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4/16/2013
1
OVERVIEW
D A T A , G R A P H S A N D T A B L E S
U P D A T E D J U N E 2 0 1 2
Indonesia’s Health Sector Review
1
Background2
The WB received requests for electronic copies of the various charts, tables andgraphs included in the reports and papers produced for the Indonesia HealthSector 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 becomeavailable
This document does not summarize all the work that was carried out, rather itincludes mainly the data and graphs. For summaries and details please refer tothe documents listed in the annex. Each slide includes the source document foreasy reference
This review was put together by the World Bank Jakarta-based health teamincluding Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi,George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved inearlier versions.
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I n d o n e s i a ’ s h e a l t h s y s t e m p e r f o r m a n c e i s c h a l l e n g e d b y a c h a n g i n g e n v i r o n m e n t :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 a r e l i k e l y t o i n c r e a s e d e m a n d a n d r e s u l t i n m o r e c o s t l y a n d m o r e d i v e r s e h e a l t h c a r e .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 e p i d e m i c s s u c h a s H I V / A I D S , H 5 N 1 ( A v i a n I n f l u e n z a ) a n d H 1 N 1 ( S w i n e I n f l u e n z a ) .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 H e a l t h I n s u r a n c e C o v e r a g e ( U H I C ) w i l l f u r t h e r i n c r e a s e d e m a n d a n d u t i l i z a t i o n .
3
Indonesia’s Dynamic Environment
Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.
4
-15,000 -10,000 -5,000 0 5,000 10,000 15,000
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Population in Thousands 2000
-15,000 -10,000 -5,000 0 5,000 10,000 15,000
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75+
Population In Thousands 2025
MalesFemales
Source: BPS 2005.
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The demographic transition may provide a ‘demographic bonus’ in the short term if those coming of working age are employed…
5
Source: Adioetomo 2007.
Dependency ratio, 1950-2050
0
10
20
30
40
50
60
70
80
90
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
year
ratio
to
wor
king
-age
pop
ulat
ion
young
eldery
window of opportunity
demographic bonus
total
…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.
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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.
0
10
20
30
40
50
60
70
Perinatal / Maternal Communicable Disease Non-communicableDisease
Injuries
SKRT'95
SKRT'01
Riskesdas07
Source: Riskesdas Survey 2007.
7
Changes in Burden of Disease in Indonesia
The obesity rate is rising and increased prevalence of risk factors will change the burden of disease – increasing the need for preventive measures.
7.7
29
23.6
15.7
15
16.8
17.8
19.9
23.2
0 5 10 15 20 25 30 35
Male
Females
Urban
Rural
Poorest
Quintile 2
Quintile 3
Quintile 4
Richest
Adult Obesity in Indonesia (%)
Source: Riskesdas Survey 2007.
8
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Increased need will demand more resources for health. Fortunately, despite the global economic crisis, the macroeconomic picture is still favorable.
World Bank. 2009. Giving More Weight to Health in Indonesia.
Pre-crisis forecast
Post-crisis forecast
45
67
8R
eal G
DP
gro
wth
rat
e
2003 2005 2007 2009 2011 2013year
Source : IMF
9
I n d o n e s i a ’ s h e a l t h s y s t e m p e r f o r m a n c e m e a s u r e d i n t e r m s o f h e a l t h o u t c o m e s , f i n a n c i a l p r o t e c t i o n , c o n s u m e r a w a r e n e s s a n d e q u i t y a n d e f f i c i e n c y i s m i x e d :
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 o n r e d u c i n g m a t e r n a l m o r t a l i t y .
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 g e o g r a p h i c a r e a s a r e v e r y l a r g e a n d c o n s t i t u t e a m a j o r p r o b l e m f o r t h e h e a l t h s e c t o r o v e r a l l .
10
Health System Performance
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6
Indonesians live longer in 2010 and child mortality has fallen dramatically since the 1960s.
11
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Life expectancy
Infant mortality
Under-five mortality
050
100
150
200
Infa
nt/u
nder
five
mor
talit
y ra
te
4050
6070
Life
exp
ecta
ncy
1960 1970 1980 1990 2000 2010year
Source : WDI 2009
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.
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7
Indonesia performs well in terms of infant mortality relative to other comparable health spending level countries but less well for its income.
13
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
China
IndiaLao PDR
Vietnam
Indonesia
Malaysia
ThailandBangladesh
Sri Lanka
Below average Above average
Bel
ow a
vera
geA
bove
ave
rage
Att
ainm
ent
rela
tive
to in
com
e
Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008
INFANT MORTALITY (2008)
Despite significant reduction in IMR over time, some neighboring countries have performed better.
14
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Indonesia
China
Sri Lanka
Vietnam Thailand
India
525
100
250
Infa
nt m
orta
lity
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010Year
Source: WDI 2009Note: y-axis log scale
Infant mortality, 1960-2009
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8
And there are large inequalities between provinces and income levels.
15
0
20
40
60
80
100
120
DI Y
ogya
kart
a
Cen
tral
Jav
a
Cen
tral
Kal
iman
tan
DK
I Jak
arta
Bal
i
Eas
t Kal
iman
tan
Nor
th S
ulaw
esi
Eas
t Jav
a
DI A
ceh
Ban
gka
Bel
itung
Jam
bi
Ria
u
Wes
t Jav
a
Sou
th S
umat
ra
Sou
th S
ulaw
esi
Lam
pung
Ban
ten
Ria
u Is
land
s
Wes
t Kal
iman
tan
Wes
t Sum
atra
Sou
th-e
ast S
ulaw
esi
Wes
t Pap
ua
Pap
ua
Ben
gkul
u
Nor
th S
umat
ra
Cen
tral
Sul
awes
i
Gor
onta
lo
Nor
th M
aluk
u
Sou
th K
alim
anta
n
Eas
t Nus
a T
engg
ara
Wes
t Nus
a T
engg
ara
Mal
uku
Wes
t Sul
awes
i
Dea
th for
eve
ry 1
000
live
birth
Infant Mortality Child Mortality
Source: DHS 2007.
In fact, some of Indonesia’s provinces are at par with some of the best and worst performing countries.
16
World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.
West Sulawesi
North Maluku
Riau IslandsWest Java
DKI Jakarta
West Nusa Tenggara
West SumatraSouth SumatraRiau
East KalimantanDI Yogyakarta
Bangladesh
Cambodia
Papua New Guinea
Uganda
Ukraine
Zimbabwe
China
Congo, Rep.
India
Niger
San Marino
Timor-Leste
Tanzania
Vietnam
050
100
150
Infa
nt m
orta
lity
per
1000
live
birt
h
Indonesia Other countries Source: IDHS (2007) & WDI 2009
Infant mortality, 2008
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9
Indonesia also performs less well on maternal mortality for its income level in international comparisons.
17
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Bangladesh
China
India
Lao PDR
Sri LankaVietnam
Indonesia
MalaysiaThailand
Below average Above average
Bel
ow a
vera
geA
bove
ave
rage
Att
ainm
ent
rela
tive
to in
com
e
Attainment relative to health spending per capitaSource: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008
MATERNAL MORTALITY, 2008
And will need extra efforts to achieve the MDG of reducing maternal deaths by 75 percent by 2015.
The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.
18
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10
Underweight among children under five years of age has declined significantly…
19
6.3 7.211.6 10.5
8.1 7.5 6.3 8 8.3 8.6 8.85.4 4.9
31.2 28.3 2019
18.317.1 19.8
19.3 19.2 19.6 19.2
13 13
37.535.5
31.629.5
26.424.6
26.127.3 27.5 28.2 28
18.4 17.9
0
5
10
15
20
25
30
35
40
1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007 2010
Pe
rce
nta
ge
Moderate
Severe
Underweight
Source : Susenas 1989-2005, Riskesdas 2007-2010
…however, stunting rates, which are an indicator of chronic malnutrition, remain very high.
20
BangladeshChina
IndiaLao PDR
Sri Lanka
VietnamIndonesia
Thailand
Below average Above average
Bel
ow a
vera
geA
bove
ave
rage
Attai
nmen
t re
lativ
e to
inco
me
Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008
Stunting Among Children under 5 years old, 2000-2009
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11
Health Spending Trends
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.
21
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.
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
0
5
10
15
20
25
30
35
40
45
2001 2002 2003 2004 2005 2006 2007* 2008* 2009**
IDR
Tri
llion
s (c
onst
ant 2
00
7 p
rice
s)
Central Province District Share of GDP
22
Government health expenditures by level of government (2001-2009)
World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.
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12
Total and public health spending in Indonesia is low relative to other comparable income countries.
23
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Cambodia
Lao PDR MalaysiaThailand
Vietnam
Samoa
Indonesia
05
1015
Tot
al H
ealth
Spe
ndin
g (%
GD
P)
100 250 1000 10000 25000GDP per capita
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
TOTAL HEALTH SPENDING VS INCOME, 2008
ChinaCambodia
Lao PDR
Malaysia
ThailandVietnam
Samoa
Indonesia
05
1015
Gov
ernm
ent
Hea
lth S
pend
ing
(% G
DP
)
10 100 250 1000 10000 25000GDP per capita
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
GOVERNMENT HEALTH SPENDING VS INCOME,2008
And government health spending as a share of the budget is even lower than total government expenditures as a share of GDP.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Indonesia
Indonesia
1020
3040
50
Gov
ernm
ent sp
endi
ng (%
GD
P)
Gov
ernm
ent he
alth
spe
ndin
g (%
bud
get)
100 250 1000 2500 10000 25000GNI per capita (US$)
Source: WDI
Government spending vs income, 2004-2006
Government spending (% GDP)
Government health spending (% budget)
24
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13
OOP spending, a measure of financial protection, is about average relative to comparators.
25
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Lao PDR
Malaysia
Philippines
Thailand
Samoa
Indonesia
Cambodia
Vietnam
020
4060
80
Out
-of-
pock
et h
ealth
spe
ndin
g(%
tot
al h
ealth
spe
ndin
g)
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
OOP spending as share of total health spendingvs Income per capita, 2008
Financial protection, measured as the OOP share of nonfood spending has improved.
Source: Equitap Update 2009.
26
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14
27
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
Malaysia (1999) Taiwan (2000) Indonesia(2006)
Thailand(2002)
Hong Kong(2000)
Sri Lanka(1997)
Philippines(1999)
Indonesia(2001)
Korea (2000) Nepal (1996) India (2000) China (2000) Bangladesh(2000)
Vietnam (1998)
% o
f hou
seh
old
s ex
ceed
ing
thre
shol
d
Greater than 25 percent of nonfood expenditures 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)
By regional standards, the incidence of catastrophic health spending is low in Indonesia.
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
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Shanxi province (C
hina) 2003
Heilongjiang (C
hina) 2003
Zhejiang (C
hina) 2003
Gansu (C
hina) 2003
Indonesia 2001
Indonesia 2006
India 1996
Mongolia*
Bangladesh 2000
Vietnam
2003
Malaysia 1996
Thailand 2002
Sri L
anka 2004
Hong K
ong 2002P
oore
st q
uin
tile
sh
are
of s
ub
sid
y
Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
4/16/2013
15
Inequities between provinces are also evident from differences in health expenditures.
29
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
District Public Health Expenditures by Province (2005)
Technical efficiency is low in Indonesia in global comparisons and there are large differences between provinces.
30
AusA
B
C
Cdn
CN
CZ
F
D
G
HKHIdn
Irl
I
JRok
LMys
M
MngNl
N
PS
ECh
Tw
T
Tk
UK
US
V
averagecase- f low
averagebed occupancy
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
percent bed occupancy rate
case
-flo
w (
case
s pe
r be
d pe
r ye
ar)
A : high case-flow low occupancy
C: high case-flow high occupancy
B: low case-flow low occupancy
D: low case-flow high occupancy
N A D
Sumut
Sumbar R i a u
J a m b i
Sumsel Bengkulu Lampung
Bangka Belitung DKI Jakarta
JabarJatengDIYJatim
Banten
B a l iNTB
NTT
KalBarKalseng
Kaltim
Sulut
SultengSulselSulteng Irian Jaya Tengah
Irian Jaya Timur
average case- f lo w
average b ed occup ancy
Kalteng
Maluku
Irian Jaya Barat
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
percent bed occupancy rate
case
-flo
w (
case
per
bed
per
yea
r)
A : high case-flow low occupancy
C: high case-flow high occupancy
B: low case-flow low occupancy
D: low case-flow high occupancy
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.
4/16/2013
16
A n a l r e a d y s t r e t c h e d h e a l t h s y s t e m w i l l i n c u r f u r t h e r p r e s s u r e d u e t o i n c r e a s e d d e m a n d f r o m o n g o i n g d e m o g r a p h i c , n u t r i t i o n 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 a s w e l l a s t h e i n t r o d u c t i o n o f u n i v e r s a l h e a l t h i n s u r a n c e c o v e r a g e .
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 f o r p r i m a r y c a r e , d o e s n o t h a v e s u f f i c i e n t b e d s o r h e a l t h w o r k e r s t o r e s p o n d t o t h e s e i n c r e a s e d n e e d s .
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 p a y m o r e t h a n t h e y n e e d t o a n d m o s t e x p e n d i t u r e s a r e o u t o f p o c k e t .
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 d i s t r i b u t i o n i n e q u i t i e s a n d q u a l i t y .
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 l e v e l o f d i s s a t i s f a c t i o n w i t h v a r i o u s a s p e c t s o f h e a l t h c a r e .
31
Indonesia’s Health Delivery System
Indonesia’s primary public health care system is extensive: more than 90percent of the population has access to primary care facilities.
Source: MoH. 2010. Health Profile.
32
Ratio Puskesmas per 100,000 Population
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
2002 2003 2004 2005 2006 2007 2008 2009 2010
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17
While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators.
33
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
China
Cambodia
Lao PDRMalaysia
Philippines
ThailandVietnam
SamoaIndonesia
05
1015
Hos
pita
l Bed
s pe
r 1,
000
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
HOSPITAL BED SUPPLY VS INCOME, 2000-2010
And Also Fewer Health Workers
34
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
China
CambodiaLao PDR
MalaysiaPhilippines
ThailandVietnam
SamoaIndonesia02
46
8D
octo
r pe
r 1,
000
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
DOCTOR SUPPLY VS INCOME, 2000-2010
CambodiaLao PDRMalaysia
Philippines
ThailandVietnam
SamoaIndonesia
05
1015
20M
idw
ives
/Nur
ses
per
1,00
0
100 250 1000 10000 25000GDP per capita, current US$
Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale
MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010
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18
At the Puskesmas level most basic services are available.
35
Quality Measures Public Settings Private Settings
Puskesmas Pustu Private Nurse
Private Midwife
Private MDs
All Settings
Structural qualityInternal water source (%) 89 71 80 84 89 84
Inpatient beds (%) 28 3 3 28 3 18Functioning microscope (%) 79 5 1 3 7 25
Tuberculosis service (%) 95 30 8 2 44 38Measles vaccines in stock (%) 97 51 5 48 11 51
Tetanus toxoid vaccine in stock (%)
97 55 9 59 12 55
Hepatitis B vaccine in stock (%) 92 52 6 54 16 52
Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult Curative Care (by Clinical Setting)(2007)
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: thenumber of hospitals and hospital beds has grown slowly.
0
20000
40000
60000
80000
100000
120000
140000
1995 1997 2000 2003 2005 2006
MoH Province, district, municipal Armed forces, police State-owned Private
Increase in numbers of hospital beds between 1995 and 2006 by ownership
36
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
4/16/2013
19
There are 3 beds per 10,000, 3.8 Puskesmas per 100,000 and 6.9 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.
37
0
2
4
6
8
10
12
14
16
0
200
400
600
800
1,000
1,200N
ort
h S
ulaw
esi
No
rth
Mal
uku
Mal
uku
Wes
t Pap
ua
Eas
t Kal
iman
tan
Cen
tral
Kal
iman
tan
Go
ront
alo
Wes
t Sum
atra
Bal
i
Ban
gka
Bel
itung
Arc
hipe
lago
Nan
ggr
oe A
ceh
Dar
ussa
lam
Ben
gku
lu
Pap
ua
So
uth
Kal
iman
tan
Cen
tral
Sul
awes
i
So
uth
Sul
awes
i
Jam
bi
D I
Yo
gya
kart
a
So
uth
Eas
t Sul
awes
i
DK
I Jak
arta
Eas
t Nus
a T
eng
gara
Cen
tral
Jav
a
Ria
u A
rch
ipel
ago
So
uth
Sum
ater
a
Ria
u
Wes
t Kal
iman
tan
No
rth
Sum
atra
Eas
t Jav
a
Wes
t Nus
a T
engg
ara
Lam
pun
g
Wes
t Sul
awes
i
Wes
t Jav
a
Ratio
# Health center
Puskesmas Hospital Bed per 10,000 pop Puskesmas per 100,000 popSource : IndonesiaHealth Profile, 2010
The ratio of physicians to population also masks significantinequities among urban and rural areas.
Source: KKI 2008.
38
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20
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.
Country Total health expenditure pc
(US$)
DPT3immunization
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
39
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…
Facility
National Java‐Bali SumatraOther
Provinces
1997 2007 1997 2007 1997 2007 1997 2007
Puskesmas
Number of Doctors 1.51 1.90 1.68 1.96 1.19 1.85 1.09 1.62
Number of Doctors (%) 3.4 7.0 1.5 5.9 2.0 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
Pustu
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
Source: IFLS 1997; 2007.
40
4/16/2013
21
…and quality, measured as diagnostic and treatment ability, varies between regions and geographic areas and has not improved much over time.
41
ServiceNational 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 ***
Child Curative Care
Public 56 64 *** 58 66 *** 48 56 *** 55 65 ***
Private 55 59 *** 57 62 *** 50 52 54 60 ***
Adult Curative Care
Public 49 56 *** 52 59 *** 43 48 *** 44 53 ***
Private 46 53 *** 48 56 *** 40 51 *** 44 51 ***
Quality of Public Health Services in Indonesia 1997-2007 (by Region)
*** 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.
0 5 10 15 20 25
India
Indonesia
Cambodia
Philippines
Vietnam
Malaysia
Thailand
Government Private
Source: WHO. 2004. The World Medicines Situation.
42
Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less thanUS$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming thecentral government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide allthe primary care medicines recommended by WHO.
Spending on drugs per capita in US$
4/16/2013
22
But most Indonesians pay more than they need to for their medicines when they buy from the private sector or from public hospitals.
Price ratio to median international indicator price
Originatorbrands
Most sold brandedgeneric
Lowest price generic
Private pharmacies
22-26 6-7 2.6
Public hospitals 22 1.7-6 2.15
Source: National Institute for Health Research and Development (NIHRD) Survey 2004.
43
Provision of health services by private health providers has grown significantly over the past decade.
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.
44
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23
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 2004 and 2009
Various Susenas : Worldbank staff calculation
43.3 43 47.740.1 38.5 39.9 41
50 50.9 47.453.7 55.8 55.3 54.1
1.8 2.6 2.8 2.6 2.7 2.3 2.34.9 3.2 4.5 3.8 2.9 2.8 2.5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2004 2005 2006 2007 2008 2009 2010
Public Private Traditional Other
However, most Indonesians continue to seek ambulatory care from private providers when ill.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2007
1997
Source: IFLS 1997 & 2007.
46
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24
Overall consumer satisfaction with inpatient and outpatient services appears good…
47
58.1
65.2
59.7
32.2 31.3 32.3
7.7
3.37.2
1.2 0.2 0.90.9 0.0 0.00
10
20
30
40
50
60
70
GDS2 (N=7.916) Susenas-Inpat ient (N=19.294) Susenas-Outpat ient (N=2.657)
Satisf ied Somewhat sat isf ied Somewhat unsat isf ied Unsat isf ied No response
Source: GSD2 and Susenas.
…although there is a high level of dissatisfaction with variousaspects of the provision of health care…
18.3
26.8
27.3
32.8
24.1
13.6
26.1
11.6
21.7
27.9
25.6
29.7
24.2
17.2
21.7
0 10 20 30 40
family visit
cleanliness
freedom of choice
private consultation
involvement in…
information availability
hospitality
waiting time
percent
inpatient outpatient
Source: Sakernas National Health Survey 2004.
48
Dissatisfaction With Various Aspects of Health Services (%)
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25
…and many people continue to opt for self-treatment or forego treatment altogether.
49
Source: Susenas various years.
38.2 34.4 34.144.1 44.4 44.7 44.0
51.750.9 51.2
44.2 45.1 46.5 46.2
10.1 14.7 14.6 11.7 10.6 8.8 9.8
0%
20%
40%
60%
80%
100%
2004 2005 2006 2007 2008 2009 2010
Facility visit, any Self treatment only No treatment
T h e n e w g o v e r n m e n t i s c o m m i t t e d t o i m p l e m e n t i n g t h e r e f o r m a n d a s s u r i n g a l l I n d o n e s i a n c i t i z e n s a c c e s s t o q u a l i t y h e a l t h s e r v i c e s a n d f i n a n c i a l p r o t e c t i o n a g a i n s t t h e i m p o v e r i s h i n g e f f e c t s o f l a r g e u n p r e d i c t a b l e m e d i c a l c a r e c o s t s .
F u l f i l l i n g t h i s c o m m i t m e n t w i l l r e q u i r e t h e d e v e l o p m e n t , i m p l e m e n t a t i o n , a n d m o n i t o r i n g o f p o l i c i e s a f f e c t i n g a l l a s p e c t s o f t h e h e a l t h s y s t e m – b a s i c p u b l i c h e a l t h p r o g r a m s ; d e l i v e r y s y s t e m s a n d l o g i s t i c a l c a p a c i t y ; q u a l i t y a n d d i s t r i b u t i o n ; o r g a n i z a t i o n , m a n a g e m e n t , a n d a c c o u n t a b i l i t y ; p h a r m a c e u t i c a l s ; f i n a n c i n g ; p u b l i c — p r i v a t e p a r t n e r s h i p s a n d a l l l e v e l s o f g o v e r n m e n t .
50
Health Financing Reform
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26
Background51
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.
Current Insurance Systems
Ministry of Labor
Ministry of Finance
Ministry of Health
Ministry of Defense
JamsostekPrivate
insuranceAskes, HMOs
Military personnel
Social security Social HMO
Commercial health insurance
PT Askes:-Civil servants-Commercial HMOs
Jamkesmas(scheme for the poor)
Types:
Coverage(millions of
people)
Free health services
Technical oversightFinancial oversight
4.16.6. including
personal accident
Civil servant: 14Commercial HMOs: 2
276.4
Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.
52
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27
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.
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.
The Current Health Policy Baseline for Health Financing Reform: System Challenges.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
4/16/2013
28
55
Framework to Assess HI Financing Options.
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.
56
Future Vision 1: Jamkesmas for All: An Indonesian NHS.
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.
4/16/2013
29
57
Future Vision 2: A Single Integrated SHI Fund.
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.
58
Future Vision 3: MHI through a Single Set of Rules Applying to Multiple SHI and NHS Type Programs.
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.
4/16/2013
30
59
No Matter Which Option is Chosen, The Devil Will Be in The Detail.
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.
T h e p u r p o s e o f t h e a c t u a r i a l e s t i m a t e s w a s t o r e s p o n d t o t h e G o I r e q u e s t t o a s s i s t i n d e v e l o p i n g b a s e l i n e e s t i m a t e s f o r t h e c o s t o f e x i s t i n g h e a l t h i n s u r a n c e p r o g r a m s a n d t o p e r f o r m a n a c t u a r i a l a n a l y s i s t o c o s t d i f f e r e n t o p t i o n s f o r a t t a i n i n g U H I C .
I t d e m o n s t r a t e s t h e i m p o r t a n c e o f t h e d e c i s i o n s t o b e t a k e n r e g a r d i n g t h e d e t a i l a s e a c h d e c i s i o n i n f l u e n c e s t h e l e v e l o f f i n a n c i n g n e e d e d .
T h e e x e r c i s e i n c l u d e d t h e d e v e l o p m e n t o f a b a s e l i n e b a s e d o n t h e 2 0 0 8 A s k e s c l a i m s d a t a , t h e c r e a t i o n o f a r a n g e o f b a s e l i n e s a n d t h e c r e a t i o n o f v a r i o u s s c e n a r i o s .
60
Actuary Estimates
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31
CMPM estimation which include out-of-pocket (OOP) expenses, subsidies to thepublic system and supply constraints assumption in various scenarios, provides amore realistic expenditure estimate ranging from Rp 20,542 CMPM to Rp 36,029.
61
Source : Actuarial costing of Universal Health Insurance Coverage in Indonesia : Options and Preliminary results, Worldbank 2011
Projecting costs forward to 2020 suggests that UC in Indonesia is likely to require anexpenditure range between Rp 127 trillion (6.66 percent of total public expenditures and 1.17percent of GDP) and Rp 221 trillion (11.58 percent and 2.03 percent).
62
Source : Actuarial costing of Universal Health Insurance Coverage in Indonesia : Options and Preliminary results, Worldbank 2011
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32
I n a l l l i k e l i h o o d , a n d f o r a v a r i e t y o f r e a s o n s , I n d o n e s i a w i l l n e e d t o b o o s t h e a l t h s p e n d i n g i n t h e n e a r f u t u r e a s i t e x p a n d s a c c e s s t o c a r e t h r o u g h t h e e x p a n s i o n o f J a m k e s m a s , t h e h e a l t h i n s u r a n c e s c h e m e f o r t h e p o o r a n d t h e n e a r p o o r .
I n a d d i t i o n , p r o j e c t i o n s b a s e d o n 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 c h a n g e s i n t h e c o u n t r y i n d i c a t e t h e r e i s l i k e l y t o b e a s i g n i f i c a n t i n c r e a s e i n t h e d e m a n d a n d n e e d f o r h e a l t h s e r v i c e s a n d m o r e s o p h i s t i c a t e d c a r e .
D e s p i t e a t r i p l i n g o f t h e p u b l i c b u d g e t f o r h e a l t h o v e r t h e p a s t f i v e y e a r s , t h i s i n c r e a s e d n e e d , c o m b i n e d w i t h t h e f a c t t h a t I n d o n e s i a r e m a i n s a c o m p a r a t i v e l y l o w s p e n d e r o n h e a l t h , i n d i c a t e s t h a t t h e r e w i l l c o n t i n u e t o b e u p w a r d p r e s s u r e o n r e s o u r c e s f o r t h e h e a l t h s e c t o r i n t h e n e a r f u t u r e .
63
More Resources for Health; Assessing Fiscal Space
Visualizing fiscal space for Indonesia: different means by which government spending on health can increase.
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
64
Conducive macroeconomic conditions
Reprioritization
Sector-specific foreign aidOther sector-specific resources
Efficiency
1
2
3
4
5
6
7
8
Fiscal space for health(increase as % of government health spending)
4/16/2013
33
One of the most important determinants of fiscal space for health is economic growth which has a positive outlook in Indonesia.
65
Pre-crisis forecast
Post-crisis forecast
45
67
8
Rea
l GDP g
rowth
rate
2003 2005 2007 2009 2011 2013Year
Source: IMF
Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for thecountry, although growth remains in the 6-7 percent range per annum over the period 2008-2013.
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Higher revenues provide extra resources, but Indonesia’s revenues as a percentage of GDP (19 percent) are low in comparison with other lower-middle-income countries.
0 5 10 15 20 25 30 35 40
Lower income
Middle income
Upper middle
Higher income
Revenue (% of GDP), 2003-2006
66
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
4/16/2013
34
Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.
Agriculture
Education
Health
Govt Apparatus National Defense
Infrastructure
Subsidies
Interest payments
0%
1%
2%
3%
4%
5%
6%
7%
1994 1996 1998 2000 2002 2004 2006 2008*
% o
f G
DP
With subsidies declining again (in 2009) there might be increased space for the health sector
67
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.
0
2
4
6
8
10
12
1995 1997 1999 2001 2003 2005
External resources (% of total health spending)
Source: WHO.
68
4/16/2013
35
In addition to increasing budgets for health, effective fiscal space may be generated by increasing the efficiency of spending.
Sri Lanka is often presented as an example of a country that has been able to attain excellenthealth outcomes with relatively low levels of resources, in part because of the underlyingefficiency of its health system.
69
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Indonesia
Sri Lanka
Abo
ve a
vera
geB
elow
ave
rage
Above average Below average-3-2
-10
12
3P
erfo
rman
ce rel
ativ
e to
per
cap
ita h
ealth
spe
ndin
g
-3 -2 -1 0 1 2 3Performance relative to income percapita
Under-five mortality
Indonesia
Sri Lanka
Abo
ve a
vera
geB
elow
ave
rage
Above average Below average-3-2
-10
12
3P
erfo
rman
ce rel
ativ
e to
per
cap
ita h
ealth
spe
ndin
g
-3 -2 -1 0 1 2 3Performance relative to income percapita
Maternal mortality
Source: WDI 2009
Performance relative to income and health spending, 2008
Local variation in performance across districts further indicates potential efficiency gains.
Kota Padang Panjang
Kab. Kediri
Kab. Bantul
Kab. Barito Selatan
Kab. Hulu Sungai Utara
Kab. Nias Selatan
Kab. Yahukimo
Kota Kediri
Kab. Semarang
Kab. Kuningan
Kab. Barru
Kab. Purbalingga
Kab. Wonosobo Burundi
Bangladesh
Pakistan
Senegal
Ukraine
Bhutan
China
Ethiopia
Indonesia
CambodiaTanzania
020
4060
8010
0
Skille
d birth atten
danc
e
Indonesia Other countries
Skilled birth attendance
Kab. Tana Toraja
Kab. Ciamis
Kab. Morowali
Kab. Subang
Kab. Parigi Moutong
Kab. Bombana
Kab. Pakpak Bharat
Kab. Madiun
Kota Ambon
Kab. Lombok Barat
Kab. Asmat
Kota Singkawang
Kab. Bangka Tengah
Bangladesh
Japan
Nepal
Papua New Guin
Somalia
Timor-Leste
Indonesia
India
Niger
Pakistan
Chad
Turkey
Uganda
Vietnam
020
4060
8010
0
Indonesia Other countries
DPT3 immunization
Source: Susenas and WDI.
70
4/16/2013
36
A t l e a s t 1 0 , 0 0 0 w o m e n c o n t i n u e t o d i e o f c h i l d b i r t h - r e l a t e d c a u s e s e v e r y y e a r i n I n d o n e s i a . 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 s i g n i f i c a n t l y , m o r e n e e d s t o b e d o n e t o a c c e l e r a t e a r e d u c t i o n i n d e a t h s a n d a c h i e v e M D G 5 .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 p r o f e s s i o n a l h e l p . 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 d e l a y t h e d e c i s i o n t o s e e k c a r e a t a f a c i l i t y . 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 m a n a g e m e n t i s p o o r a n d d e a t h r a t e s a t f a c i l i t i e s r e m a i n h i g h , e s p e c i a l l y , b u t n o t o n l y , i n p o o r a r e a s .
71
Focus on MDG 5: Reducing Maternal Death
There has been an impressive improvement in skilled birth attendance since 1987, but the poor continue to lag behind.
72
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37
Disparities exist between province, economic quintiles, and education levels.
0
20
40
60
80
100Maluku
WestSulaw
esi
NorthMaluku
EastNusaTenggara
Papua
Banten
Gorontalo
SoutheastSulaw
esi
WestPapua
SouthSulawesi
CentralSulaw
esi
WestKalimantan
WestNusaTenggara
SouthSumatra
CentralKalimantan
WestJava
Jambi
Lampung
Bengkulu
DIAceh
EastKalimantan
SouthKalimantan
EastJava
WestSum
atra
BangkaBelitung
CentralJava
NorthSum
atra
Riau
NorthSulaw
esi
RiauIslands
Bali
DIYogyakarta
DKIJakarta
percentage
Deliveryassistant&placebyprovince
%SBA %FacilitybasedeliveryData source : IDHS 2007
73
Most poor women continue to deliver their babies at home with traditional birth attendants (TBAs) where the risk of maternal death is highest…
74
-
100
200
300
400
500
600
700
800
0102030405060708090
100
Poorest Poorer Middle Richer Richest
Ma
tern
al
De
ath
p
er
100
,00
0 L
ive
Bir
ths
% A
NC
/Pro
fess
ion
al
de
liv
ery
ANC/Prof del ANC/No prof delNo care (No ANC/No prof del) No ANC/Prof delMMR
Source: DHS 2007.
4/16/2013
38
…even though midwives are almost everywhere and are equally distributed.
Note: All types of midwives included. Source: Indonesia Health Profile 2008.
Government target is 100 midwives per 100,000 population by 2010.
75
Midwife availability has increased significantly, however, TBAremains the preferred choice of provider for childbirth.
World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.
76
DIY
WJ
CJ
DKI
EJ
DKI
WJ
CJ
DIY
EJ
4060
8010
012
0%
Del
iver
y by
hea
lth p
rofe
ssio
nal
20 40 60 80100Ratio midwife per 100000 pop
SBA VS Ratio midwife, 2007
DKI DIY
EJ
WJ
CJ
DKI
WJ
CJ
DIY
EJ
4060
8010
012
0%
Del
iver
y by
hea
lth p
rofe
ssio
nal
200 400600Ratio TBA per 100000 pop
SBA VS Ratio TBA, 2007
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, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java
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There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.
77
Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.
78
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
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
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Ob-Gyns provide the most comprehensive services but reach only a limited population.
79
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.
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.
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81
CONTINUUM OF CARE
Increasing the DEMAND
PUSKESMAS+Private Clinic
HOSPITAL (pub;priv)
MOTHER AND BABY SURVIVEDAND WELL
Quality of Obstetric Care• Quality assurance in health facilities• Accreditation• Referral network• Recording and reporting system
Pregnant women & Comm.
Access• Financing
• Transportation
Logical Framework(intervention model)
I M P A C T S T O D A T E :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 -t h i r d o f t h e p o p u l a t i o n i s c u r r e n t l y b e i n g c o v e r e d , a c c o r d i n g t o o f f i c i a l d a t a ( S u s e n a s s u r v e y d a t a i n d i c a t e s l o w e r c o v e r a g e r a t e s ) .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 h o u s e h o l d s .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 i n c r e a s e d , e s p e c i a l l y f o r i n p a t i e n t s e r v i c e s .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 o f t h e p o o r a n d n e a r - p o o r ; t h o s e w i t h J a m k e s m a s c o v e r a g e h a v e l o w e r O O P p a y m e n t s ( a m e a s u r e o f f i n a n c i a l p r o t e c t i o n ) a n d J a m k e s m a s b e n e f i c i a r i e s h a v e a l o w e r i n c i d e n c e o f c a t a s t r o p h i c m e d i c a l e x p e n d i t u r e s w h e n c o m p a r e d w i t h t h o s e w i t h n o i n s u r a n c e o r t h o s e w i t h o t h e r f o r m s o f i n s u r a n c e .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 u t i l i z a t i o n i n t h e p o o r e s t p r o v i n c e s ( N T T , P a p u a , M a l u k u ) .
82
Focus on JamkesmasUpdate in December 2011
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42
Almost half of population covered by health insurance, and nearly 30% of population covered by Jamkesmas
83
5.7
4.32.91.92.3
40
6
4.22.93.1.9
43
11
4.52.831
36
10
4.82.62.61.1
37
9.9
5.13.12.52.2
37
16
5.2
3.72.31.3
34
13
5
4.52.81.7
36
020
4060
Num
ber
of hou
sehol
ds (
mill
ion)
2004 2005 2006 2007 2008 2009 2010
Data source : Susenas 2004-2010
Household-level insurance coverage, 2004-2010
Jamkesmas/Askeskin/Health Card Askes
Jamsostek Private
Other No insurance
High utilization of outpatient care among those who covered by Jamkesmas, increase used of Jamkesmas for outpatient and inpatient care
84
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
0.0
5.1
.15
.2U
tiliz
atio
n ra
te
2003 2004 2005 2006 2007 2008 2009 2010 2011Year
All
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
0.0
5.1
.15
.2U
tiliz
atio
n ra
te
2003 2004 2005 2006 2007 2008 2009 2010 2011Year
Bottom 3 deciles
Source: SUSENAS 2004-2010
Outpatient utilization rate, 2004-2010by insurance type
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
01
23
4pe
rcen
tage
2003 2004 2005 2006 2007 2008 2009 2010 2011Year
All
No insurance
Jamkesmas/Askeskin/Health Card
Other insurance
0.5
11.
52
2.5
33.
54
perc
enta
ge
2003 2004 2005 2006 2007 2008 2009 2010 2011Year
Bottom 3 deciles
Source: SUSENAS 2004-2010
Inpatient utilization rate, 2004-2010by insurance type
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health spending is highest among households that had at least one inpatient utilization visit among any of the family members
85
01.
0e+
062.
0e+
063.
0e+
064.
0e+
065.
0e+
06
Hou
seho
ld h
ealth
exp
endi
ture
in p
ast
year
(Rup
iah)
00 10 01 11Utilization pattern
OOP health expenditureby utilization pattern
0.0
5.1
.15
Hou
seho
ld h
ealth
exp
endi
ture
sha
reof
tot
al c
onsu
mpt
ion
expe
nditu
re
00 10 01 11Utilization pattern
As share of total consumptionby utilization pattern
Source: SUSENAS 2010Utilization pattern: 00=0 outpatient and 0 inpatient visits; 10=1 or more outpatient and 0 inpatient visits01=0 outpatient and 1 or more inpatient visits; 11=1 or more outpatient and 1 or more inpatient visits
the share of health in total consumption expenditures – when conditioned on those utilizing inpatient care – are generally lower among
Jamkesmas/Askeskin/Kartu Sehat households across 2004-201086
Health expenditure and health share of household expenditure among those with at least one inpatient visit, 2004-2010
All No insurance Jamkesmas/Askeskin/
Kartu Sehat
Other insurance
Year Healthexpenditure
(share of totalexpenditure %)
Healthexpenditure
(share of totalexpenditure %)
Healthexpenditure
(share of totalexpenditure %)
Healthexpenditure
(share of totalexpenditure %)
2004 Rp 1,629,763(10.9%)
Rp 1,626,499(11.9%)
Rp 1,006,313(9.5%)
Rp 1,898,414(9.8%)
2005 Rp 1,881,057(10.0%)
Rp 1,856,633(11.3%)
Rp 1,155,444(8.9%)
Rp 2,308,581(8.3%)
2006 Rp 1,653,611(8.3%)
Rp 1,867,575(9.9%)
Rp 893,536(6.7%)
Rp 1,944,168(7.2%)
2007 Rp 1,738,784(8.1%)
Rp 1,846,480(9.1%)
Rp 1,104,266(7.6%)
Rp 2,126,047(6.9%)
2009 Rp 3,066,949(10.3%)
Rp 3,171,209(11.3%)
Rp 1,959,415(9.2%)
Rp 4,054,062(9.6%)
2010 4,151,826 (11.9%)
4,145,972 (13.2%)
1,955,121 (9.9%)
6,152,485 (11.5%)
Source: 2008 data not included due to problems with expenditure module
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I n v e s t i n g i n I n d o n e s i a ’ s H e a l t h : C h a l l e n g e s a n d O p p o r t u n i t i e s f o r F u t u r e P u b l i c S p e n d i n g . H e a l t h P u b l i c E x p e n d i t u r e R e v i e w – J u n e 2 0 0 8
I n d o n e s i a ’ s D o c t o r s , M i d w i v e s a n d N u r s e s : C u r r e n t S t o c k , I n c r e a s i n g N e e d s , F u t u r e C h a l l e n g e s a n d O p t i o n s . H e a l t h H u m a n R e s o u r c e s R e v i e w – J a n u a r y 2 0 0 9
G i v i n g M o r e W e i g h t t o H e a l t h : A s s e s s i n g F i s c a l S p a c e f o r H e a l t h i n I n d o n e s i a – J a n u a r y 2 0 0 9
H e a l t h F i n a n c i n g i n I n d o n e s i a : a R e f o r m R o a d M a p – J u n e 2 0 0 9
N e w I n s i g h t s i n t o t h e P r o v i s i o n o f H e a l t h S e r v i c e s i n I n d o n e s i a : a H e a l t h W o r k F o r c e S t u d y – O c t o b e r 2 0 0 9
‘ a n d t h e n s h e d i e d ’ : I n d o n e s i a M a t e r n a l H e a l t h A s s e s s m e n t –D e c e m b e r 2 0 0 9
A c t u a r i a l C o s t i n g o f U n i v e r s a l H e a l t h I n s u r a n c e C o v e r a g e i n I n d o n e s i a : O p t i o n s a n d P r e l i m i n a r y R e s u l t s – J a n u a r y 2 0 1 1
Annex: World Bank Studies for the HSR
87
F o r t h c o m i n g :
E n h a n c i n g H e a l t h E q u i t y a n d F i n a n c i a l P r o t e c t i o n i n I n d o n e s i a : H o w W e l l D o e s J a m k e s m a s d o ? J a m k e s m a sR e v i e w P a p e r
- M a r c h 2 0 1 2
88
Annex: Forthcoming World Bank Studies
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P h a r m a c e u t i c a l s : W h y R e f o r m i s N e e d e d – M a r c h 2 0 0 9 A c c e l e r a t i n g I m p r o v e m e n t i n M a t e r n a l H e a l t h : W h y R e f o r m i s N e e d e d – J u n e 2 0 1 0 F i n a n c i n g U n i v e r s a l C o v e r a g e : A s s e s s i n g F i s c a l S p a c e i n I n d o n e s i a – J u l y 2 0 1 0 A c h i e v i n g U n i v e r s a l C o v e r a g e : D i f f e r e n t S t a g e s o f H a r m o n i z a t i o n o f I m p l e m e n t i n g H e a l t h I n s u r a n c e I n f o r m a t i o n S y s t e m s – A u g u s t 2 0 1 0H e a l t h P r o f e s s i o n a l E d u c a t i o n i n I n d o n e s i a : W h y R e f o r m i s N e e d e dM 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 gA c t u a r i a l E s t i m a t e s : W h a t w o u l d U n i v e r s a l H e a l t h I n s u r a n c e C o v e r a g e b y 2 0 2 0 C o s t ?
F o r t h c o m i n g :
89
Annex: World Bank Policy Notes Series