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SUPPLY-SIDE READINESS FOR UNIVERSAL HEALTH COVERAGE: Assessing the Depth of Coverage for Non-Communicable Diseases in Indonesia

THE WORLD BANK

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THE WORLD BANK OFFICE JAKARTA Jakarta Stock Exchange Building Tower II/12-13th Fl.Jl. Jend. Sudirman Kav. 52-53Jakarta 12910Tel: (6221) 5299-3000Fax: (6221) 5299-3111www.worldbank.org/id/health

THE WORLD BANK1818 H Street N.W.Washington, D.C. 20433 USATel: (202) 458-1876Fax: (202) 522-1557/1560Email: [email protected]: www.worldbank.org

Printed in June 2014

This work is a product of the staff of The World Bank with external contributions, The fi ndings, interpretations, and conclusions expressed in this work do not necessarily refl ect the views of The World Bank, its Board of Exective Directors, or the governments they represent.

The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.

For any questions regarding this report, please contact: [email protected]

SUPPLY-SIDE READINESS FOR UNIVERSAL HEALTH COVERAGE: Assessing the Depth of Coverage for Non-Communicable Diseases in Indonesia

Report No. 88523-ID

Supply-Side Readiness for Universal Health Coverage

iv

Contributors

Th is policy paper has been prepared by a team consisting of members from the Indonesia Ministry of Health’s National Institute of Health Research and Development (Soewarta Kosen, Ingan Tarigan, Yuslely Usman, Tati Suryati, Endang Indriasih, Harimat, Idawati Muas, Retno Widyastuti, Merry Luciana, Tita Rosita and Dwi Hapsari), and the World Bank’s Indonesia Health, Nutrition, and Population Team (Ajay Tandon, Wei Aun Yap, and Eko Pambudi); Additional inputs were provided by Pandu Harimurti, Puti Marzoeki, Stephanus Indrajaya, Xialu Bi, Rong Li, and Darren Dorkin. Comments from Toomas Palu, Owen Smith, Karima Saleh, David Evans, Robert Yates, Broto Wasisto, and Gayle Martin are gratefully acknowledged.

Th is paper was edited by Diana van Walsum. All photographs used in this paper are courtesy of John Estey and Eko Pambudi.

Assessing the Depth of Coverage for Non-Communicable Diseases in Indonesia

v

Contents

Contributors ..................................................................................................................................... iv

List of Abbreviations and Acronyms .................................................................................................. viii

Executive Summary ........................................................................................................................... 2

1. Introduction ............................................................................................................................... 6

2. Background ................................................................................................................................ 102.1 Implementation of Universal Health Coverage Reforms in Indonesia ................................... 102.2 Rising Non-Communicable Disease Burden in Indonesia .................................................... 112.3 Supply-Side Implications of Universal Health Coverage ....................................................... 14

2.3.1 Depth of Coverage in Indonesia .................................................................................. 152.3.2 Provider Payment Mechanisms .................................................................................... 16

3. Supply-side Readiness Assessment ............................................................................................... 223.1 Framework for Analysis ........................................................................................................ 223.2 Data Sources ........................................................................................................................ 24

4. Supply-Side Readiness Assessment for Non-Communicable Diseases .......................................... 264.1 General Service Readiness .................................................................................................... 264.2 Human Resources for Health ............................................................................................... 284.3 Diabetes Mellitus ................................................................................................................. 284.4 Cardiovascular Conditions ................................................................................................... 324.5 Chronic Respiratory Conditions ........................................................................................ 36

5. Conclusions ................................................................................................................................ 40

6. Policy Implications ..................................................................................................................... 44

ANNEX A ........................................................................................................................................ 48

ANNEX B ........................................................................................................................................ 49


vi

List of Tables

Table 1: Top 10 causes of disease burden in Indonesia, 1990-2010................................................ 13

Table 2: Top 10 risk factors in Indonesia, 2010 ............................................................................. 13

Table 3: Benefi t package entitlement and provider payment .......................................................... 17

Table 4: Supply-side implications for provision of DM-related care at the primary level ................ 30

Table 5: Availability of equipment for DM-related care at Puskesmas ............................................ 31

Table 6: Percent of Puskesmas reporting availability of blood glucose and urine tests for diabetes ...................................................................................................................... 31

Table 7: Supply-side implications for provision of cardiovascular conditions at the primary level .......................................................................................................... 35

Table 8: Provinces with <75% of all Puskesmas reporting captopril availability ............................. 36

Table 9: Share of DALYs lost from chronic respiratory diseases in Indonesia, 1990-2010 .............. 36

Table 10: Supply-side implications for provision of chronic respiratory disease-related care at the primary level .............................................................................................................. 37


vii

List of Figures

Figure 1: Burden of disease by cause in Indonesia, 1990-2010 ........................................................ 11

Figure 2: Share of population aged 65+ in selected EAP countries, 1950-2070 ............................... 12

Figure 3: Th ree dimensions of UHC ............................................................................................... 15

Figure 4: Supply-side assessment framework ................................................................................... 22

Figure 5: Service Delivery Indicators Model.................................................................................... 23

Figure 6: Basic amenities in puskemas in Indonesia ....................................................................... 27

Figure 7: Availability of basic amenities at Puskesmas by province ................................................. 27

Figure 8: Burden of diabetes mellitus in Indonesia, 1990-2010 ...................................................... 29

Figure 9: Availability of blood glucose and urine tests in Puskesmas by province ............................. 32

Figure 10: Hypertension prevalence among adults aged 18+ years by province in Indonesia, 2007 ........................................................................................................... 34

Figure 11: NCD Service Readiness Indicator Index, by Province, 2011 ............................................ 41

Figure 12: Prevalence of Diabetes, by Province (Riskasdes, 2007) ..................................................... 41

Figure 13: NCD Service Readiness Indicator Index vs. Selected Economic Indicators (Provincial-level) ............................................................................................................. 42


viii

List of Abbreviations and Acronyms

Askes : Asuransi KesehatanAusAID : Australian Agency for International DevelopmentBPJS : Badan Penyelenggara Jaminan SosialCAD : coronary artery diseasesCOPD : chronic obstructive pulmonary diseaseCRDs : chronic respiratory diseasesDALYs : Disability-adjustted life yearsDM : diabetes mellitusDRGs : diagnosis-related groupsGIZ : German Society for International CooperationHFCS : Health Facility Costing StudyHRH : human resources for healthINA-CBGs : Indonesia Case-based GroupsJamsostek : Jaminan Sosial Tenaga KerjaJKN : Jaminan Kesehatan NasionalMOH : Ministry of HealthNCD : non-communicable diseasesOOP : out-of-pocketPETS : Public Expenditure Tracking SurveyPuskesmas : Pusat Kesehatan Masyarakat (public primary care facilities)Rifaskes : Riset Fasilitas KesehatanRiskesdas : Riset Kesehatan DasarSARA : service availability and readiness assessmentSJSN : Sistem Jaminan Sosial NasionalUHC : universal health coverageWHO : World Health Organization

EXECUTIVE SUMMARY


2

Executive Summary

Indonesia is currently in the midst of major reforms of its health system, which have resulted in the institutionalization of one of the largest single-payer universal health coverage (UHC) programs in the world. At the same time, the country is undergoing a rapid epidemiological transition and non-communicable diseases (NCDs) are now the dominant share of the overall disease burden in the country. Indonesia faces several challenges to eff ective implementation of UHC in terms of expanding breadth, height, and depth of coverage, especially in addressing NCD conditions, which are generally chronic in nature, require careful patient case management over time, and are most cost-eff ectively addressed at the primary care level. Given this backdrop, this policy paper focuses on the issue of supply-side readiness from the perspective of assessing the depth of UHC in Indonesia, especially in rural and remote areas of the country where a large proportion of the poor and near-poor populations reside, and with a focus on key tracer NCD conditions – diabetes mellitus (DM), chronic cardiovascular conditions, and chronic respiratory conditions – at the public primary care (Puskesmas) level in Indonesia. Th e paper compares supply-side implications of UHC benefi t entitlements as derived from national health facility and program-specifi c guidelines with the World Health Organization’s (WHO) recommendations for service availability and readiness assessment (SARA) for these same tracer NCD conditions. Using a variety of information sources – including analysis of the 2011 Rifaskes facility census – the paper assesses the ability of Indonesia’s public health system to provide eff ective coverage for NCDs across the country.

Results from the analysis show that, even though DM is now the eighth (and rising) cause of the overall disease burden in Indonesia, service readiness for basic diagnosis and basic treatment of DM is limited. For example, only 70 percent of urban Puskesmas could conduct a blood glucose test for the diagnosis and monitoring of DM. In rural Puskesmas, this readiness indicator declined to 51 percent nationwide and in some provinces, such as Gorontalo, Papua, Southeast Sulawesi, Maluku, North Sulawesi, and West Papua, less than 20 percent of Puskesmas fulfi lled this indicator. Basic pharmaceutical treatment for DM is more encouraging with 90 percent of Puskesmas stocking glibenclamide; however, only 48 percent stocked metformin. As over 95 percent of Puskesmas reported the availability of functioning blood pressure apparatus and over 99 percent reported the same of stethoscopes, most Puskesmas have the necessary equipment to diagnose hypertension. Th e availability of medical treatment for hypertension using captopril, a commonly used antihypertensive medication in Indonesia, is fair. Nationwide, 84 percent of Puskesmas stocked this medication, although defi ciencies were notable in rural Puskesmas in provinces such as West Sulawesi, Maluku, and Papua, where captopril was available in less than 70 percent of Puskesmas. Furthermore, in the case of hypercholesterolemia, only a third of Puskesmas nationally reported the ability to conduct cholesterol tests and only 36 percent reported the availability of simvastatin, a common treatment for hypercholesterolemia. In the case of chronic respiratory diseases such as asthma, over 75 percent of all Puskesmas reported the availability of basic treatments such as salbutamol, prednisolone, and oxygen. Th ere are geographic variations, with less than 75 percent of Puskesmas reporting availability of salbutamol and prednisolone in Central Sulawesi, West Sulawesi, and Papua.


3

Putting all the available indicators for the three NCD tracer conditions together into an index reveals that the defi ciencies are especially prominent at the primary care level in 12 of 33 provinces in Indonesia, especially in the eastern part of the country where 18 percent of the country’s total population and 22 percent of Indonesia’s rural population resides: North Sumatera, Bengkulu, East Nusa Tenggara, North Sulawesi, Central Sulawesi, Southeast Sulawesi, Gorontalo, West Sulawesi, Maluku, North Maluku, West Papua, and Papua. By way of contrast, supply-side readiness for NCDs appears not to be a problem in public hospitals across all provinces in Indonesia.

Th e analysis reported in this policy note underscores that – in order to attain UHC – there needs to be a focus not just on increasing the breadth and height but also on ensuring that eff ective depth of coverage exists, especially in the rural and remote areas of the country and for primary care. It is not enough to specify a comprehensive benefi t package on paper if facilities do not have the basic supply-side readiness conditions to be able to provide key services. In ensuring and expanding eff ective depth of coverage, various policy implications should be considered. Firstly, although this paper sheds some light on the existence of defi ciencies on the supply-side, further eff orts and systematic analysis are required in order to understand why supply-side defi ciencies exist so that the appropriate policy measures can be instituted. Furthermore, as fi nancing gradually shifts from the supply-side to the demand-side, the mechanics of this demand-side fi nancing should be leveraged to improve service readiness at facilities in an optimal manner. Greater clarity is required on the implications of the benefi t package, both for providers (in order to understand what inputs are required to provide the benefi t package) and for the insured, through improved socialization of benefi t entitlements so that the insured are better able to understand what services they should be able to receive through Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan. Although the survey and census analyzed in this paper provide a snapshot of some aspects of service readiness, regular independent monitoring and evaluation of supply readiness is required: both as part of the routine due diligence functions of the insurance administrator and also as evaluation of the health provision system in order to inform Ministry of Health (MoH) policy. Regardless of whether investments in service readiness are predominantly driven by supply-side investments or by demand-side fi nancing mechanisms, it is clear that overall investments in service readiness for NCDs are required, in order to maximize effi ciency gains from the prevention and prudent management of these chronic conditions. Finally, although the scope of the paper is focused on facilities, risk factors for NCDs should be addressed holistically, through public health interventions beyond the health facility and indeed, beyond the health sector alone.


4

INTRODUCTION


6

1. Introduction

Non-communicable diseases (NCDs) now account for the largest share of the overall burden of disease in Indonesia. Whereas in 1990 only about 37 percent of morbidity and mortality in the country was due to NCDs, by 2010 this number had risen to 58 percent.1 Th is increase is expected to continue as the share of the population aged 65 years and older will begin to rise rapidly beginning in 2015, and ageing will bring an even higher susceptibility to NCDs in Indonesia. With this rapid epidemiological transition in the backdrop, Indonesia is currently implementing a series of health system reforms aimed at attaining universal health coverage (UHC) for its population by 2019. Th ese reforms include the merger of several existing contributory and non-contributory social health insurance schemes with streamlined uniform benefi ts under a single-payer umbrella beginning in 2014, followed by a gradual expansion in breadth of coverage to those currently uncovered by 2019.

Th ere are several challenges facing eff ective implementation of UHC in Indonesia, both from a health fi nancing and a service delivery perspective. Some key issues from a health fi nancing perspective are the collection of contributions from the non-poor in the informal sector, ensuring adequate fi scal space for fi nancing coverage for the poor and near-poor, managing an eff ective transition from supply-side to demand-side fi nancing of the health system, reducing out-of-pocket (OOP) payments, and ensuring cost containment and fi nancial sustainability of UHC. From a service delivery perspective, important challenges remain related to ensuring supply-side readiness in terms of addressing the rise in NCDs, provision of the UHC benefi t package in a coordinated manner, meeting current and future demand for health care, improving quality of care, leveraging and regulating private provision, and ensuring availability of human resources for health (HRH) across the country, among others.

Th is policy paper focuses on the issue of supply-side readiness from the perspective of assessing the eff ective depth of UHC in Indonesia, especially in rural and remote areas of the country where a large proportion of the poor and near-poor populations reside.2 Insurance coverage under UHC implies benefi t entitlements and – in some cases – restrictions as to what services will be eligible for reimbursement. As Indonesia moves towards an increase in demand-side insurance-oriented fi nancing of its health system, assessing the extent to which benefi t entitlements are actually available is a key consideration in ensuring that UHC is eff ective. In particular, given the rapid rise in NCDs in the country. Th is policy paper assesses the ability of Indonesia’s public primary care health facilities to provide preventive, diagnostic, and curative care for selected tracer NCD conditions: diabetes mellitus (DM), cardiovascular conditions, and chronic respiratory diseases. Th e paper compares supply-side implications of UHC benefi t entitlements as derived from national health facility and program-specifi c guidelines with the WHO’s recommendations

1 Institute of Health Metrics and Evaluation (2013).2 “Eff ective” is a reference to the realization of the benefi t package, not to the impact on health outcomes.


7

for service availability and readiness assessment (SARA) for these same tracer NCD conditions.3 Next, using a variety of information sources – including analysis of the Rifaskes facility census triangulated with other sources of information – the paper assesses the ability of Indonesia’s public primary care health system to provide coverage for the selected tracer NCD conditions across the country and discusses policy implications for eff ective implementation of UHC in Indonesia.

Th e focus in the paper is on highlighting gaps in benefi t entitlements and service readiness to stimulate policy dialogue on ways to enhance UHC implementation in the country. It is important to note at the outset that this policy paper is not an exhaustive study of the key determinants of tracer NCDs in Indonesia. Needless to say, even if service delivery inputs are available, the ability and eff orts of providers – as well as the actions and behaviors of households and key interventions in other sectors – remain areas of consideration in ensuring that any intended reforms lead to improvements in NCDs and other health outcomes. As discussed later in the paper, there are many risk factors associated with NCDs. Th e availability of preventive, diagnostic, and curative medical care services is one – but only one – critical factor in addressing the burden of disease related to NCDs in Indonesia and to ensure eff ective UHC implementation. Addressing the rising burden of NCDs in Indonesia will require a coordinated eff ort from both within and outside the health sector.

Th e remainder of the policy note is structured as follows: Section II provides some background and context related both to NCDs and to UHC in Indonesia. Section III analyzes the benefi t package for key tracer NCD conditions, derives the supply-side implications of the benefi t package, and compares these implications to the WHO’s SARA-recommended indicators. Section IV presents results from analysis of data related to the eff ective depth and distribution of coverage for key NCD conditions in Indonesia. Section V concludes with a summary and some policy implications.

3 Th e WHO’s SARA is a health facility assessment toolkit that is designed to help collect and analyze information on key aspects of service delivery in a health system, such as the availability of key human resources and infrastructure resources as well as basic equipment, basic amenities, essential medicines, diagnostic tools, and the readiness of facilities to provide health care interven-tions for tracer conditions. For more details see: WHO. 2012. Measuring Service Availability and Readiness: A Health Facility Assessment Methodology for Monitoring Health System Strengthening. Geneva: World Health Organization.


8

BACKGROUND


10

2. Background

2.1 Implementation of Universal Health Coverage Reforms in Indonesia

Indonesia has mixed public-private provision of health care services, with the public sector taking a generally dominant role in rural areas and for secondary levels of care. For primary care, Indonesia has more than 9,000 public Puskesmas, each serving catchment areas of 25,000-30,000 individuals (approximately a third of Puskesmas also provide inpatient services). Private provision has been increasing rapidly in recent years, including for primary care. Of the 163,000 hospital beds in the country, about 52,000 are managed by the private sector. In 2011, household survey data estimates indicated that less than half of all Indonesians reported having some form of health insurance coverage.4 An estimated 21 percent of all households had coverage under the non-contributory Jamkesmas scheme which targeted the poor and near-poor; 8.9 percent of households were covered by Askes, Indonesia’s social insurance program for the public sector; 7.9 percent were covered under Jamsostek, the private sector insurance program for the formal sector; and 7.1 percent were covered by other forms of insurance. 58.5 percent of all Indonesian households reported having no health insurance coverage in 2011. Coverage of benefi ts under social programs such as Jamkesmas and Askes was skewed towards provision by the public sector, although private provider enrollment in these programs has been increasing rapidly in recent years. Th ere is evidence indicating that expansion of insurance coverage has increased utilization rates, especially inpatient utilization, among the poor and near-poor. Nevertheless, OOP spending remains the dominant source of fi nancing, and is high even among those with coverage.5

Indonesia is currently in the midst of implementing a series of health system reforms aimed at attaining UHC for its population by 2019. Th e universal right to health care was included as an amendment to Indonesia’s constitution in 1999. However, the impetus for UHC came a few years later, in a 2004 landmark legislation -- the Sistem Jaminan Sosial Nasional or the SJSN Law – which formed the legal basis for attaining several social protection objectives in the country. In 2011, the government passed a ground-breaking follow-up law that defi ned the administrative and implementation arrangements – the Badan Penyelenggara Jaminan Sosial or BPJS Law – which stipulated that several existing contributory and non-contributory social health insurance schemes be merged to provide streamlined uniform benefi ts under a single-payer umbrella beginning in 2014. Following institutionalization of the single-payer insurance administrator (BPJS Kesehatan) in 2014, the government plans to incrementally extend coverage to the entire population by 2019. Th e unifi ed insurance program is referred to as Jaminan Kesehatan Nasional (JKN). BPJS Kesehatan is expected to contract with both public and private providers for delivery of the JKN benefi t package beginning in 2014.

4 Offi cial MoH data indicates 63.5 percent individual coverage rate in 2011.5 UNICO Indonesia study.


11

With these reforms in mind, service delivery issues are increasingly relevant in Indonesia. Th is report builds on an earlier report focused on the health workforce, which found that although the quantity of health workers had increased, the deployment and distribution of health workers was still skewed and thin in rural areas of Indonesia. Although training requirements and opportunities had expanded, the quality of public and private health services, as measured by ability to diagnose and treat, was “marginal” and overall quality remained low.6

2.2 Rising Non-Communicable Disease Burden in Indonesia

Like several other countries in the region, Indonesia is undergoing a rapid demographic and epidemiological transition. NCDs now account for the largest share of the burden of disease in Indonesia. Whereas in 1990 only about 37 percent of morbidity and mortality in Indonesia was due to NCDs, by 2010 this number had risen to 58 percent (Figure 1).7 Th is trend is expected to continue in the coming years, with the share of NCDs in the disease burden continuing to rise as the population ages. Beginning in 2015, the share of the population aged 65 years and older is projected to increase rapidly in Indonesia (Figure 2).

FIGURE 1: BURDEN OF DISEASE BY CAUSE IN INDONESIA, 1990-2010

6 World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Workforce Study. Washington, DC: World Bank.7 Institute of Health Metrics and Evaluation (2013).

1990 2000 2010

7%

56% 37%

9%

43%

49%

9%

56%

58%

Injuries

Non-CommunicableCommunicable

Injuries

Non-Communicable

Communicable Injuries

Non-Communicable

Communicable

Source: IHME


12

FIGURE 2: SHARE OF POPULATION AGED 65+ IN SELECTED EAP COUNTRIES, 1950-2070

Stroke, an NCD, was responsible for the largest share of the overall disease burden in Indonesia, causing 8 percent of all disability-adjusted life years (DALYs) lost due to morbidity and premature mortality in 2010 (Table 1).8 Stroke was also the leading cause of premature mortality in Indonesia. Ischemic heart disease, unipolar depressive disorders, and diabetes are other prominent NCDs in the top ten causes of the disease burden, with most of these conditions having doubled their share of the disease burden in Indonesia over the period 1990-2010 (Table 1).

8 DALYs refer to aggregated healthy years of time lost at the population level as a result of disease-related morbidity and prema-ture mortality.

Population aged 65+, 1950-2070Sh

are

of to

tal p

opul

atio

n (%

)

0

1950 1970 1990 2010Year

2030 2050 2070

5

10

15

20

25

30China

Thailand

Vietnam

Indonesia

Philippines

Source: UN


13

TABLE 1: TOP 10 CAUSES OF DISEASE BURDEN IN INDONESIA, 1990-20109

Rank in 2010 Top ten diseases/conditions in 2010

DALYs lost share

1990 2000 2010

1 Stroke 4.3% 6.3% 8.0%

2 Tuberculosis 7.5% 7.6% 7.6%

3 Road injury 3.3% 4.6% 4.7%

4 Low back and neck pain 2.8% 3.8% 4.5%

5 Diarrheal diseases 6.9% 5.6% 4.0%

6 Ischemic heart disease 1.9% 2.8% 3.8%

7 Unipolar depressive disorders 2.6% 3.4% 3.8%

8 Diabetes 1.7% 2.6% 3.5%

9 Lower respiratory infections 13.7% 5.9% 3.0%

10 Neonatal encephalopathy 2.5% 3.3% 2.9%

DALYs per 100,000 44,144 35,074 32,053

Life expectancy in years 62 66 69

Source: Institute of +Health Metrics and Evaluation (2013)

Th e rise in NCDs in Indonesia is a result of several socio-demographic and lifestyle factors. Ageing is one contributory factor, although the prevalence of NCDs among younger age groups in Indonesia is also increasing. Physical inactivity, unhealthy diets, tobacco use, and harmful alcohol consumption are key risk factors for NCDs. Several of these risk factors – including dietary risks, hypertension, smoking, high fasting plasma glucose, and physical inactivity – are prominent among the top ten risk factors contributing to the overall disease burden in the country (Table 2). Th e share of dietary risks and high blood pressure as contributors to DALYs lost has more than doubled over the period 1990-2010 (Table 2).

TABLE 2: TOP 10 RISK FACTORS IN INDONESIA, 2010

Rank in 2010 Top ten risk factors in 2010DALYs lost share

1990 2000 2010

1 Dietary risks 5.2% 10.2% 10.7%

2 High blood pressure 4.8% 7.4% 10.0%

3 Smoking 6.3% 6.1% 8.2%

4 Household air pollution 9.6% 6.5% 5.9%

5 High fasting plasma glucose 2.8% 3.9% 4.7%

6 Physical inactivity -- -- 3.1%

7 Occupational risks 1.9% 2.6% 2.8%

8 High body-mass index 0.4% 1.2% 2.8%

9 Iron defi ciency 2.9% 2.8% 2.4%

10 Ambient particulate matter pollution 1.8% 1.8% 2.1%

Source: Institute of Health Metrics and Evaluation (2013)

9 NCDs were 51.4 percent of the top ten DALYs in Indonesia, with the top ten conditions accounting for 45.7 percent of the total disease burden in the country.


14

From a health fi nancing and service delivery perspective, NCDs tend to be of a chronic nature, typifi ed by long durations and slow progression rates, but they can also result in rapid premature death (for example, with stroke and cardiovascular conditions) or an expensive period of disability and morbidity. In addition, NCDs are often preceded typically by a sub-clinical phase in which preventative strategies may be eff ective in delaying or reversing disease progression. For these reasons, NCDs can be relatively costly to treat and require sustained case management, often requiring multiple contacts with the health system over one’s lifetime. In addition to the crucial role played by public health eff orts aimed at reducing risk factors for NCDs on a population level, the management of NCDs also requires primary care services to play an important and eff ective role in screening and delivering preventive and promotive interventions which, for most NCDs, are far more cost-eff ective than treatment at advanced stages of progression. Th ere is also evidence to suggest that NCDs are more likely to result in catastrophic health spending, placing households at risk of impoverishment.10 Given the lifestyle nature of risk factors, an additional challenge is that several promotive and preventive interventions for addressing NCDs tend to lie outside the immediate purview of health systems – in the tax, agricultural, education, urban design, and transport sectors – and some of these interventions are generally not amenable to inclusion as part of traditional insurance benefi t packages.

2.3 Supply-Side Implications of Universal Health Coverage

UHC – ensuring that everyone has access to quality health services when needed, without experiencing fi nancial hardship as a result – can be conceptualized as having three key dimensions: “breadth”, “height”, and “depth” (Figure 3).11 Breadth refers to the proportion of the population that is covered; height refers to the proportion of health costs that are paid by pooled funds as opposed to via direct OOP payments; and depth refers to the benefi t package of services that are covered by pooled fi nancing (and the defi nition of services can be broadened to include provision of public health interventions).12 For example: by expanding coverage to include the non-poor informal sector (as intended by BJPS Kesehatan), breadth is expanded; by excluding additional services such as cosmetic surgery, depth is reduced; and by covering the costs of medications and removing co-payments and deductibles (as intended by BJPS Kesehatan) so that patients do not need to pay out-of-pocket for these, height is increased. Th ese dimensions are often interrelated, as poor service coverage due to supply-side readiness problems can drive the insured to alternative non-empanelled private providers, in eff ect rendering fi nancial coverage or even population coverage meaningless. A key challenge in implementing UHC is to balance the expansion of these three dimensions, by making the appropriate trade-off s (given resource constraints) between breadth, depth, and height. Although all dimensions are important, this paper focuses on ensuring depth of coverage – not just on paper, but also in eff ect – especially in rural, remote regions of the country and in light of the rapid transition to an NCD-dominated disease profi le in Indonesia.

10 World Bank. 2011. Th e Growing Danger of Non-Communicable Diseases: Acting Now to Reverse Course. Washington, DC: World Bank.11 WHO. 2010. World Health Report: Health Systems Financing – Th e Path to Universal Coverage. Geneva: World Health Organi-zation.12 Ibid.


15

FIGURE 3: THREE DIMENSIONS OF UHC

2.3.1 Depth of Coverage in Indonesia

From 2014 onwards, various social insurance schemes including Jamkesmas (for the poor and non-poor) and Askes (for civil servants) have been merged into JKN, which has a single-payer administrator (BPJS Kesehatan). Th e structure of the benefi t packages imply that the eff ective depth of coverage for NCDs is sensitive to the readiness of empanelled health facilities. All social health insurance schemes prior to 2014 defi ne their benefi t packages generally, not by the coverage of specifi c diseases but by the types of services that are eligible for coverage (e.g., health promotion, medical screening, consultations, examination, diagnostics, and treatment); in the case of Askes, specifi c diagnostic tests and medical interventions were also mentioned. Th e benefi t packages allude to treatment guidelines, which were level-specifi c in Indonesia and which for many diseases specify the names of drugs that should be used. For public health facilities, a national essential drug list exists and is used to defi ne which drugs can be provided to public health facilities (these are typically procured by district health offi ces).13 Th ese social health insurance schemes also defi ned a “negative list” of specifi c services and benefi ts that are not eligible under these schemes.

Th e JKN benefi t package is comprehensive and similar to that of Jamkesmas. Th e benefi t package has been defi ned in terms of covering everything except for:

• Health services that do not follow stipulated procedures, including referrals• Health services in facilities that are not contracted by BPJS Kesehatan, except for emergencies• Health services that are covered by occupational accidental insurance• Health services abroad, cosmetic procedures, health services for infertility, and orthodontic services• Health disorders/diseases caused by drug addiction and/or alcohol• Health problems caused by self-harm activities• Complementary treatment using alternative/traditional medicine unless declared eff ective by health

technology assessments• Experimental procedures, health equipment for households, contraceptives, baby food, and milk• Health services for disaster situations.

13 Daftar Obat Esensial Nasional 2011. Ministry of Health, Indonesia.

Includeother services

Direct costs: proportion of the costs covered

Services: which services are covered?Population: who is covered?

Extend to non-covered

Reduce cost sharing and fees

Current pooled funds

Total Health Expenditure


16

Despite the elaboration of the JKN benefi t package, the eff ective depth of coverage of NCDs will depend on an interplay between the service readiness of these facilities (the focus of this policy note), government clinical guidelines, the national essential drug list, the service types defi ned in the schemes, and the exclusionary “negative list” defi ned in the schemes. Details of the social health insurance schemes and their benefi t packages are summarized in Table 3 below. Given the importance of referrals under JKN, and for cost-eff ectiveness considerations more generally, it is especially important that the primary care sector play its role in the health system in terms of being ready to provide the stipulated services.

All public health providers were automatically included in these health fi nancing schemes, whereas private providers are subject to an accreditation process, with a grace period of 5 years for primary care facilities and 3 years for hospitals. Although including all public providers helps to expand the theoretical breadth (population) coverage to include the population in the catchment area of all public providers, this is likely at the expense of the depth (services) of coverage as these facilities many not be ready to provide these services. Th e degree of independence and robustness of the accreditation process for private providers would be an area ripe for further research.

2.3.2 Provider Payment Mechanisms

Provider payment mechanisms can infl uence the service readiness of health facilities, and hence are summarized here in order to contextualize the fi ndings and policy implications. Demand-side payments from social health insurance schemes are not the primary source of revenue for health facilities. For example, health facilities receive equipment and drugs (except for contraceptive, immunization, and any drugs related to vertical programs such as HIV/AIDS, TB and malaria) from (and determined by) local governments and, in some instances, through a fund operated by the central government (though with expected but often not realized contributions from the local government) called the Special Allocation Fund (Dana Alokasi Khusus). Operational budgets (including salaries) are also provided by both the central government, through the General Allocation Fund (Dana Alokasi Umum), and by local governments. Vertical programs, likewise, are funded through the central government. Th e supply-side readiness of Puskesmas is hence, to a large extent, infl uenced by a combination of local and central government supply-side fi nancing. Th is caveat should be considered in the following discussion on provider payment mechanisms used by the social health insurance schemes.

Indonesia’s social insurance schemes made a distinction between primary care services and secondary care (referral) services. Capitation was the predominant provider payment mechanism at the primary care level although there were important variations. Askes diff erentiated between the type of primary care provider: with capitation payments ranging from Rp 2,000 per month at small Puskesmas to Rp 6,500 per month for empanelled family doctors. Jamkesmas initially paid capitation payments directly to Puskesmas but, since 2011, capitation payments are made to district health offi ces, which then reimburse Puskesmas on a fee-for-service basis, depending on actual utilization. Th ese arrangements are expected to be continued for Puskesmas under BPJS implementation as of 2014. Capitation payments do not currently expose primary care facilities to the costs of referrals made, leading to the risk of inappropriate referrals


17

made not for clinically justifi ed reasons, but merely to shift the costs and burden of managing a patient to secondary care or tertiary care facilities. Furthermore, there is the risk of incentivizing undertreatment under capitation systems, which is somewhat mitigated by the fact that Puskesmas do not need to fi nance the purchasing of essential medicines and commodities themselves, but receive these without charge on request from district health offi ces.

At the secondary and tertiary care (referral) levels, a form of diagnosis-related groups (DRGs) called Indonesia Case-based Groups (INA-CBGs) were used to pay providers under the Jamkesmas scheme. BJPS Kesehatan is also using this provider payment mechanism as of 2014, replacing the tariff system used by Askes currently in which a comprehensive schedule of tariff s varying by the hospital class/specialization is used to pay for specifi cally defi ned diagnostic tests and medical interventions. Additional details of this provider payment mechanism are summarized in Table 3.

TABLE 3: BENEFIT PACKAGE ENTITLEMENT AND PROVIDER PAYMENT

Health Insurance

SchemeTarget Group Provider Payment

Mechanism Benefi t Package ‘Negative list’

Askes1 Civil servants, pensioners, veterans, and independence pi-oneers, and their immediate family members

Primary care outpatient services:

Rp 2,000 per member per month for health centers with one or no general physicians; Rp 4,000 for health center with two or more general physicians; Rp 5,500 – 6,500 for family doctor.

Basic inpatient services:Rp 80,000 per day

Secondary care (referral) level: Tariff of charges for inpa-tient care depending on four classes of hospitals - A, B, C, and D – and class of accom-modation (I or II). Detailed tariff of charges for specifi c diagnostic tests and medical interventions (varying by hospital class)

At the primary care level, the following services types are included: medicines and medical consumables, (ii) promo-tive and preventative care, (iii) curative care, and (iv) rehabilitation. Basic inpa-tient services are covered where this is provided by the Puskesmas.

For formal referrals to secondary care (referral) level: A detailed schedule of diagnostic tests and medical interventions are included. Interventions are only permitted for specifi c medical indications.

Selected excluded services:

• For childbirth, only the fi rst two living children are covered.


18

Health Insurance



Jamkesmas2 The poor and non-poor, occu-pants of social institutions, pris-oners and victims of disasters (for one-year)

(approx. 76.4 mil-lion individuals)

Primary care outpatient services: Prior to 2011, Pusk-esmas received a capitation of Rp 1,000 per member per month. From 2011, district health offi ces receive this capitation of Rp 1,000 per member per month instead, and pay Puskesmas on a fee-for-service basis depending on utilization.

Secondary care (referral) facilities are paid by using a form of diagnosis-related groups called Indonesia Case-based Groups (INA-CBGs)

At the primary care level (Puskesmas and network providers), the following service types are included: (i) consultation and coun-seling; (ii) simple laborato-ries (blood test, urine test, and feces); (iii) minor med-ical intervention; (iv) dental examination and interven-tion, including revocation and tooth patches by dentist; (v) prenatal care, postpartum visit, lactation consultation, neonatal and under-fi ve care, including basic immunization; (vi) family planning consul-tation; and (vii) provision of formulary drugs. Basic inpatient services at the primary level are included as well.

At the secondary care (referral) level, the fol-lowing additional service types are included: (i) medical rehabilitation and (ii) specialist consultations and examinations. Class III inpatient accommoda-tion is covered, as are the following additional service types: (i) intensive care, (ii) high-risk obstetrics, and (iii) specialist and major surgery.


• Cosmetic proce-dures

• General check-ups• False prosthetic

teeth• Unproven alterna-

tive medicine• Infertility treat-

ment.

TABLE 3: BENEFIT PACKAGE ENTITLEMENT AND PROVIDER PAYMENT (CONTINUED)


19

Health Insurance



JKN3 (2014 – onwards)

Universal cov-erage for any resident (mini-mum 6-months residency) is provided through defi ned catego-ries:

• Non-contribut-ing members (the poor and those without means to pay), whose contri-butions are covered by the government

• Salaried em-ployees and wage-earners, whose contri-butions are par-tially covered by the employer

• Self-employed, unsubsidized contributions

• Civil servants, the military, police, indepen-dence pioneers, veterans, and pensioners.

Primary care facilities4 (all eligible public facilities and empanelled private facilities) are paid by capitation based on the number of regis-tered members. For public Puskesmas, the capitation is understood to be paid to district health offi ces who then reimburse Puskesmas on a fee-for-service basis based on utilization (as per the current arrangements for Jamkesmas).

Secondary care (referral) facilities are paid by using a form of diagnosis-related groups called Indonesia Case-based Groups (INA-CBGs), using a standard tariff deter-mined in agreement with the Minister and reviewed twice yearly5.

Medicines and medical consumables are covered by JKN and are to be reimbursed at prices determined by the Minister.

Funding of medicines and commodities for vertical pro-grams – e.g., contraceptives and immunizations - will still be covered by those vertical programs.

A single benefi t package (for medical benefi ts) is defi ned for all members. Non-medical benefi ts, such as ambulance services and accommodation, are dependent on the category of membership, though upgrades of the class of accommodation are per-mitted if the diff erence is paid separately.

At the primary care level, the following service types are included: (i) admin-istrative costs, (ii) pro-motive and preventative care (including medical check-ups, lifestyle and risk factor advice, basic immunizations, family planning including vasec-tomies and tubal ligations, and medical screening), (iii) medical examinations, (iv) medications and medical consumables (as clinically justifi ed), (v) consultations, (vi) non-specialist surgical and non-surgical treat-ment, (vii) blood transfu-sions, and (viii) fi rst-line diagnostic tests.

At the secondary care (referral) level, outpatient and inpatient service types are defi ned. Outpatient care includes: (i) adminis-trative costs, (ii) specialist medical examinations and consultations, (iii) specialist treatment, (iv) implants, (v) second-line diagnostic tests, (vi) rehabilitation, (vii) blood transfusions, and (viii) forensic services and mortuary services. Inpa-tient service types include both intensive care and non-intensive care.


• Infertility treatment• Orthodontic treat-

ment• Complementary

medicine (not assessed through HTAs)

• Cosmetics• Self-infl icted health

problems (including drug or alcohol addictions)

• Work hazards and diseases covered by work insurance

• Medical treatment obtained abroad.

TABLE 3: BENEFIT PACKAGE ENTITLEMENT AND PROVIDER PAYMENT (CONTINUED)


20

SUPPLY-SIDEREADINESS ASSESSMENT


22

3. Supply-side Readiness Assessment

3.1 Framework for Analysis

Th e framework used in this paper for assessing supply-side readiness for UHC is summarized below in Figure 4. As depicted in the fi gure, the supply-side assessment begins with an examination of the current benefi t package for Jamkesmas and Askes, two of the biggest social health insurance programs merged under BPJS in 2014, as well as the proposed package under JKN. Detailed supply-side implications for the provision of the benefi t package were derived from program-specifi c Puskesmas guidelines that detail equipment, diagnostic tests, and medicines that are stipulated. Th e paper also compares the supply-side implications from program-specifi c Puskesmas guidelines with those recommended by the WHO SARA framework. Although the WHO SARA framework specifi es various elements required for a particular category of services – for example, cardiovascular conditions – it does not generally specify the exact combination of indicators required to treat a particular (stage of ) disease, nor does it generally specify alternatives nor capture the full diversity of potential treatment options (for example, there are a wide variety of anti-hypertensive medications in reality, but only a select few “tracer” drugs are chosen). Furthermore, due to limitations of the data sources, which were not initially conceived for this form of analysis, there are important omissions in indicators captured by the census and survey. For these reasons, it may be misleading to generate disease-specifi c composite measures (which require the presence of a set of indicators together), although in future iterations of data collection and analysis, this would be a valuable measurement. Th e lack of an exhaustive list of all available drugs and commodities at the health facility limits the interpretation of some aspects of the analysis.

FIGURE 4: SUPPLY-SIDE ASSESSMENT FRAMEWORK

NCDs

guidelines

guidelines


23

In assessing the depth of UHC, it is important to link the provision of covered benefi ts to the concept of service delivery. Service delivery can be conceptualized as consisting of three key dimensions: (i) inputs; (ii) ability; and (iii) eff ort.14 Th is paper focuses primarily on “service delivery inputs”, in the terminology of the Service Delivery Indicators model, which is analogous to “service readiness” in the WHO SARA framework. Needless to say, even if service delivery inputs are available, the ability and eff orts of providers – as well as the actions and behaviors of households and key interventions in other sectors – remain areas of consideration in ensuring that any intended reforms lead to improvements in NCDs and other health outcomes. Th e Service Delivery Indicators model is summarized in Figure 5. By converging elements from both the Service Delivery Indicators model, and the UHC model, this framework is hence an attempt at linking health fi nancing structures to service delivery.

FIGURE 5: SERVICE DELIVERY INDICATORS MODEL15

In addition, in assessing the depth of UHC, it is important to note that the three dimensions of UHC (depth, breadth, and height) are not independent and mutually exclusive: ensuring depth of coverage has implications for the breadth and height of UHC as well. Universal availability of the benefi t package for all – not just those who are well-off and live in urban areas – is a key aspect of ensuring that UHC is not a hypothetical aspiration but a realized policy designed to enhance health and improve social protection. Also, high OOP payments – that is, low height of UHC – can be (and often are) a result of poor depth of coverage if patients have to pay OOP for drugs or seek care elsewhere in private facilities that are outside the social health insurance network.

14 World Bank. 2012. Service Delivery Indicators Concept Note. Washington, DC: World Bank.15 http://www.sdindicators.org/

EXPENDITURE

OUTCOMES

INPUTS

PROVIDER ABILITYPROVIDER EFFORT$ $ $ $ $


24

3.2 Data Sources

Th e assessment of the depth of coverage reported in this policy note using the framework outlined above is based primarily on analysis of the 2011 Rifaskes facility census data, triangulated with information from the 2011 Health Facility Costing Study (HFCS) as well as evidence reported in recent literature where applicable. Th e Rifaskes facility data was collected by the Ministry of Health’s National Institute Health Research and Development Ministry in 2011. Th e inclusion criterion for the Rifaskes census was that the facilities had to be established prior to 2010. Th e response rate of 685 hospitals and 8,981 Puskesmas was a 100 percent by all eligible public health facilities owned by central, provincial, and district governments. Th e data includes information on human resources, medical equipment, organization and management, health services, and outputs of most essential health services. Data was collected through interviews, observations, and also from secondary sources. Independent validation of the Rifaskes data was conducted by three public health faculties in Indonesia: University of Indonesia, Airlangga University, and Hasanudin University.

Where possible, basic triangulation of Rifaskes data was done with the HFCS dataset which was a nationwide costing study commissioned by the Ministry of Health in 2011, fi nanced by the German Society for International Cooperation (GIZ) and the Australian Agency for International Development (AusAID) with technical support from Oxford Policy Management, GIZ, and Universitas Gadjah Mada. Th e facility survey sampled 234 Puskesmas, 120 government general hospitals, and 80 private general hospitals across 15 provinces in 30 districts/cities. Th e sample was selected using a stratifi ed random sampling method so as to ensure national representativeness of the facility data. Th e primary objective of the GIZ health facility study was to calculate the cost of service provision. For this purpose, the study collected very detailed information about assets, drugs, equipment, and supplies from Q4 2010 until Q3 2011. Some modules were collected monthly; others were collected quarterly or annually. To ensure data quality, an independent verifi cation team was established consisting of staff from four universities: University of Indonesia, Universitas Gadjah Mada, University of Airlangga, and University of Hasannudin. Th e richness of the database and the time period of data collection make it useful to triangulate with Rifaskes data. Indicators that overlap with Rifaskes in that the same piece of equipment or drug is reported available, are noted as footnotes in the paper where and if there are large discrepancies.

Although a small number (80) of private general hospitals were sampled in the HFCS, this is not nationally representative and the sampling methodology and criteria were unclear. In addition, with respect to the national insurance scheme (BPJS), private providers are subject to an accreditation process, and hence defi ciencies in their supply-side readiness would be expected to result in exclusion from the scheme (and in potential impact on population coverage, or breadth, if there are no alternative providers) rather than impact the depth (services) of coverage. A Public Expenditure Tracking Survey (PETS) covering health facilities is anticipated in the coming year. It is expected that the explanatory power of this service-readiness analysis can be enhanced using advanced statistical techniques that compare facilities’ expenditure and revenue data with their readiness.

Annex A summarizes key information regarding both the Rifaskes and GIZ facility datasets used in the analysis reported in this policy note.

SUPPLY SIDEREADINESS ASSESSMENTFOR NON-COMMUNICABLEDISEASES


26

4. Supply-Side Readiness Assessment for Non-Communicable Diseases

As mentioned above, cardiovascular diseases – including stroke and ischemic heart disease -- were the leading causes of the overall disease burden and the leading causes of premature mortality in Indonesia in 2010. Although the eff ective availability of treatment of stroke and acute heart disease events (such as heart attacks) is a key consideration in reducing the contribution of cardiovascular diseases to the overall disease burden, it is far more cost-eff ective and meaningful to focus on the ability of Indonesia’s health facilities to diagnose, treat, and manage chronic cardiovascular conditions at the primary care level. In addition to cardiovascular conditions, the policy note also assesses service availability and readiness of Indonesia’s primary care facilities to provide care for two additional prominent NCDs in the country: DM and chronic respiratory diseases (CRDs).

4.1 General Service Readiness

Th e WHO SARA framework includes two domains: general service readiness and specifi c service readiness for specifi c diseases/conditions such as DM, cardiovascular conditions, and chronic respiratory care. General service readiness encompasses the basics required to provide any medical service, such as availability of water and a private room for consultations.

Almost all Puskesmas in Indonesia had electricity and a private room for consultations. Basic communications such as telephones were present in 84 percent of Puskesmas, but computers with internet access were much less common, available only in 16 percent of Puskesmas (Figure 6).

Th ere is a nearly twofold variation between provinces with the lowest and highest general service readiness. In Papua, the mean basic amenities index was 46 percent compared with 89 percent for DI Yogyakarta (Figure 7).16 As almost all Puskesmas had electricity and a private room, most of the diff erences between provinces appear to be driven by the availability of water, toilets, basic communications, and referral transportation. As the primary role of Puskesmas in the management of NCDs is to provide a comfortable place for outpatient medical consultations, the near universal availability of electricity and a private room was encouraging.

16 Th e index is the average of available indicator divide by minimum indicator’s required; for example, the basic amenities index in province A was 50 percent, meaning that on average health centers in province A only had half of the stipulated minimum indicators.


27

FIGURE 6: BASIC AMENITIES IN PUSKEMAS IN INDONESIA

Source: Rifaskes (2011)

FIGURE 7: AVAILABILITY OF BASIC AMENITIES AT PUSKESMAS BY PROVINCE


Transportation

Computer + internet

Communication

Toilets

Private room

Water and sanitation

Electricity

82.4

16.4

83.8

74.4

99.8

71.8

97.9

Puskesmas has each component (%)

0 10 20 30 40 50 60 70 80 90 100

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Perc

ent

Hea

lth

Cent

er H

as E

ach

Com

pone

nt

Province

Basic amenities indexToilete

ElectricityCommunication

Water and sanitationComputer+internet

Private roomTransportation


28

4.2 Human Resources for Health

Th e Rifaskes census, which was not intended to specifi cally explore issues related to human resources for health (HRH), nevertheless includes several questions on the numbers and qualifi cations of staff working at the health facility as well as in-service training received. Th is information has been leveraged using the SARA framework in order to inform service readiness. However, it should be noted that additional dimensions – that is, provider ability (e.g., knowledge) and provider eff ort (e.g., presence at the health facility) – are not included in the Rifaskes census.

Complementary work on HRH focuses on human resource inputs as well as some measure of health provider ability (using health cases or vignettes, covering prenatal care, child curative care, and adult curative care) from the 1997 and 2007 Indonesian Family Life Survey.17 Regarding adult curative care, of closest relevance to NCDs, the HRH study fi nds that over the 10 years from 1997 to 2007, ability scores have generally increased, that public providers have marginally higher scores than private providers, and that ability scores are marginally higher in urban compared with rural areas.

4.3 Diabetes Mellitus

DM, a prominent chronic NCD, occurs when the body does not produce enough insulin (Type 1 DM) or the body is not able to eff ectively use the insulin that is produced (Type 2 DM).18 Th e result is raised blood sugar levels that, over time, damage nerves and blood vessels. Globally, 6.4 percent of the population aged 20-79 is estimated to be diabetic.19 Th ere are no known preventive interventions for Type 1 DM, treatment of which requires insulin therapy; however, Type 2 DM – which accounts for 90% of all DM cases globally – can be prevented with weight management, physical activity, and a healthy diet. Of particular relevance to Indonesia, where the prevalence of undernutrition is high, there is an established association between low birth weight and Type 2 DM.20 Th e management of Type 2 DM and its complications involves lifestyle adjustments, oral medication, and/or insulin injections.

DM is ranked as the eighth highest cause of the overall disease burden in Indonesia, accounting for 3.5 percent of DALYs in 2010 (Table 1).21 Th e burden of DM in Indonesia has more than doubled over the past 20 years (Figure 8). High fasting glucose levels as a risk factor accounted for 4.7 percent of all DALYs in the same year, while related risk factors – dietary risks, physical inactivity, and high body-mass index – are also prominent in Indonesia (Table 2). Riskasdes data estimated the prevalence of diagnosed DM as 0.7 percent in Indonesia in 2007.22 Th e prevalence estimate was higher (1.1 percent)

17 World Bank. 2010. New Insights in to the Provision of Health Services in Indonesia: A Health Workforce Study. Washington, DC: World Bank18 Insulin is a hormone that regulates blood sugar.19 Shaw, JE, RA Sicree, and PZ Zimmet. 2010. “Global estimates of the prevalence of diabetes for 2010 and 2030.” Diabetes Research and Clinical Practice 87(1): 4-14.20 Taylor, A, AD Dangour, and K Srinath Reddy. 2013. “Only collective action will end undernutrition,” Lancet S0140-6736(13): 61084-3; De Boo, AH and JE Harding. 2006. “Th e developmental origins of adult disease (Barker hypothesis).” Australian and New Zealand Journal of Obstetrics and Gynaecology 46 (1): 4–14.21 A robust comparison or analysis of the risk factors and burden of NCDs is beyond the scope of this paper.22 Indonesia Basic Health Research (Riskesdas) is routine survey conducted by NIHRD-MoH every 3 years. Th e sample size is around 240.000 household and the data represented national level and provincial level


29

when including those who were untreated but reported symptoms of diabetes. Blood glucose tests among the urban population aged 15 years and older indicated a prevalence rate of 5.7 percent, with an additional 10.2 percent having impaired glucose tolerance.23 In the provinces of West Papua and North Sulawesi, more than a quarter of urban residents aged 15 years and older were either diabetic or had impaired glucose tolerance.

FIGURE 8: BURDEN OF DIABETES MELLITUS IN INDONESIA, 1990-2010

As summarized in Table 4, the supply-side implications for the diagnosis and treatment of DM at the primary care level were similar in both the government’s Puskesmas basic service standard guidelines and the WHO’s SARA toolkit, except that the former also specifi ed availability of glipizid as being essential for DM-related care at Puskesmas. As information on staff training received for NCDs was not captured in Rifaskes, the paper uses a proxy measure as to the proportion of Puskesmas that had at least one doctor on staff .

23 Impaired glucose tolerance (and the related impaired fasting glycaemia) is an early stage of DM, where the formal diagnostic criteria have not been fully met.

Source: IHME (2013)

Shar

e of

DAL

Ys lo

st (%

)

Year

1990 1995 2000 2005 20101.5

2.0

2.5

3.0

3.5


30

TABLE 4: SUPPLY-SIDE IMPLICATIONS FOR PROVISION OF DM-RELATED CARE AT THE PRIMARY LEVEL

Domain WHO SARA guidelines (2012)Diabetes guidelines for

Puskesmas (2013) & essential drugs list (2011)

Indicators used for assessment

Staff & Training

• National guidelines available for diabetes diagnosis and treatment

• At least one staff member trained in diagnosis and treatment of diabetes in previous two years.

• Guidelines for diabetes diag-nosis and treatment

• Staff trained in diabetes diag-nosis and treatment.

• At least one doctor on staff at Puskesmas.

Equipment • Blood pressure apparatus (digital blood pressure machine or man-ual sphygmomanometer with stethoscope)

• Adult scale• Measuring tape• Height board/stadiometre.

• Blood pressure apparatus• Stethoscope• Adult scale• Measuring tape• Height board/ stadiometre.

• Blood pressure apparatus• Stethoscope• Adult scale• Measuring tape.

Diagnostics • Blood glucose• Urine dipstick (protein)• Urine dipstick (ketones).

• Glucometer and strips• Urine dipstick.

• Blood glucose test• Urine test.

Medicines & Commodities

• Metformin cap/tab• Gilbenclamide cap/tab• Insulin injectable • Glucose injectable solution.

• Metformin cap/tab• Glibenclamide cap/tab• Glipizid.

• Metformin cap/tab • Gilbenclamide cap/tab• Glucose injectable solu-

tion.

Nationally, about 95.7 percent of all Puskesmas reported having a doctor on staff (94.8 percent of rural Puskesmas and 98.4 percent of urban Puskesmas). Across provinces, only in Papua was the availability of doctors at Puskesmas below a threshold level of 75 percent (Annex B).

Regarding basic equipment for DM-related care, analysis of Rifaskes data indicates that the availability of blood pressure apparatus, stethoscopes, and adult scales was excellent across the country: over 95 percent of all Puskesmas in the country reported all three key pieces of equipment being available.24 Th ere were no signifi cant diff erences in the availability of blood pressure apparatus, stethoscopes, and adult scales by type and location of Puskesmas: whether rural versus urban, with and without beds, and across provinces. Only in the province of Maluku did only 73 percent of the 103 Puskesmas without beds have blood pressure apparatus, the only subcategorical grouping of Puskesmas within any province for which the reported availability was less than the benchmark threshold of 75 percent. On the other hand, the availability of measurement tape, to estimate waist circumference, was low: only 59 percent of Puskesmas nationally reported having this.25 Only in two provinces (DI Yogyakarta and East Java) was the availability of measurement tape in Puskesmas greater than 75 percent.

24 Over 80 percent of all Puskesmas in the HFCS facility sample reported having blood pressure monitors and adult weighing scales and 68 percent reported having height measurement/stadiometre.25 A similar magnitude was reported in the HFCS facility sample.


31

TABLE 5: AVAILABILITY OF EQUIPMENT FOR DM-RELATED CARE AT PUSKESMAS

Type of Puskesmas Equipment for DM at Puskesmas

Blood pressure apparatus Stethoscope Adult scale Measuring tape

Rural Puskesmas 95.4% 99.0% 97.6% 58.8%

Urban Puskesmas 96.8% 99.6% 97.9% 58.5%

Puskesmas without beds 94.8% 98.9% 97.4% 59.0%

Puskesmas with beds 97.5% 99.5% 98.2% 58.2%

Indonesia 95.8% 99.1% 97.7% 58.7%


Th e diagnostic and monitoring capacity of Puskesmas was very low: only 54 percent of Puskesmas nationally reported being able to conduct blood glucose tests, which are crucial in the management of DM, and only 47 percent reported being able to conduct urine tests.26 Urban Puskesmas were far more likely to report having diagnostic capacity to conduct both blood glucose and urine tests for DM, although even among urban Puskesmas the share reporting availability was below the threshold value of 75 percent (Table 6). Th e availability (or lack thereof ) of blood glucose and urine tests was correlated across provinces: provinces with higher capacity to conduct blood glucose tests also had a generally higher capacity to conduct urine tests (Figure 9). In Gorontalo, Papua, West Papua, Southeast Sulawesi, Maluku, North Sulawesi, East Nusa Tenggara, and West Papua, less than 25 percent of all Puskesmas reported being able to conduct either blood glucose or urine tests. In Gorontalo and North Sulawesi, two provinces where the urban prevalence of diabetes was estimated to be around 8 percent for those 15 years of age or older, less than 20 percent of urban Puskesmas reported being able to conduct blood glucose and urine tests. DI Yogyakarta and East Java were the only two provinces where more than 75 percent of all Puskesmas were able to diagnose diabetes using blood glucose and urine tests.27

TABLE 6: PERCENT OF PUSKESMAS REPORTING AVAILABILITY OF BLOOD GLUCOSE AND URINE TESTS FOR DIABETES

Location Percent of Puskesmas

with blood glucose test with urine test

Rural 51.0% 43.0%

Urban 70.0% 64.0%

Indonesia 55.5% 48.0%


26 Th e Rifaskes questionnaire does not diff erentiate between the diff erent types of urine tests (e.g., for protein, ketones, or sug-ar). Almost all hospitals, on the other hand, reported being able to conduct urine tests.27 In a 2007 study of 252 Puskesmas and 20 private health centers in 8 provinces (DKI Jakarta, West Java, North Sumatera, West Sumatera, DI Yogyakarta, East Java, Bali, and South Sulawesi) found similar results with 82.0 percent of health centers reporting availability of blood glucose tests and 76.3 percent reporting urinary tests; in addition, a third of general physicians and 78.9 percent of other health personnel had not received any training in type 2 diabetes mellitus; see Widyahening, IS and P Soewondo. 2012. “Capacity for management of type 2 diabetes mellitus in primary health centers in Indonesia.” Journal of Indonesian Medical Association 62(11): 439-443.


32

FIGURE 9: AVAILABILITY OF BLOOD GLUCOSE AND URINE TESTS IN PUSKESMAS BY PROVINCE

Regarding medicines and commodities related to DM, about 80 percent of all Puskesmas nationally reported having glucose injectable solution, used to treat low glucose levels occasionally caused by treatment. Rifaskes did not collect information on availability of oral diabetic medications such as metformin or glibenclamide, or injectable insulin at the Puskesmas level. In the HFCS facility sample, only about half of all Puskesmas reported having metformin, while glibenclamide was available in almost 90 percent of all Puskesmas in the sample.28

4.4 Cardiovascular Conditions

Relevant cardiovascular conditions for Indonesia include hypertension, coronary heart disease, cerebrovascular diseases, and peripheral arterial disease. In addition to genetic dispositions, risk factors for cardiovascular conditions include unhealthy diets, physical inactivity, and smoking. As a result, individuals often exhibit “intermediate” risk factors such as hypertension, DM, high total cholesterol, and high body mass index. Prevention and treatment of hypertension, DM, and high total cholesterol – in addition to lifestyle change interventions – are key in preventing and managing these cardiovascular conditions. Although, as mentioned earlier, the SARA framework does not generally diff erentiate individual diagnoses like hypertension and hypercholesterolemia, but instead focuses on a cluster of conditions – without disaggregating service indicators by diagnoses – for the purposes of this report, three common diagnoses are highlighted: (i) hypertension (the main focus, due to relevance to Indonesia and availability of data), (ii) coronary artery disease (which can result in a “heart attack” or myocardial infarction), (iii) congestive heart failure, and (iv) hypercholesterolemia.

28 Th ese magnitudes are similar to those reported elsewhere for Indonesia; see: Cameron, A. 2013. Understanding Access to Medi-cines in Low and Middle-Income Countries through the use of Price and Availability Indicators. Utrecht: Gildeprint Drukkerijen.

Urine testBlood glucose test

Perc

ent o

f pus

kesm

as (%

)

100

80

60

40

20

0


33

Hypertension (i.e., high blood pressure) is defi ned as systolic blood pressure equal to or above 140 mm Hg and/or diastolic blood pressure equal to or above 90 mm Hg. Normal levels of blood pressure are essential for effi cient functioning of organs and body functions. Although some hypertensive people exhibit symptoms such as headaches, dizziness, palpitations, and nose bleeds, most people with hypertension do not exhibit any symptoms at all, making regular screening essential for detection and control. Th e WHO estimates that globally about 40 percent of all adults over the age of 25 suff er from hypertension.29 Unhealthy diets (including diets high in salt and fat, and diets low in fruits and vegetables), physical inactivity, and stress are prominent lifestyle risk factors for hypertension. Genetic factors can play a role, and hypertension can also be a result of other conditions such as during pregnancies and due to endocrine dysfunctions. Untreated hypertension increases cardiovascular risk and is a major risk factor for stroke as well as for ischemic heart disease.30

Th e prevalence of primary hypertension is high in Indonesia.31 Th e national prevalence of hypertension among adults aged 18 years or older was estimated to be 31.7 percent in 2007.32 Th ere was a wide variation in the prevalence of hypertension across provinces in the country: West Papua and Papua had generally lower prevalence rates, while South Kalimantan and East Java had higher prevalence rates (Figure 10). An estimated 10 percent of the overall burden of disease and 370,314 deaths were attributable to high blood pressure in Indonesia in 2010.

WHO SARA guidelines recommend that, in order for facilities to be able to diagnose and treat chronic cardiovascular conditions: (i) at least one staff member in the facility should have received training for diagnosis and treatment of chronic cardiovascular conditions in the previous two years, and national guidelines for the diagnosis and treatment of chronic cardiovascular conditions be available at the facility; (ii) health facilities should have, at the minimum, stethoscopes, functional digital blood pressure machines or manual sphygmomanometers with stethoscopes, and adult scales; as well as (iii) angiotensin converting enzyme (ACE) inhibitors, thiazides, beta blockers, calcium channel blockers, aspirin, metformin, and oxygen.

Hypertension medications as specifi ed in the basic treatment guidelines for Puskesmas and in the formulary include: hydrochlorothiazide, reserpine, propranolol, captopril, and nifedipine. Guidelines for Puskesmas also specify that each facility should have “blood pressure apparatus”.33 Th e guidelines furthermore mention that treatment of chronic cardiovascular conditions includes management of hypertension and heart failure. In addition, the National Guideline for Controlling Risk Factors of Cardiovascular Diseases includes coronary artery disease for treatment in Puskesmas.

29 WHO. 2013. A Global Brief on Hypertension: Silent Killer, Global Public Health Crisis. Geneva: World Health Organization.30 Ibid.31 “Primary” hypertension is defi ned as hypertension that is not the result of some other underlying condition; in case of the latter, the term “secondary” hypertension is used.32 NIHRD. 2009. Report on Result of National Basic Health Research 2007. Jakarta: National Institute of Health Research and Development, Ministry of Health. 33 MOH. 2007. Guideline for Basic Medical Intervention at Health Center, Ministry of Health


34

FIGURE 10: HYPERTENSION PREVALENCE AMONG ADULTS AGED 18+ YEARS BY PROVINCE IN INDONESIA, 2007

While diagnosis of coronary artery disease (CAD) may rely mostly on symptoms and simple equipment such as blood pressure apparatus and stethoscopes, confi rmation of CAD requires referral to secondary care facilities. However, it is expected that primary providers, including Puskesmas, can provide emergency measures if a cardiovascular event is suspected. Isosorbide dinitrate, aspirin, nitroglycerine, and diltiazem are used for anginal attack in CAD before referral. With reference to congestive heart failure, digoxin and furosemide are commonly used for managing mild congestive heart failure on an ambulatory basis. Th ese additional drugs have been added to the list of specifi c service-readiness guidelines summarized in Table 7.

Indonesia national prevalence 31.7%

Prev

alen

ce (%

)

40

30

20

10

0


35

TABLE 7: SUPPLY-SIDE IMPLICATIONS FOR PROVISION OF CARDIOVASCULAR CONDITIONS AT THE PRIMARY LEVEL

Domain WHO SARA guidelinesCardiovascular guidelines

for Puskesmas (2013) & essential drugs list (2011)


Staff & Training • National guidelines available for diagnosis and treatment of chronic cardiovascular condi-tions

• At least one staff member trained in diagnosis and man-agement of chronic cardiovas-cular conditions in previous two years.

• Guidelines for cardiovascular diagnosis and treatment

• Staff trained in cardiovascular diagnosis and treatment.


Equipment • Stethoscope• Blood pressure apparatus• Adult scale.

• Stethoscope• Blood pressure apparatus• Adult scale.

• Stethoscope• Blood pressure apparatus• Adult scale.

Diagnostics -- -- --


• ACE inhibitor (e.g., enalapril)• Thiazides• Beta blockers (e.g., atenolol)• Calcium channel blockers (e.g.,

amlodipine)• Aspirin• Metformin• Oxygen cylinders or concentra-

tors.

• ACE inhibitors (captopril)• Thiazides (hydrochlorothia-

zide)• Beta-blocker (atenolol, pro-

pranolol)• Calcium-channel block-

ers(nifedipine)• Aspirin• Diltiazem• Amlodipine• Furosemide• Isosorbid dinitrate• Nitroglycerine• Digoxin• Simvastatin.

• ACE inhibitor (captopril)• Thiazide (hydrochlorothi-

azide)• Beta blocker (propranolol)• Calcium channel blockers

(nifedipine)• Metformin• Oxygen.

Rifaskes data indicate a generally strong readiness among most Puskesmas in Indonesia to diagnose and treat primary hypertension. Over 95 percent of all puskemas nationally reported having functional blood pressure apparatus, over 99 percent reported having a stethoscope, and 84 percent reported the availability of captopril, a common (but not the only) medication for treating hypertension.34 Availability was high even in rural Puskesmas: while 86 percent of urban Puskesmas reported availability of captopril, the corresponding number for rural Puskesmas was 83 percent (Table 8). Nevertheless, some provincial-level defi ciencies were signifi cant, especially with regard to reported availability of captopril: for example, less than 75 percent of Puskesmas in West Sulawesi, Maluku, Papua, East Nusa Tenggara, North Maluku, and Central Sulawesi reported availability of captopril (Table 8).

34 WHO reported the availability of captopril in Indonesia in 2004 as 33 percent (Originator) and 93 percent (Generics) in public sectors; For more details see: WHO. 2006. Gelders S, Ewen M, Noguchi N, Laing R. Price, availability and aff ordabil-ity. An international comparison of chronic disease medicines. Cairo: World Health Organization Regional Offi ce for the Eastern Mediterranean; Captopril was available in over 95 percent of the hospitals in Indonesia.


36

TABLE 8: PROVINCES WITH <75% OF ALL PUSKESMAS REPORTING CAPTOPRIL AVAILABILITY

Province Proportion of Puskesmas reporting availability of captopril

Total Rural

West Sulawesi 50.0% 51.4%

Maluku 63.1% 59.3%

Papua 66.6% 63.1%

East Nusa Tenggara 70.4% 70.6%

North Maluku 74.0% 68.5%

Central Sulawesi 74.1% 72.1%

Indonesia 83.8% 83.1%


Additional data on medications was extracted from HFCS in order to provide a picture of drug availability for other cardiovascular diagnoses. With regard to congestive heart failure (there is some overlap or dual-use of drugs with hypertension), data shows that furosemide was available in 84 percent of Puskesmas, isosorbide dinitrate in 60 percent, digoxin 72 percent, furosemide 83 percent, thiazide 79 percent, nifedipine 60 percent, isosorbide dinitrate 60 percent, propanolol 52 percent, and diltiazem 22 percent. Regarding hypercholesterolemia, HFCS data shows that simvastatin is available in 36 percent of Puskesmas and higher in urban (50 percent) than rural Puskesmas (27 percent). It is more available in the Java-Bali (42 percent) region than non-Java-Bali regions (32 percent). Although the ability to conduct cholesterol screening was not included in either the WHO’s SARA guidelines or in Indonesia’s national cardiovascular guidelines, it is notable that nationally only about 35 percent of Puskesmas report being able to conduct cholesterol screening tests (31 percent of rural Puskesmas and 44 percent of urban Puskesmas reported being able to do so). Less than 10 percent of Puskesmas in the provinces of Maluku, Gorontalo, East Nusa Tenggara, Southeast Sulawesi, and Papua reported being able to test for cholesterol.

4.5 Chronic Respiratory Conditions

Chronic respiratory diseases – asthma, chronic obstructive pulmonary disease (COPD), and other diseases of the airways and lung structures – are another growing NCD challenge; Asthma and COPD accounted for an estimated 1.0 percent and 2.6 percent of all DALYs lost in 2010 in Indonesia (up from 0.8 percent and 1.7 percent, respectively, in 1990) (Table 9). Riskesdas estimated the national prevalence of asthma to be 3.5 percent in 2007, with the provinces of Gorontalo, Central Sulawesi, West Papua, and South Kalimantan having prevalence rates in excess of 5.0 percent of the population.

TABLE 9: SHARE OF DALYS LOST FROM CHRONIC RESPIRATORY DISEASES IN INDONESIA, 1990-2010

Disease/condition Share of DALYs lost

1990 2000 2010

Chronic respiratory diseases 3.4% 4.2% 4.7%

Asthma 0.8% 1.0% 1.0%

COPD 1.7% 2.2% 2.6%

Source: IHME (2013)


37

Several risk factors for chronic respiratory diseases – including smoking as well as household air pollution – are prominent in Indonesia (Table 2). Th e prevalence of smoking among males in Indonesia is particularly high: the latest 2011 Global Adult Tobacco Survey (GATS) estimated that two out of every three adult Indonesian males smoked tobacco (versus only 2.7 percent of adult females) and this ratio has been increasing over time.35 Th e prevalence of smoking was generally higher in rural areas: 37.7 percent of all adults smoked in rural areas versus 31.9 percent in urban areas. Kretek cigarette smoking was especially popular in the country, and is the dominant modality of tobacco consumption in both urban and rural areas. Exposure to second-hand smoke was also a large problem in the country: 51.3 percent of adults who worked indoors and 78.4 percent of adults at home reported being exposed to second-hand smoke.36

Table 10 summarizes the supply-side implications for provision of chronic respiratory disease-related care at the primary level derived from SARA and the Puskesmas guidelines. Facility data were available to assess the availability of stethoscopes, salbutamol, prednisone or prednisolone, and oxygen in Puskesmas across the country.

TABLE 10: SUPPLY-SIDE IMPLICATIONS FOR PROVISION OF CHRONIC RESPIRATORY DISEASE-RELATED CARE AT THE PRIMARY LEVEL

Domain WHO SARA guidelinesPuskesmas guidelines for

CRD (2011) & essential drugs list (2011)6


Staff & Training • At least one staff received training in the diagnosis and management of chronic respiratory diseases in the last two years

• National guidelines available for the diagnosis and management of chronic respiratory diseases.

Minimum competency level defi ned.


Equipment • Stethoscope• Peak fl ow meter• Spacers for inhalers.

-- • Stethoscope.

Diagnostics -- • Hemoglobin. --


• Salbutamol inhaler• Beclomethasone inhaler• Prednisolone cap/tabs• Hydrocortisone cap/tabs• Epinephrine injectable• Oxygen concentrators or cylinders.

• Salbutamol• Prednisolone cap/tabs• Epinephrine injectable• Oxygen• Terbutaline• Aminophylline• Bronchodilators.

• Salbutamol• Prednisolone• Prednisone • Amenophylline• Oxygen.

35 GATS 2011.36 Ibid.


38

In general, at the national level, the availability of the selected indicators appeared to be good: 99 percent of Puskesmas reported having stethoscopes; and over 75 percent of all Puskesmas reported having salbutamol, prednisolone, and oxygen.37 Again, some provincial-level defi ciencies were notable: for example, in the provinces of Central Sulawesi, West Sulawesi, and Papua, less than 75 percent of Puskesmas reported availability of salbutamol and prednisolone. HFCS data shows that prednisolone was available in more than 94 percent of Puskesmas. In addition salbutamol was available in 76 percent of Puskesmas, but aminophylline (another bronchodilator) was available in 90 percent of Puskesmas.

37 Oxygen was relevant only for Puskesmas with beds, with 80.7 percent of 5,639 Puskesmas with beds reported availability.

CONCLUSIONS


40

5. Conclusions

Indonesia is currently in the midst of major reforms of its health system that, have resulted in the institutionalization of one of the largest single-payer UHC programs in the world. At the same time, the country is undergoing a rapid epidemiological transition and NCDs are now the dominant share of the overall disease burden in the country. Indonesia faces several challenges to eff ective implementation of UHC in terms of expanding the breadth, height, and depth of coverage, especially in addressing NCDs that are generally chronic in nature and require careful disease management over time. Given this backdrop, this policy note has outlined a framework for assessing the “eff ective depth” of coverage in terms of supply-side readiness to diagnose and manage key tracer NCD conditions at the public primary care level: DM, cardiovascular conditions, and chronic respiratory conditions.

Regarding supply-side readiness, although DM is the eighth (and rising) cause of the overall disease burden in Indonesia, the service readiness for basic diagnosis and basic treatment of DM is limited. For example, only 70 percent of urban Puskesmas (where the prevalence of DM is higher) could conduct a blood glucose test for the diagnosis and monitoring of DM. In rural Puskesmas, this readiness indicator declined to 51 percent nationwide and in some provinces, such as Gorontalo, Papua, Southeast Sulawesi, Maluku, North Sulawesi, and West Papua, less than 20 percent of Puskesmas fulfi lled this indicator. Basic pharmaceutical treatment for DM is more encouraging, with 90 percent of Puskesmas stocking glibenclamide but only 48 percent stocking metformin.

As over 95 percent of Puskesmas reported the availability of functioning blood pressure apparatus and over 99 percent reported the same of stethoscopes, most Puskesmas have the necessary equipment to diagnose hypertension. Th e availability of medical treatment for hypertension using captopril, a commonly used antihypertensive medication in Indonesia, is fair. Nationwide, 84 percent of Puskesmas stocked this medication, although defi ciencies were notable in rural Puskesmas in provinces such as West Sulawesi, Maluku, and Papua, where captopril was available in less than 70 percent of Puskesmas. Furthermore, in the case of hypercholesterolemia, only a third of Puskesmas nationally reported the ability to conduct cholesterol tests and only 36 percent reported the availability of simvastatin, a common treatment for hypercholesterolemia.

In the case of chronic respiratory diseases such as asthma, over 75 percent of all Puskesmas reported the availability of basic treatments such as salbutamol, prednisolone, and oxygen. Th ere are geographic variations, with less than 75 percent of Puskesmas in Central Sulawesi, West Sulawesi, and Papua reporting availability of salbutamol and prednisolone.

A basic index of NCD service readiness indicators can be constructed by combining all available NCD-related service readiness indicators. To construct this, the mean availability (or “score”) of all available NCD-related service readiness indicators was calculated. Next, the mean of all these scores was calculated for all facilities. Each indicator and each facility was weighted equally, as there is no available valid method at the moment for meaningfully weighting each individual indicator, and there is not enough information for the population catchment coverage of each facility to generate population weights


41

(as is done for Service Delivery Indicators). Using this basic methodology, provincial-level NCD service readiness can be mapped (Figure 11), revealing that in the eastern part of the country and representing 15 percent of the country’s total population and almost a fi fth of all of Indonesia’s poor and near-poor residents (in North Sumatera, Bengkulu, East Nusa Tenggara, North Sulawesi, Central Sulawesi, Southeast Sulawesi, Gorontalo, West Sulawesi, Maluku, North Maluku, West Papua, and Papua) there are substantial defi ciencies (using an index of 75 as the cut-off ) in NCD service provision. Of these, provinces with the lowest levels of NCD supply readiness were Papua, West Papua, and Maluku (Annex B).

FIGURE 11: NCD SERVICE READINESS INDICATOR INDEX, BY PROVINCE, 2011

FIGURE 12: PREVALENCE OF DIABETES, BY PROVINCE (RISKASDES, 2007)

NCD index

[0,65]

[65,75]

[75,85]

[85,100]

Source: Rifaskes 2011

NCD supply-side readiness index, by province

Diabetes prevalence (%)

[0,5]

[5,10]

[10,15]

[15,20]

Source: Riskesdas 2007

Diabetes prevalence, by province


42

NCD supply readiness is correlated to economic indicators: richer provinces with generally lower poverty rates also tended to have better NCD supply readiness, although there are some exceptions to this (Figure 12). Provinces with relatively poor NCD supply readiness (NCD index < 75%) also tended to be those where distances to hospitals was higher than the national average and the availability of HRH was low, indicating broader problems related to service delivery and not just for NCDs.

FIGURE 13: NCD SERVICE READINESS INDICATOR INDEX VS. SELECTED ECONOMIC INDICATORS (PROVINCIAL-LEVEL)

Defi ciencies appear not to be a problem at the hospital level across all provinces in Indonesia (Annex B), at least based on the indicators that were available for NCD tracers from the hospital census. In addition, it is important to note that this analysis is limited to government facilities, but in reality, private primary care providers play a large and increasing role. Th ere is no systematic information about service readiness in the private sector. Although it may not be representative of all private primary care providers, analysis of the profi les of family doctors both in the Askes and Jamsostek programs would help to provide some understanding of the service readiness of private providers.

NCD

sup

ply-

read

ines

s in

dex

0=Lo

wes

t 1

00=H

ighe

st

Source: NCD supply: Rifaskes,2011; Economic Indicators: Susenas 2010; Poverty rate: BPS (Central Bureau of Statistics), 2010

Poverty rate (%)Annual per capita consumption (’000s IDR)

NCD

sup

ply-

read

ines

s in

dex

0=Lo

wes

t 1

00=H

ighe

st

50.00 60.00 70.00 80.00 90.00 100.0050

60

70

80

90

100

0.00 10.00 20.00 30.00 40.0050

60

70

80

90

100

DI Yogyakarta

Central JavaEast Java

BaliDI Aceh

Bengkulu

East Nusa Tenggara

Papua

Maluku

West Papua

North SulawesiGorontalo

Indonesia

DI Yogyakarta

Central JavaEast Java

BaliDI Aceh

Bengkulu

East Nusa Tenggara

PapuaMaluku

West Papua

North Sulawesi

Gorontalo

Indonesia

POLICY IMPLICATIONS


44

6. Policy Implications

Th e analysis reported in this policy note underscores that in order to attain UHC there needs to be a focus not just on increasing the breadth and height but also in ensuring that eff ective depth of coverage exists, especially in the rural and remote areas of the country and at the primary care level. It is not enough to specify a comprehensive benefi t package on paper if facilities do not have the basic supply-side readiness conditions to be able to provide key services.38 In addition to identifying where and along what dimensions the key supply-side defi ciencies exist, it is also important to better understand why this is the case. Some policy implications to ensure this are summarized below.

Understand Why Supply-Side Defi ciencies Exist. Th e analysis above has utilized Rifaskes and other facility data to demonstrate where some of the defi ciencies in supply-side readiness exist at the public primary care level in Indonesia and looked at some broad province-level correlates. One key next step would be to gain a better and more systematic understanding of why these defi ciencies exist and what can be done to overcome them. Are supply-side defi ciencies a result of data collection and reporting defi ciencies, lack of fi nancing, information fl ow issues, and/or other forms of implementation challenges? In this regard, proposed provincial consultations and analytical work related to assessment of public fi nancial fl ows at diff erent levels of government (central, provincial, district) and health facilities could provide an excellent opportunity to help fi ll in some of the gaps.

Leverage Demand-Side Financing to Improve Service Readiness at Facilities. At the primary care level, where the predominant provider payment method for health facilities is capitation, this payment should be linked directly or indirectly to the attainment of minimum standards analogous to the accreditation of private facilities. Although the expediency with which the government is expanding geographic coverage using public facilities is understandable, the insurance administrator could assess public facilities in order to signal to local governments where investments are required. Initial standards could start at a basic level and rise as the program develops, with the credible threat that facilities could be deregistered from the program if standards are not met, thus allowing and incentivizing facilities to upgrade their service readiness. As fi nancing gradually shifts from supply-side to demand-side, an appropriate level of autonomy for health facilities, coupled with enhanced managerial capacity to manage revenues, would need to be found for public health facilities. At the secondary level, DRG-related payments could be made conditional on the adequacy of services provided in order to encourage investments in improving service readiness. As the health system evolves, additional measures to mitigate negative incentives inherent in capitation systems – such as over and inappropriate referral to secondary care and undertreatment – are likely to be required.

38 Indonesia is not alone in this regard. In general, there are clear defi ciencies in the supply-side readiness of primary care facil-ities in providing NCD-related care across most low- and middle-income countries. See: WHO. 2010. Global Status Report on Non-Communicable Diseases. Geneva: World Health Organization.


45

Clarify Supply-Side Implications of Benefi t Package. As the analysis reported in this policy note indicates, it is not enough to specify a benefi t package on paper; in moving forward to implementing UHC, Indonesia needs to ensure that there are clear supply-side implications that are derived from the specifi cation of the unifi ed BPJS Kesehatan benefi t package, in terms of what equipment, training, diagnostic capabilities, and medicines are to be provided at diff erent levels of care and to clearly specify accountabilities for this provision. In this regard, BPJS may want to reconsider its plans for automatic accreditation of public facilities and to consider an independent accreditation process for public facilities as the program develops.

Improve Socialization of Benefi t Entitlements. Eff ective implementation of UHC will also require patients to be clear as to what benefi ts they are entitled to, and providers to be clear as to the minimum requirements for provision of services. For NCDs, Indonesia does have comprehensive guidelines in place; the issue is more of ensuring that these guidelines are widely disseminated to and internalized by providers. An electronic form of disseminating the latest clinical guidelines for NCDs (and other conditions) may hence be useful.

Regular Independent Monitoring and Evaluation of Supply Readiness. Th e MoH should consider institutionalized collection of regular and relevant facility-level data (from a sample of facilities, including private sector facilities, as the private sector contributes to a large proportion of health service provision) and ensure that the data collected refl ects national guidelines and norms and can help shed light not just on where the defi ciencies lie but also why they exist. Providers of traditional, complementary, and alternative therapy should also be considered for inclusion in the collection of health facility data, in order to capture the unique nuances of such providers, and to explore interrelations between these providers and allopathic providers. It is understood that preparations are currently underway by the MoH to conduct a follow-up health facility survey, which will complement a further Public Expenditure Tracking Survey of health facilities. Facility data collection should be independent and, ideally, separate from routine administrative data monitoring. If possible, data should also be collected from a sample of benefi ciaries to ensure that UHC service provision is occurring as intended and that patients are receiving the care they are entitled to. Th is will be especially critical over the period of expansion of UHC from 2014 to 2019.

Invest in Service Readiness for NCDs. In order for investments in the expansion of the breadth and height of UHC to be fully realized, the depth of coverage for NCDs needs to be addressed: to maximize effi ciency gains from the prevention and prudent management of these chronic diseases and conditions by minimizing their costly and harmful complications. Findings from this health facility survey and the additional surveys mentioned earlier should shed light on the appropriate balance of investments fl owing from the supply side versus fi nancing received from the demand side. However, regardless of the exact mechanism of fi nancing used, it should be noted that public health spending in Indonesia is comparatively low considering its economic status, and an expansion in public health fi nancing generally would be helpful, not only to ensure the long-term sustainability of BJPS Kesehatan, but also to improve the health and productivity of the Indonesian population.


46

Address Risk factors for NCDs Holistically. Although the scope of analysis provided in this paper is focused on facility service readiness, many of the risk factors for NCDs (summarized in Table 2), such as dietary risks, smoking, indoor air pollution, and physical inactivity, should be addressed through public health interventions beyond the confi nes of health facilities and indeed, beyond the health sector alone. Various cross-sectoral interventions will need to be considered – including taxation policy for tobacco, interventions to promote physical activity at schools and in the workplace, the designs of urban spaces, and environmental and energy policy.

ANNEXES


48

ANNEX A

Rifaskes HFCS

Year of data collection 2011 2010-11

Sampling National census of all Puskesmas and government general hospitals

Nationally representative survey (stratifi ed random sampling) in 15

provinces, 30 districts

Government hospitals 685 120

Private hospitals - 80

Number of Puskesmas, of which 9,005 (8,981 used for analysis) 234 (217 used for analysis)

Urban Puskesmas 2,364 82

Rural Puskesmas 6,617 135

Puskesmas with beds 3,052 90

Puskesmas without beds 5,929 127

Provincial7

DI Aceh 311

North Sumatera 506

West Sumatera 248

Riau 195

Jambi 171

South Sumatera 298

Bengkulu 173

Lampung 265

Bangka Belitung 57

Riau Island 65

DKI Jakarta 336

West Java 1031

Central Java 861

DI Yogyakarta 121

East Java 949

Banten 206

Bali 114

West Nusa Tenggara 149

East Nusa Tenggara 302

West Kalimantan 233

Central Kalimantan 176

South Kalimantan 217

East Kalimantan 213

North Sulawesi 167

Central Sulawesi 163

South Sulawesi 406

Southeast Sulawesi 233

Gorontalo 74

West Sulawesi 81

Maluku 161

North Maluku 101

West Papua 104

Papua 294


49

AN

NEX

B

Prov

ince

Equi

pmen

tD

iagn

osti

csM

edic

ines

& C

omm

odit

ies

NCD

in

dex

Pusk

esm

asAt

leas

t on

e do

c-to

r

Bloo

d pr

essu

re

appa

ratu

s

Stet

ho-

scop

eAd

ult

scal

eM

easu

r-in

g ta

pe

Bloo

d gl

ucos

e te

stU

rine

test

Glu

cose

in

ject

able

so

lutio

nCa

ptop

ril

Oxy

gen

Salb

u-ta

mol

Pred

niso

-lo

neAv

erag

e

DI A

ceh

98.7

%94

.9%

100.

0%98

.4%

41.8

%53

.7%

49.2

%83

.0%

81.4

%78

.6%

85.5

%85

.2%

77.4

%

Nor

th S

umat

era

95.1

%89

.7%

98.4

%94

.5%

44.4

%33

.8%

16.0

%76

.7%

85.0

%73

.6%

73.1

%80

.0%

69.6

%

Wes

t Sum

ater

a98

.8%

98.8

%10

0.0%

96.0

%60

.9%

82.7

%68

.5%

75.0

%91

.5%

88.5

%89

.1%

93.5

%85

.9%

Riau

100.

0%95

.4%

100.

0%96

.4%

59.5

%60

.5%

56.4

%88

.2%

91.8

%91

.4%

85.6

%88

.1%

83.0

%

Jam

bi97

.7%

96.5

%98

.8%

98.2

%53

.8%

52.6

%60

.8%

86.5

%84

.7%

86.4

%61

.2%

94.1

%79

.4%

Sout

h Su

mat

era

91.9

%94

.3%

100.

0%97

.7%

57.4

%43

.6%

46.6

%82

.2%

91.9

%86

.6%

85.9

%78

.5%

78.6

%

Beng

kulu

96.5

%98

.3%

100.

0%99

.4%

54.9

%27

.2%

16.2

%83

.2%

79.2

%82

.5%

81.5

%85

.0%

73.4

%

Lam

pung

100.

0%91

.3%

99.2

%98

.9%

64.4

%49

.8%

43.0

%80

.8%

87.5

%75

.0%

76.6

%92

.8%

78.1

%

Bang

ka B

elitu

ng10

0.0%

100.

0%10

0.0%

96.5

%57

.9%

57.9

%56

.1%

80.7

%87

.7%

90.0

%82

.5%

93.0

%82

.0%

Riau

Isla

nd10

0.0%

93.8

%10

0.0%

98.5

%49

.2%

64.6

%60

.0%

95.4

%92

.3%

83.3

%86

.2%

95.4

%83

.5%

DKI

Jaka

rta

98.8

%10

0.0%

100.

0%10

0.0%

64.4

%76

.1%

65.2

%76

.1%

82.6

%71

.7%

80.4

%91

.3%

82.5

%

Wes

t Jav

a98

.0%

97.5

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-

(Foo

tnot

es)

1 M

inist

ry o

f Hea

lth D

ecre

e 41

6 (2

011)

on

Hea

lth S

ervi

ce T

ariff

s for

Mem

bers

of A

skes

2 M

inist

ry o

f Hea

lth D

ecre

e 40

(201

2) o

n G

uide

lines

for t

he Im

plem

enta

tion

of th

e Ja

mke

smas

Pro

gram

3 Pr

esid

entia

l Dec

ree

No.

12

Year

201

3 on

Hea

lth In

sura

nce

4 BJ

PS K

eseh

atan

mem

bers

regi

ster a

t a p

rimar

y ca

re fa

cilit

y of

thei

r cho

ice,

whi

ch p

lays

a g

ate-

keep

er ro

le fo

r ref

erra

ls to

seco

ndar

y ca

re. Th

e sy

stem

can

onl

y be

byp

asse

d in

the

case

of

em

erge

ncie

s (in

clud

ing

to n

on-e

mpa

nelle

d fa

cilit

ies)

or i

f the

mem

ber i

s out

statio

n. N

on-e

mpa

nelle

d fa

cilit

ies a

re re

imbu

rsed

on

‘repl

acem

ent c

osts’

for e

mer

genc

y tre

atm

ent o

f BPJ

S K

eseh

atan

mem

bers

.5

Th e

Min

istry

of H

ealth

is m

anda

ted

to c

ondu

ct H

ealth

Tec

hnol

ogy

Asse

ssm

ents

(HTA

s) a

nd p

rovi

de c

linic

al g

uide

lines

6 In

the

Pusk

esm

as g

uide

lines

(200

7) th

e ro

le o

f Pus

kesm

as is

to d

iagn

ose

“clin

ical

CO

PD”,

whi

le it

s sev

erity

defi

ned

at h

ighe

r lev

el u

sing

spiro

met

er. Th

us,

Pusk

esm

as w

ill g

ive

simpl

e tre

atm

ent,

if sy

mpt

oms p

ersis

t the

pat

ient

or c

linic

al a

sses

smen

t sho

ws i

t is s

ever

e C

OPD

the

patie

nt sh

ould

be

refe

rred

.7

HFC

S da

ta is

repr

esen

tativ

e at

nat

iona

l and

stra

ta le

vel a

nd n

ot re

pres

enta

tive

at p

rovi

nce

leve

l.

supply-side readiness for universal health coverage€¦ · supply-side readiness conditions to be...

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