in the reports and papers produced for the Indonesia Health
Sector Review
 In response, this synthesis report has been created. It includes the key charts,
tables and graphs that can be downloaded
 This is a living document and updates will be inserted when new data become
available
 This document does not summarize all the work that was carried out, rather it
includes mainly the data and graphs. For summaries and details please refer to
the documents listed in the annex. Each slide includes the source document for
easy reference
This review was put together by the World Bank Jakarta-based health team
including Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi,
George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved in
earlier versions.
Indonesia’s Dynamic
Environment
3
Indonesia’s health system performance is challenged by a
changing environment:
O n g o i n g d e m o g r a p h i c a n d e p i d e m i o l o g i c a l t r a n s i t i o n s t h a t
are likely to increase demand and result in more costly and
more diverse health care.
A d d i t i o n a l p r e s s u r e w i l l c o m e f r o m e m e r g i n g d i s e a s e s a n d
epidemics such as HIV/AIDS, H5N1 (Avian Influenza) and
H1N1 (Swine Influenza).
T h e i m p l e m e n t a t i o n o f L a w N o . 4 0 / 2 0 0 4 o n U n i v e r s a l
Health Insurance Coverage (UHIC) will further increase
demand and utilization.
Indonesia’s population is growing: by 2025 there will be 273 million
people and the elderly population will almost double to 23 million.
4
75+
75+
70-74
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
-15,000
-10,000
-5,000
5-9
5-9
0-4
0-4
0
5,000
10,000
Population in Thousands 2000
Source: BPS 2005.
Males
Females
70-74
15,000
-15,000 -10,000 -5,000
0
5,000
10,000 15,000
Population In Thousands 2025
The demographic transition may provide a ‘demographic bonus’ in
the short term if those coming of working age are employed…
5
Dependency ratio, 1950-2050
90
total
ratio to working-age population
80
demographic bonus
70
young
window of opportunity
60
50
40
30
20
10
eldery
0
1950
1960
1970
1980
1990
2000
year
Source: Adioetomo 2007.
2010
2020
2030
2040
2050
…but may also have serious implications for the delivery and
financing of health care; doubling the need for care from aging
alone.
6
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Although communicable disease remains a large burden, with the changing
age structure disease patterns will shift to noncommunicable disease and
injuries, increasing and diversifying the demand for health care further.
7
Changes in Burden of Disease in Indonesia
70
60
50
SKRT'95
40
SKRT'01
Riskesdas07
30
20
10
0
Perinatal / Maternal
Source: Riskesdas Survey 2007.
Communicable Disease
Non-communicable
Disease
Injuries
The obesity rate is rising and increased prevalence of risk factors
will change the burden of disease – increasing the need for
preventive measures.
8
Adult Obesity in Indonesia (%)
Richest
23.2
Quintile 4
19.9
Quintile 3
17.8
Quintile 2
16.8
Poorest
15
Rural
15.7
Urban
23.6
Females
29
Male
7.7
0
5
Source: Riskesdas Survey 2007.
10
15
20
25
30
35
Increased need will demand more resources for health. Fortunately,
despite the global economic crisis, the macroeconomic picture is
still favorable.
8
9
6
7
Pre-crisis forecast
4
5
Post-crisis forecast
2003
2005
2007
Source : IMF
World Bank. 2009. Giving More Weight to Health in Indonesia.
2009
year
2011
2013
Health System Performance
10
Indonesia’s health system performance measured in terms of
health outcomes, financial protection, consumer awareness
and equity and efficiency is mixed:
I n d o n e s i a s c o r e s h i g h l y o n r e d u c i n g c h i l d m o r t a l i t y b u t l o w
on reducing maternal mortality.
I n e q u i t i e s i n h e a l t h o u t c o m e s b e t w e e n i n c o m e l e v e l s a n d
geographic areas are very large and constitute a major
problem for the health sector overall.
Indonesians live longer in 2010 and child mortality has fallen
dramatically since the 1960s.
200
150
100
50
50
Infant mortality
Infant/underfive mortality rate
60
Under-five mortality
Life expectancy
0
40
Life expectancy
70
11
1960
1970
1980
1990
2000
year
Source : WDI 2009
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
2010
But geographic inequities remain large: life expectancy varies
between 60 in West Nusa Tenggara and 75 in Yogyakarta.
12
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Indonesia performs well in terms of infant mortality relative to other
comparable health spending level countries but less well for its income.
13
Above average
INFANT MORTALITY (2008)
Malaysia
Vietnam
Sri Lanka
Thailand
Below average
ChinaBangladesh
Lao PDR
Indonesia
India
Below average
Above average
Attainment relative to health spending per capita
Source: WDI 2009, WHO 2008
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Despite significant reduction in IMR over time, some neighboring
countries have performed better.
14
100
250
Infant mortality, 1960-2009
Indonesia
Thailand
25
Vietnam
India
China
5
Sri Lanka
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
Source: WDI 2009
Note: y-axis log scale
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
0
Source: DHS 2007.
Infant Mortality
Child Mortality
West Sulawesi
Maluku
West Nusa Tenggara
East Nusa Tenggara
South Kalimantan
North Maluku
Gorontalo
Central Sulawesi
North Sumatra
Bengkulu
Papua
West Papua
South-east Sulawesi
West Sumatra
West Kalimantan
Riau Islands
Banten
Lampung
South Sulawesi
South Sumatra
West Java
Riau
Jambi
Bangka Belitung
DI Aceh
East Java
North Sulawesi
East Kalimantan
Bali
DKI Jakarta
Central Kalimantan
Central Java
DI Yogyakarta
Death for every 1000 live birth
And there are large inequalities between provinces and income
levels.
15
120
100
80
60
40
20
In fact, some of Indonesia’s provinces are at par with some of the
best and worst performing countries.
16
100
150
Infant mortality, 2008
50
West Sulawesi
North Maluku
Riau Islands
West Java
DKI Jakarta
Congo,Niger
Rep.
West Nusa TenggaraTanzania
West Sumatra
South Sumatra
Riau
East Kalimantan
DI Yogyakarta
India
Timor-Leste
Uganda
Cambodia
Zimbabwe
Papua New Guinea
Bangladesh
Vietnam
China
Ukraine
0
San Marino
Indonesia
Other countries
Source: IDHS (2007) & WDI 2009
World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.
Indonesia also performs less well on maternal mortality for its
income level in international comparisons.
17
Above average
MATERNAL MORTALITY, 2008
Vietnam
Sri Lanka
Below average
China
Thailand
Malaysia
Bangladesh
India
Lao PDR
Indonesia
Below average
Above average
Attainment relative to health spending per capita
Source: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
And will need extra efforts to achieve the MDG of reducing
maternal deaths by 75 percent by 2015.
18
The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.
Underweight among children under five years of age has declined
significantly…
19
40
Moderate
37.5
Severe
35.5
35
30
Percentage
Underweight
31.6
29.5
26.4
25
24.6
31.2
20
28.3
20
19
18.3
15
17.1
19.8
19.3
28.2
27.5
27.3
26.1
19.2
19.6
28
19.2
18.4
13
10
11.6
5
6.3
7.2
1989
1992
10.5
8.1
7.5
6.3
8
8.3
8.6
8.8
1999
2000
2001
2002
2003
2004
2005
5.4
0
1995
Source : Susenas 1989-2005, Riskesdas 2007
Source: Susenas various years.
1998
2007*
…however, stunting rates, which are an indicator of chronic
malnutrition, remain very high.
20
Above average
Stunting Among Children under 5 years old, 2000-2009
Thailand
Sri Lanka
Below average
Bangladesh
Vietnam
China
Indonesia
Lao PDR
India
Below average
Above average
Attainment relative to health spending per capita
Source: WDI 2009, WHO 2008
Health Spending Trends
21
By any measure Indonesia’s public spending on health is low and inequitably distributed:
 Indonesia’s public health spending as a proportion of GDP has stagnated in recent years
and compares unfavorably with other comparable income countries.
 Indonesia’s Out-of-Pocket (OOP) spending is about average for its income level and has
improved in recent years.
 Indonesia does reasonably well on reducing catastrophic spending incidence but less well
on health insurance coverage and equity.
 Public spending on health is inequitably distributed across provinces and income
quintiles.
Despite substantial increases in government health expenditures as
a share of GDP over recent years, Indonesian governments barely
spends 1 percent of GDP on health.
22
Government health expenditures by level of government (2001-2009)
IDR Trillions (constant 2007 prices)
45
1.2%
40
1.0%
35
30
0.8%
25
0.6%
20
15
0.4%
10
0.2%
5
0
0.0%
2001
Central
2002
2003
Province
2004
2005
District
2006
2007*
2008*
Share of GDP
World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.
2009**
Total and public health spending in Indonesia is low relative to
other comparable income countries.
23
GOVERNMENT HEALTH SPENDING VS INCOME,2008
10
10
Government Health Spending (% GDP)
15
15
TOTAL HEALTH SPENDING VS INCOME, 2008
Samoa
China
Thailand Malaysia
Samoa
Vietnam
Thailand
China
Cambodia
Indonesia
Lao PDR
Malaysia
0
Indonesia
0
Lao PDR
5
5
Vietnam
Cambodia
100
250
1000
10000
25000
10
GDP per capita
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
100
250
1000
GDP per capita
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
10000 25000
And government health spending as a share of the budget is even
lower than total government expenditures as a share of GDP.
24
30 40 50
Government spending vs income, 2004-2006
20
Government spending (% GDP)
Indonesia
10
Government health spending (% budget)
Indonesia
100
250
1000
2500
GNI per capita (US$)
Source: WDI
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
10000
25000
OOP spending, a measure of financial protection, is about average
relative to comparators.
25
80
OOP spending as share of total health spending
vs Income per capita, 2008
60
Cambodia
Lao PDR
Vietnam
Philippines
40
China
Malaysia
20
Indonesia
Thailand
0
Samoa
100
250
1000
10000
GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
25000
Financial protection, measured as the OOP share of nonfood
spending has improved.
26
Source: Equitap Update 2009.
By regional standards, the incidence of catastrophic health
spending is low in Indonesia.
27
18.0
16.0
14.0
% of households exceeding threshold
12.0
10.0
8.0
6.0
4.0
2.0
0.0
Malaysia (1999) Taiwan (2000)
Indonesia
(2006)
Thailand
(2002)
Hong Kong
(2000)
Sri Lanka
(1997)
Philippines
(1999)
Indonesia
(2001)
Greater than 25 percent of nonfood expenditures
Korea (2000)
Nepal (1996)
India (2000)
China (2000)
Bangladesh
(2000)
Vietnam (1998)
Greater than 10 percent of total expenditures
Catastrophic payments for health care are defined as OOP payments in excess of a substantial
proportion of the household budget, usually 10-40 percent (Van Doorslaer et al. 2006; Xu et al, 2003)
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Equity of public spending on health could be improved; it is low in
international comparisons and has not changed much since 2001.
28
Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region
Poorest quintile share of subsidy
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Hong Kong 2002
Sri Lanka 2004
Thailand 2002
Malaysia 1996
Vietnam 2003
Bangladesh 2000
Mongolia*
India 1996
Indonesia 2006
Indonesia 2001
Gansu (China) 2003
Zhejiang (China) 2003
Heilongjiang (China) 2003
Shanxi province (China) 2003
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Inequities between provinces are also evident from differences in
health expenditures.
29
District Public Health Expenditures by Province (2005)
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Technical efficiency is low in Indonesia in global comparisons and
there are large differences between provinces.
30
average
case- f low
A: high case-flow
low occupancy
average
case- f low
100
C: high case-flow
high occupancy
A: high case-flow
low occupancy
C: high case-flow
high occupancy
80
80
T
M
60
N
UK
C
V
F LA
G
Irl
Tk US Aus E
Idn H HK
I
Ch
PB
Cdn
CZ
S
Nl
D Mng
Mys
40
average
bed occupancy
CN
case-flow (case per bed per year)
case-flow (cases per bed per year)
100
Banten
Kalseng
Bangka Belitung NTB
B a l i DKI Jakarta
Sulsel
Sumsel Sulteng
Sulteng Irian Jaya Tengah
Jatim
Bengkulu Jabar
R i a u Jateng
Kaltim
KaltengLampung DIY
average
Sumbar
N AIrian
D Jaya Barat
bed occupancy
J a mb i
Sumut
Irian Jaya Timur
Maluku
60
40
Sulut
20
Tw Rok
J
20
B: low case-flow
low occupancy
B: low case-flow
low occupancy
D: low case-flow
high occupancy
10
20
30
40
50
60
70
80
90
D: low case-flow
high occupancy
0
0
0
0
NTT
KalBar
100
10
20
30
40
50
60
70
80
90
percent bed occupancy rate
percent bed occupancy rate
Technical efficiency is ideally measured using case-mix unit cost data, however these
are not available in Indonesia. Instead case-flow and average bed occupancy are used.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
100
Indonesia’s Health Delivery
System
31
An already stretched health system will incur further pressure
due to increased demand from ongoing demographic, nutrition
and epidemiological transitions as well as the introduction of
universal health insurance coverage.
I n d o n e s i a ’ s h e a l t h i n f r a s t r u c t u r e , a l t h o u g h w i d e l y a v a i l a b l e
for primary care, does not have sufficient beds or health
workers to respond to these increased needs.
P h a r m a c e u t i c a l s u p p l i e s a r e r e a s o n a b l e b u t m o s t I n d o n e s i a n
pay more than they need to and most expenditures are out of
pocket.
T h e r e i s a p r e s s i n g n e e d t o a d d r e s s h u m a n r e s o u r c e s
distribution inequities and quality.
S a t i s f a c t i o n l e v e l s o v e r a l l a r e g o o d a l t h o u g h t h e r e i s a h i g h
level of dissatisfaction with various aspects of health care.
Indonesia’s primary public health care system is extensive: more than 90
percent of the population has access to primary care facilities.
32
Ratio Puskesmas per 100,000 Population
Source: MoH. 2008. Health Profile.
While Indonesia has a well-developed primary health system, it has
fewer hospital beds than comparators.
33
5
10
15
HOSPITAL BED SUPPLY VS INCOME, 2000-2010
Vietnam
Lao PDR
0
Cambodia
100
250
China
Thailand
Malaysia
Philippines
Samoa
Indonesia
1000
10000
GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
25000
And Also Fewer Health Workers
34
MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010
China
Philippines
100
250
15
10
5
Philippines
Malaysia
Thailand
Samoa
Indonesia
1000
10000
GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
Lao
PDR
Cambodia
Vietnam
0
0
Vietnam
Lao PDR
Cambodia
Midwives/Nurses per 1,000
2
4
6
8
20
DOCTOR SUPPLY VS INCOME, 2000-2010
25000
100
250
Malaysia
Samoa
Thailand
Indonesia
1000
10000
GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008
Note: GDP per capita in current US$; Log scale
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
25000
At the Puskesmas level most basic services are available.
35
Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult
Curative Care (by Clinical Setting)(2007)
Quality Measures
Public Settings
Puskesmas
Structural quality
Internal water source (%)
Private Settings
Private
Nurse
Pustu
Private
Midwife
Private
MDs
All
Settings
89
71
80
84
89
84
Inpatient beds (%)
Functioning microscope (%)
28
79
3
5
3
1
28
3
3
7
18
25
Tuberculosis service (%)
Measles vaccines in stock (%)
95
97
30
51
8
5
2
48
44
11
38
51
Tetanus toxoid vaccine in stock
(%)
Hepatitis B vaccine in stock (%)
97
55
9
59
12
55
92
52
6
54
16
52
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
Secondary and tertiary care have not progressed equally: the
number of hospitals and hospital beds has grown slowly.
36
Increase in numbers of hospital beds between 1995 and 2006 by ownership
140000
120000
100000
80000
60000
40000
20000
0
1995
MoH
1997
2000
Province, district, municipal
2003
Armed forces, police
2005
State-owned
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
2006
Private
Health Center
Ratio bed per 10,000
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Health center ratio per 100,000
Indonesia
Banten
West Java
Lampung
West Nusa Tenggara
East Java
Riau
South Sumatra
South East Sulawesi
North Sumatra
Central Java
Jambi
Bangka Belitung Island
West Kalimantan
Bengkulu
East Nusa Tenggara
Central Kalimantan
Central Sulawesi
South Kalimantan
South Sulawesi
Nanggroe Aceh Darussalam
North Maluku
Gorontalo
DKI Jakarta
D I Yogyakarta
West Sumatra
East Kalimantan
Bali
Papua
Maluku
North Sulawesi
West Papua
# Health center
1,200
1,000
6
600
400
4
200
2
0
0
Ratio
There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6
hospitals per 1,000,000 Indonesians, however, on average, there
are serious inequities among provinces.
37
10
8
800
The ratio of physicians to population also masks significant
inequities among urban and rural areas.
38
Source: KKI 2008.
DPT3 immunization, often considered a good indicator of health
system coverage, is low for Indonesia’s health expenditure level and
may indicate low levels of efficiency.
39
Country
Total health expenditure pc (US$)
DPT3 immunization
coverage
Indonesia
26
70
Uganda
22
84
Rwanda
19
95
Tajikistan
18
85
Tanzania
17
90
Nepal
16
75
Pakistan
15
80
Bangladesh
12
88
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Analysis of the number of staff per primary care facility illustrates
inequalities at the facility level…
40
Facility
National
Java-Bali
Sumatra
Other
Provinces
1997 2007
1997 2007
1997 2007
1997 2007
Puskesmas
Number of Doctors
Number of Doctors (%)
1.51 1.90
3.4
7.0
1.68 1.96
1.5
5.9
1.19 1.85
2.0
1.09 1.62
6.8
15.9 11.3
Number of Midwives
5.85 3.69
5.76 3.44
6.33 5.28
5.62 3.18
Number of Nurses
5.05 6.14
4.58 5.60
6.16 7.16
5.84 7.61
Number of Midwives
0.98 0.81
1.06 0.76
1.13 1.17
0.44 0.21
Number of Nurses
1.08 1.06
1.02 1.09
1.16 1.08
1.16 0.89
Pustu
Source: IFLS 1997; 2007.
…and quality, measured as diagnostic and treatment ability, varies
between regions and geographic areas and has not improved much
over time.
41
Quality of Public Health Services in Indonesia 1997-2007 (by Region)
Service
National
Java/Bali
Sumatra
Other Provinces
1997 2007 P= 1997 2007 P= 1997 2007 P= 1997 2007 P=
Prenatal Care
Public
42
46 ***
45
47
**
35
39
**
38
49 ***
Private
40
44 ***
43
46 ***
34
37
**
39
46 ***
Public
56
64 ***
58
66 ***
48
56 ***
55
65 ***
Private
55
59 ***
57
62 ***
50
52
54
60 ***
Public
49
56 ***
52
59 ***
43
48 ***
44
53 ***
Private
46
53 ***
48
56 ***
40
51 ***
44
51 ***
Child Curative Care
Adult Curative Care
*** p<0.01, **p<0.05
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
In international comparisons Indonesia spends little on medicine
per capita, and most expenses are out-of-pocket.
42
Spending on drugs per capita in US$
Thailand
Malaysia
Vietnam
Philippines
Cambodia
Indonesia
Government
India
0
5
10
15
20
Private
25
Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less than
US$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming the
central government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide all
the primary care medicines recommended by WHO.
Source: WHO. 2004. The World Medicines Situation.
But most Indonesians pay more than they need to for their medicines
when they buy from the private sector or from public hospitals.
43
Price ratio to median
international
indicator price
Private pharmacies
Public hospitals
Originator brands
Most sold branded
generic
Lowest price generic
22-26
6-7
2.6
22
1.7-6
2.15
Source: National Institute for Health Research and Development (NIHRD) Survey 2004.
Provision of health services by private health providers has grown
significantly over the past decade.
44
 At the national level, physician practices per 1,000 of population grew
at 38.5 percent
 The number of midwife practices per 1,000 population increased by
4.64 percent.
 And the majority of
physicians working in a
Puskesmas supplement
their income through
private service provision
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
And utilization of private health providers fell after Askeskin was
introduced and the utilization of Puskesmas increased.
45
Changes in choice between public and private sector between 1999 and 2008
World Bank. 2009. Doctors, Midwives and Nurses: Health Work Force Review.
However, most Indonesians continue to seek ambulatory care from
private providers when ill.
46
100%
90%
80%
70%
60%
50%
40%
30%
2007
20%
1997
10%
0%
Source: IFLS 1997 & 2007.
Overall consumer satisfaction with inpatient and outpatient
services appears good…
47
Source: GSD2 and Susenas.
…although there is a high level of dissatisfaction with various
aspects of the provision of health care…
48
Dissatisfaction With Various Aspects of Health Services (%)
21.7
waiting time
26.1
17.2
hospitality
13.6
24.2
24.1
information availability
29.7
involvement in Decision making
32.8
25.6
private consultation
27.3
27.9
26.8
freedom of choice
21.7
cleanliness
18.3
11.6
family visit
0
5
10
15
20
percent
inpatient
Source: Sakernas National Health Survey 2004.
outpatient
25
30
35
…and many people continue to opt for self-treatment or forego treatment
altogether.
49
Source: Susenas various years.
Health Financing Reform
50
The new government is committed to implementing the
reform and assuring all Indonesian citizens access to
quality health services and financial protection against the
impoverishing effects of large unpredictable medical care
costs.
Fulfilling this commitment will require the development,
implementation, and monitoring of policies affecting all
aspects of the health system – basic public health programs;
delivery systems and logistical capacity; quality and
distribution; organization, management, and accountability;
pharmaceuticals; financing; public—private partnerships
and all levels of government.
Background
51
 The 2004 Social Security legislation (Law No. 40) envisages coverage of the




entire population through a mandatory health insurance system evolving from
the existing insurance programs.
As of 2009 the government has covered some 76 million poor and near poor
through the Jamkesmas program, funded through the central government
budget.
However, progress over the last five years has been slow in developing the final
configuration of the health insurance system and the transition plan to provide
health insurance to the remaining 50+ percent of the population who currently
lack coverage remains to be developed.
Many local governments have developed their own financing schemes, some for
the uncovered non-poor.
The health insurance reform is complicated by the big bang decentralization
reform that took place in 2001 which transferred most of the authority and
responsibility for assuring service delivery capacity to local governments.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Health insurance systems in Indonesia since 2008.
52
Current Insurance Systems
Ministry of
Labor
Jamsostek
Types:
Coverage
(millions of
people)
Social security
Social HMO
4.1
Ministry of
Finance
Private
insurance
Commercial
health insurance
6.6. including
personal
accident
Ministry of
Health
Ministry of
Defense
Askes,
HMOs
PT Askes:
-Civil servants
-Commercial HMOs
Civil servant: 14
Commercial HMOs: 2
Military
personnel
Jamkesmas
(scheme for
the poor)
76.4
Free health
services
2
Technical oversight
Financial oversight
Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.
The Current Health Policy Baseline for Health Financing Reform:
System Strengths.
53
 The country has favorable demographic circumstances with dependency ratios







falling over the next 30 years
There are high educational and literacy levels
The government is committed to reform
Health spending levels are not excessive
The country achieves reasonable health outcomes, financial protection and
consumer satisfaction
There is substantial experience with health insurance programs
There is an extensive primary care delivery system
Pharmaceuticals are generally available
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
The Current Health Policy Baseline for Health Financing Reform:
System Challenges.
54
 Half the population lacks health insurance coverage
 Health financing and delivery systems are highly fragmented
 Human and physical infrastructures are limited and face quality and efficiency




problems
Salary and capital subsidies to public health providers preclude the
development of a ‘level playing field’ for both public and private providers to
compete on the basis of price
Critical data for decision making are lacking, including national and
subnational health accounts, detailed information on the numbers, risk profiles
of the insured and the uninsured, and unit cost information
Design features of the Jamsostek and Askes programs result in high OOP costs
for program beneficiaries and limit operational effectiveness and sustainability
Local contributions vary widely, current intergovernmental fiscal
redistributions may not adequately reflect local fiscal capacity and need, and
the fiscal capacity of districts vary widely.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Framework to Assess HI Financing Options.
55
 What is the ‘ultimate’ HI system of Universal Coverage (UC)
under Law No. 40:
 single unitary Social Health Insurance (SHI); or
 multiple systems under a single set of rules; or
 a unitary general revenue funded system (e.g., Jamkesmas for all)?
 What are the specific details of this system with respect to:
 single or multiple funds;
 eligibility of different groups including informal sector workers;
 benefits covered including cost sharing and referral requirements;
 financing including public subsidies and regional contributions;
 provider payment and cost containment;
 quality assurance;
 Administration; and
 the role of the private sector.
 What are the transition policies to get to (UC)?
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Future Vision 1: Jamkesmas for All: An Indonesian NHS.
56
 This approach approximates a National Health Service like that in Sri
Lanka.
 It reflects the fact that more than half of the population is currently
poor or near poor, and thus has a very limited ability to pay.
 It also recognizes the inherent difficulty of identifying the 61 percent of
workers who are in the informal sector and having them pay premiums.
 By picking up formal sector workers through general revenues, firms
might be more competitive as their 3-6 percent payroll contributions
would be eliminated and/or could be replaced by more efficient and
equitable broad-based taxes.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Future Vision 2: A Single Integrated SHI Fund.
57




This approach approximates the ‘new’ national SHI model (now called
Mandatory Health Insurance (MHI)) where the SHI is funded through
both wage-based contributions for public and private sector workers (and
retirees) and government general revenue contributions for the poor and
other disadvantaged groups.
Under this approach there would be a single standardized national HI
fund (although one could also establish multiple funds as in Germany or
Japan).
The poor would be financed through the GoI budget, while government
and private sector workers would be funded as now through wage-based
contributions.
The GoI would need to decide if informal sector workers would be
covered by the GoI like the poor (as in Thailand) or whether mechanisms
can be developed to make them contribute some share of their earnings.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Future Vision 3: MHI through a Single Set of Rules Applying to
Multiple SHI and NHS Type Programs.
58
 This approach could be considered as a variant of Option 2 or a combination







of Options 1 and 2.
Existing programs would be scaled up to include the entire population.
All the poor and other disadvantaged groups would be covered through
Jamkesmas.
All private sector workers would be covered through Jamsostek (possibly
though elimination of the opt out, employer size, and wage ceiling
restrictions and adding requirements to cover retirees).
Civil servants and civil service retirees would be covered through Askes (or
the Askes program could be folded into Jamsostek, or conversely).
A decision would need to be made about how to handle informal sector
workers.
The three programs would have separate administrative structures but
would operate under the same set of rules concerning issues such as benefits
and contracting/provider payment.
There might be cross-subsidies required across programs on the financing
side.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
No Matter Which Option is Chosen, The Devil Will Be in The
Detail.
59
 Administrative and governance arrangements
 Defining the benefit package
 Determining eligible groups
 Determining purchasing/contracting arrangements and cost





containment policies
Estimating actuarially sound premium levels
Determining financing sources
Defining revenue collection mechanisms
Defining transition steps to new system
Developing and implementing monitoring and evaluation procedures
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Actuary Estimates
Update in March 2011
60
The purpose of the actuarial estimates was to respond to
the GoI request to assist in developing baseline estimates
for the cost of existing health insurance programs and to
perform an actuarial analysis to cost different options for
attaining UHIC.
It demonstrates the importance of the decisions to be taken
regarding the detail as each decision influences the level of
financing needed.
The exercise included the development of a baseline based
on the 2008 Askes claims data, the creation of a range of
baselines and the creation of various scenarios.
More Resources for Health;
Assessing Fiscal Space
61
In all likelihood, and for a variety of reasons, Indonesia will
need to boost health spending in the near future as it expands
access to care through the expansion of Jamkesmas, the
health insurance scheme for the poor and the near poor.
In addition, projections based on demographic and
epidemiological changes in the country indicate there is
likely to be a significant increase in the demand and need for
health services and more sophisticated care.
Despite a tripling of the public budget for health over the
past five years, this increased need, combined with the fact
that Indonesia remains a comparatively low spender on
health, indicates that there will continue to be upward
pressure on resources for the health sector in the near future.
Visualizing fiscal space for Indonesia: different means by which
government spending on health can increase.
62
Fiscal space for health
(increase as % of government health spending)
Conducive macroeconomic conditions
Efficiency
Reprioritization
1
2
3
4
5
6
7
8
Other sector-specific resources
Sector-specific foreign aid
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
One of the most important determinants of fiscal space for health is
economic growth which has a positive outlook in Indonesia.
63
8
Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for the
country, although growth remains in the 6-7 percent range per annum over the period 2008-2013.
6
7
Pre-crisis forecast
4
5
Post-crisis forecast
2003
2005
2007
2009
Year
2011
Source: IMF
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
2013
Higher revenues provide extra resources, but Indonesia’s revenues as a
percentage of GDP (19 percent) are low in comparison with other lowermiddle-income countries.
64
Higher income
Upper middle
Middle income
Lower income
0
5
10
15
20
25
30
35
Revenue (% of GDP), 2003-2006
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
40
Given current low levels of spending for health compared to other
sectors, a good case can be made for reprioritizing in favor of
health.
65
7%
With subsidies declining again (in 2009) there might be increased space for the health sector
6%
5%
Subsidies
% of GDP
4%
3%
Interest payments
2%
Education
Infrastructure
National Defense
Govt Apparatus
1%
Agriculture
0%
1994
1996
1998
2000
2002
2004
2006
2008*
Health
World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Indonesia’s has not depended significantly on external resources
for health in recent years.
66
12
10
8
6
4
2
0
1995
1997
1999
2001
2003
External resources (% of total health spending)
Source: WHO.
2005
In addition to increasing budgets for health, effective fiscal space
may be generated by increasing the efficiency of spending.
67
Sri Lanka is often presented as an example of a country that has been able to attain excellent
health outcomes with relatively low levels of resources, in part because of the underlying
efficiency of its health system.
Performance relative to income and health spending, 2008
Below average
3
0
1
2
Below average
2
0
1
Maternal mortality
Indonesia
Above average
-3
Below average
-2
-1
0
1
2
3
Performance relative to income percapita
Above average
-1
-2
Sri Lanka
-3
Above average
-2
-1
Indonesia
-3
Performance relative to per capita health spending
3
Under-five mortality
Sri Lanka
Above average
-3
Below average
-2
-1
0
1
2
3
Performance relative to income percapita
Source: WDI 2009
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Local variation in performance across districts further indicates
potential efficiency gains.
68
80
80
Turkey
Turkey
Kab. Kab.
Madiun
Madiun Bangladesh
Bangladesh
Uganda
Uganda
Pakistan
Pakistan
Kab. Kab.
Ciamis
Ciamis
Kota Kota
Ambon
Ambon NepalNepal
100
Kab. Kediri
Kab. Semarang
Kab. Kediri
Kab. Semarang
80
JapanJapan
Vietnam
Vietnam
Kab.Kab.
TanaTana
Toraja
Toraja
Skilled
birth attendance
Skilled
birth attendance
Kota Padang
Panjang
Kota Kediri
Kota Padang
Panjang
Kota KediriUkraineUkraine
China China
80
100
DPT3
immunization
DPT3
immunization
100
Global
comparison
of Indonesian
districts,
Global
2005
comparison
of Indonesian
districts,
2005
Kab. Bantul
Kab. Bantul
Kab. Kuningan
Kab. Kuningan
Indonesia
Indonesia
Kab. Barito
Kab. Selatan
Barito Selatan
Kab. Barru
Kab. Barru
60
Kab. Kab.
Subang
Subang
Kab. Kab.
Asmat
Asmat Papua
New Guinea
Papua
New Guinea
60
Skilled birth attendance
Skilled birth attendance
60
60
Indonesia
Indonesia
Kab. Kab.
Morowali
Kab. Kab.
Lombok
Barat Barat
Morowali
Lombok
Kab.Kab.
Parigi
Moutong
India India
Timor-Leste
Parigi
Moutong
Timor-Leste
Kota Kota
Singkawang
Singkawang
40
Kab. Nias
Selatan
BurundiBurundi
Kab.
Nias Selatan
Kab. Wonosobo
Kab. Wonosobo
Pakistan
Pakistan
20
ChadChad
40
NigerNiger
Somalia
Somalia
20
40
20
20
40
Kab. Kab.
Bombana
Kab. Kab.
Bangka
Tengah
Bombana
Bangka
Tengah
SenegalSenegal
Bhutan
Bhutan
Kab. Hulu
Utara Utara
Kab. Purbalingga
Kab.Sungai
Hulu Sungai
Kab.
Purbalingga
Tanzania
Tanzania
Cambodia
Cambodia
Bangladesh
Bangladesh
Kab.Kab.
Pakpak
Bharat
Pakpak
Bharat
Indonesia
Other
countries
Indonesia
Other
countries
ource:
SUSENAS
& WDI
Source:
SUSENAS
& WDI
Source: Susenas and WDI.
Ethiopia
Ethiopia
0
0
0
0
Kab. Yahukimo
Kab. Yahukimo
Indonesia
Other Other
countries
Indonesia
countries
Focus on MDG 5: Reducing
Maternal Death
69
At least 10,000 women continue to die of childbirth -related
causes every year in Indonesia.
E v e n t h o u g h s k i l l e d b i r t h a t t e n d a n c e h a s i n c r e a s e d
significantly, more needs to be done to accelerate a reduction in
deaths and achieve MDG5.
A l a r g e n u m b e r o f w o m e n c o n t i n u e t o d e l i v e r a t h o m e w i t h o u t
professional help.
H i g h l e v e l s o f u n c e r t a i n t y a b o u t m e d i c a l e x p e n s e s c o n t i n u e t o
delay the decision to seek care at a facility.
E v e n w h e n w o m e n r e a c h a f a c i l i t y o n t i m e , q u a l i t y o f
management is poor and death rates at facilities remain high,
especially, but not only, in poor areas.
There has been an impressive improvement in skilled birth
attendance since 1987, but the poor continue to lag behind.
70
Maluku
West Sulawesi
North Maluku
East Nusa Tenggara
Papua
Banten
Gorontalo
Southeast Sulawesi
West Papua
South Sulawesi
Central Sulawesi
West Kalimantan
West Nusa Tenggara
South Sumatra
Central Kalimantan
West Java
Jambi
Lampung
Bengkulu
DI Aceh
East Kalimantan
South Kalimantan
East Java
West Sumatra
Bangka Belitung
Central Java
North Sumatra
Riau
North Sulawesi
Riau Islands
Bali
DI Yogyakarta
DKI Jakarta
percentage
Disparities exist between province, economic quintiles, and
education levels.
71
Delivery assistant & place by province
100
80
60
40
20
0
Data source : IDHS 2007
% SBA
% Facility base delivery
Most poor women continue to deliver their babies at home with
traditional birth attendants (TBAs) where the risk of maternal
death is highest…
100
90
80
70
60
50
40
30
20
10
0
800
700
600
500
400
300
200
100
Poorest
Poorer
ANC/Prof del
No care (No ANC/No prof del)
MMR
Source: DHS 2007.
Middle
Richer
Richest
ANC/No prof del
No ANC/Prof del
Maternal Death
per 100,000 Live Births
% ANC/Professional delivery
72
…even though midwives are almost everywhere and are equally
distributed.
73
Government target is 100 midwives per 100,000 population by 2010.
Note: All types of midwives included. Source: Indonesia Health Profile 2008.
Midwife availability has increased significantly, however, TBA
remains the preferred choice of provider for childbirth.
74
CJ
EJ
DKI
DIY
CJ
80
DKI
100
120
SBA VS Ratio TBA, 2007
EJ
WJ
WJ
60
% Delivery by health professional
DIY
40
40
60
80
100
120
SBA VS Ratio midwife, 2007
20
40
60 80100
Ratio midwife per 100000 pop
200
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.
400600
There is a serious shortage of Ob-Gyns in Indonesia and the few
there are cluster in richer urban areas.
75
Although more than 70 percent of pregnant women receive
antenatal care by skilled providers, the quality of care varies widely.
76
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.
Ob-Gyns provide the most comprehensive services but reach only a
limited population.
77
Antenatal Care Services by Type of Assistance in West Java (DHS 2007)
World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.
Four areas for priority action to improve the health status of
Indonesian mothers: Being implemented in ongoing pilots.
78
1.
Improving coordination between public and
private sector services at provincial and
district levels
2. Strengthening coordination between
community-based services and hospital services
3.Reducing financial barriers to utilization of
maternal health services
4. Improving clinical skills and quality assurance
Increase research into near miss and maternal death for
better understanding of the local contributing factors. Use
this analysis to determine whether factors such as access to
SHI, ANC, and place of delivery had an impact on outcomes
•Improve vital statistics registration, particularly for deaths
among women of reproductive age
•Address the unmet need for access to emergency obstetric
care among the large majority of the female population
•Conduct a hospital assessment for maternal health to
identify barriers to care within the facility context
•Review the social insurance coverage amounts to expand
what is reimbursed and to cover the true cost of having a
delivery with a skilled provider.
•Review reimbursement mechanisms in the case of referral
upwards to a hospital for complications.
•Improve the quality of the skilled provider, particularly the
Bidan di Desa by building on existing initiatives (such as
Bidan Delima) and linking quality of care to accreditation
and certification.
•Look at the implementation of the comprehensive
emergency obstetric services to find areas of improvement.
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
Focus on Jamkesmas
Update in March 2011
79
IMPACTS TO DATE:
C o v e r a g e h a s e f f e c t i v e l y b e e n i n c r e a s e d a n d a n e s t i m a t e d o n e third of the population is currently being covered, according to
official data (Susenas survey data indicates lower coverage rates).
F o r t y - t h r e e p e r c e n t o f t h o s e c o v e r e d a r e p o o r a n d n e a r - p o o r
households.
U t i l i z a t i o n o f h e a l t h s e r v i c e s a m o n g J a m k e s m a s b e n e f i c i a r i e s h a s
increased, especially for inpatient services.
J a m k e s m a s h a s a p r o t e c t i v e e f f e c t o n t h e O O P h e a l t h e x p e n d i t u r e s
of the poor and near-poor; those with Jamkesmas coverage have
lower OOP payments (a measure of financial protection) and
Jamkesmas beneficiaries have a lower incidence of catastrophic
medical expenditures when compared with those with no insurance
or those with other forms of insurance.
G e o g r a p h i c a n a l y s i s s h o w s s i g n i f i c a n t i n c r e a s e s i n i n p a t i e n t
utilization in the poorest provinces (NTT, Papua, Maluku).
Annex:
World Bank Studies for the HSR
80
 Investing in Indonesia’s Health: Challenges and Opportunities for
Future Public Spending. Health Public Expenditure Review – June 2008
 Indonesia’s Doctors, Midwives and Nurses: Current Stock,
Increasing Needs, Future Challenges and Options. Health Human
Resources Review – January 2009
 Giving More Weight to Health: Assessing Fiscal Space for Health in
Indonesia– January 2009
 Health Financing in Indonesia: a Reform Road Map – June 2009
 New Insights into the Provision of Health Services in
Indonesia: a Health Work Force Study – October 2009
 ‘and then she died’: Indonesia Maternal Health Assessment –
December 2009
Annex:
Forthcoming World Bank Studies
81
Forthcoming:
 Actuarial Costing of Universal Health Insurance
Coverage in Indonesia: Options and Preliminary Results
– January 2011
 Enhancing Health Equity and Financial Protection
in Indonesia: How Well Does Jamkesmas do? Jamkesmas
Review Paper
- March 2011
Annex:
World Bank Policy Notes Series
82
 Pharmaceuticals : Why Reform is Needed – March 2009
 Accelerating Improvement in Maternal Health : Why Reform
is Needed – June 2010
 Financing Universal Coverage: Assessing Fiscal Space in
Indonesia – July 2010
 Achieving Universal Coverage: Different Stages of
Harmonization of Implementing Health Insurance Information
Systems – August 2010
Forthcoming:
 Health Professional Education in Indonesia: Why Reform is
Needed
M a t e r n a l H e a l t h M e e t s H e a l t h F i n a n c i n g