indonesia’s health sector review · updated june 2012 indonesia’s health sector review 1...

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OVERVIEW

D A T A , G R A P H S A N D T A B L E S

U P D A T E D J U N E 2 0 1 2

Indonesia’s Health Sector Review

1

Background2

The WB received requests for electronic copies of the various charts, tables andgraphs included in the reports and papers produced for the Indonesia HealthSector Review

In response, this synthesis report has been created. It includes the key charts,tables and graphs that can be downloaded

This is a living document and updates will be inserted when new data becomeavailable

This document does not summarize all the work that was carried out, rather itincludes mainly the data and graphs. For summaries and details please refer tothe documents listed in the annex. Each slide includes the source document foreasy reference

This review was put together by the World Bank Jakarta-based health teamincluding Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi,George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved inearlier versions.

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I n d o n e s i a ’ s h e a l t h s y s t e m p e r f o r m a n c e i s c h a l l e n g e d b y a c h a n g i n g e n v i r o n m e n t :O n g o i n g d e m o g r a p h i c a n d e p i d e m i o l o g i c a l t r a n s i t i o n s t h a t a r e l i k e l y t o i n c r e a s e d e m a n d a n d r e s u l t i n m o r e c o s t l y a n d m o r e d i v e r s e h e a l t h c a r e .A d d i t i o n a l p r e s s u r e w i l l c o m e f r o m e m e r g i n g d i s e a s e s a n d e p i d e m i c s s u c h a s H I V / A I D S , H 5 N 1 ( A v i a n I n f l u e n z a ) a n d H 1 N 1 ( S w i n e I n f l u e n z a ) .T h e i m p l e m e n t a t i o n o f L a w N o . 4 0 / 2 0 0 4 o n U n i v e r s a l H e a l t h I n s u r a n c e C o v e r a g e ( U H I C ) w i l l f u r t h e r i n c r e a s e d e m a n d a n d u t i l i z a t i o n .

3

Indonesia’s Dynamic Environment

Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.

4

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

Population in Thousands 2000

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

Population In Thousands 2025

MalesFemales

Source: BPS 2005.

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The demographic transition may provide a ‘demographic bonus’ in the short term if those coming of working age are employed…

5

Source: Adioetomo 2007.

Dependency ratio, 1950-2050

0

10

20

30

40

50

60

70

80

90

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

year

ratio

to

wor

king

-age

pop

ulat

ion

young

eldery

window of opportunity

demographic bonus

total

…but may also have serious implications for the delivery and financing of health care; doubling the need for care from aging alone.

6

World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.

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Although communicable disease remains a large burden, with the changing age structure disease patterns will shift to noncommunicable disease and injuries, increasing and diversifying the demand for health care further.

0

10

20

30

40

50

60

70

Perinatal / Maternal Communicable Disease Non-communicableDisease

Injuries

SKRT'95

SKRT'01

Riskesdas07

Source: Riskesdas Survey 2007.

7

Changes in Burden of Disease in Indonesia

The obesity rate is rising and increased prevalence of risk factors will change the burden of disease – increasing the need for preventive measures.

7.7

29

23.6

15.7

15

16.8

17.8

19.9

23.2

0 5 10 15 20 25 30 35

Male

Females

Urban

Rural

Poorest

Quintile 2

Quintile 3

Quintile 4

Richest

Adult Obesity in Indonesia (%)

Source: Riskesdas Survey 2007.

8

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Increased need will demand more resources for health. Fortunately, despite the global economic crisis, the macroeconomic picture is still favorable.

World Bank. 2009. Giving More Weight to Health in Indonesia.

Pre-crisis forecast

Post-crisis forecast

45

67

8R

eal G

DP

gro

wth

rat

e

2003 2005 2007 2009 2011 2013year

Source : IMF

9

I n d o n e s i a ’ s h e a l t h s y s t e m p e r f o r m a n c e m e a s u r e d i n t e r m s o f h e a l t h o u t c o m e s , f i n a n c i a l p r o t e c t i o n , c o n s u m e r a w a r e n e s s a n d e q u i t y a n d e f f i c i e n c y i s m i x e d :

I n d o n e s i a s c o r e s h i g h l y o n r e d u c i n g c h i l d m o r t a l i t y b u t l o w o n r e d u c i n g m a t e r n a l m o r t a l i t y .

I n e q u i t i e s i n h e a l t h o u t c o m e s b e t w e e n i n c o m e l e v e l s a n d g e o g r a p h i c a r e a s a r e v e r y l a r g e a n d c o n s t i t u t e a m a j o r p r o b l e m f o r t h e h e a l t h s e c t o r o v e r a l l .

10

Health System Performance

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Indonesians live longer in 2010 and child mortality has fallen dramatically since the 1960s.

11

World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.

Life expectancy

Infant mortality

Under-five mortality

050

100

150

200

Infa

nt/u

nder

five

mor

talit

y ra

te

4050

6070

Life

exp

ecta

ncy

1960 1970 1980 1990 2000 2010year

Source : WDI 2009

But geographic inequities remain large: life expectancy varies between 60 in West Nusa Tenggara and 75 in Yogyakarta.

12


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Indonesia performs well in terms of infant mortality relative to other comparable health spending level countries but less well for its income.

13

World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.

China

IndiaLao PDR

Vietnam

Indonesia

Malaysia

ThailandBangladesh

Sri Lanka

Below average Above average

Bel

ow a

vera

geA

bove

ave

rage

Att

ainm

ent

rela

tive

to in

com

e

Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008

INFANT MORTALITY (2008)

Despite significant reduction in IMR over time, some neighboring countries have performed better.

14


Indonesia

China

Sri Lanka

Vietnam Thailand

India

525

100

250

Infa

nt m

orta

lity

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010Year

Source: WDI 2009Note: y-axis log scale

Infant mortality, 1960-2009

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And there are large inequalities between provinces and income levels.

15

0

20

40

60

80

100

120

DI Y

ogya

kart

a

Cen

tral

Jav

a

Cen

tral

Kal

iman

tan

DK

I Jak

arta

Bal

i

Eas

t Kal

iman

tan

Nor

th S

ulaw

esi

Eas

t Jav

a

DI A

ceh

Ban

gka

Bel

itung

Jam

bi

Ria

u

Wes

t Jav

a

Sou

th S

umat

ra

Sou

th S

ulaw

esi

Lam

pung

Ban

ten

Ria

u Is

land

s

Wes

t Kal

iman

tan

Wes

t Sum

atra

Sou

th-e

ast S

ulaw

esi

Wes

t Pap

ua

Pap

ua

Ben

gkul

u

Nor

th S

umat

ra

Cen

tral

Sul

awes

i

Gor

onta

lo

Nor

th M

aluk

u

Sou

th K

alim

anta

n

Eas

t Nus

a T

engg

ara

Wes

t Nus

a T

engg

ara

Mal

uku

Wes

t Sul

awes

i

Dea

th for

eve

ry 1

000

live

birth

Infant Mortality Child Mortality

Source: DHS 2007.

In fact, some of Indonesia’s provinces are at par with some of the best and worst performing countries.

16

World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.

West Sulawesi

North Maluku

Riau IslandsWest Java

DKI Jakarta

West Nusa Tenggara

West SumatraSouth SumatraRiau

East KalimantanDI Yogyakarta

Bangladesh

Cambodia

Papua New Guinea

Uganda

Ukraine

Zimbabwe

China

Congo, Rep.

India

Niger

San Marino

Timor-Leste

Tanzania

Vietnam

050

100

150

Infa

nt m

orta

lity

per

1000

live

birt

h

Indonesia Other countries Source: IDHS (2007) & WDI 2009

Infant mortality, 2008

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Indonesia also performs less well on maternal mortality for its income level in international comparisons.

17


Bangladesh

China

India

Lao PDR

Sri LankaVietnam

Indonesia

MalaysiaThailand


Bel

ow a

vera

geA

bove

ave

rage

Att

ainm

ent

rela

tive

to in

com

e

Attainment relative to health spending per capitaSource: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008

MATERNAL MORTALITY, 2008

And will need extra efforts to achieve the MDG of reducing maternal deaths by 75 percent by 2015.

The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.

18

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Underweight among children under five years of age has declined significantly…

19

6.3 7.211.6 10.5

8.1 7.5 6.3 8 8.3 8.6 8.85.4 4.9

31.2 28.3 2019

18.317.1 19.8

19.3 19.2 19.6 19.2

13 13

37.535.5

31.629.5

26.424.6

26.127.3 27.5 28.2 28

18.4 17.9

0

5

10

15

20

25

30

35

40

1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007 2010

Pe

rce

nta

ge

Moderate

Severe

Underweight

Source : Susenas 1989-2005, Riskesdas 2007-2010

…however, stunting rates, which are an indicator of chronic malnutrition, remain very high.

20

BangladeshChina

IndiaLao PDR

Sri Lanka

VietnamIndonesia

Thailand


Bel

ow a

vera

geA

bove

ave

rage

Attai

nmen

t re

lativ

e to

inco

me

Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008

Stunting Among Children under 5 years old, 2000-2009

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Health Spending Trends

By any measure Indonesia’s public spending on health is low and inequitably distributed:

Indonesia’s public health spending as a proportion of GDP has stagnated in recent years and compares unfavorably with other comparable income countries.

Indonesia’s Out-of-Pocket (OOP) spending is about average for its income level and has improved in recent years.

Indonesia does reasonably well on reducing catastrophic spending incidence but less well on health insurance coverage and equity.

Public spending on health is inequitably distributed across provinces and income quintiles.

21

Despite substantial increases in government health expenditures as a share of GDP over recent years, Indonesian governments barely spends 1 percent of GDP on health.

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

0

5

10

15

20

25

30

35

40

45

2001 2002 2003 2004 2005 2006 2007* 2008* 2009**

IDR

Tri

llion

s (c

onst

ant 2

00

7 p

rice

s)

Central Province District Share of GDP

22

Government health expenditures by level of government (2001-2009)

World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.

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12

Total and public health spending in Indonesia is low relative to other comparable income countries.

23


China

Cambodia

Lao PDR MalaysiaThailand

Vietnam

Samoa

Indonesia

05

1015

Tot

al H

ealth

Spe

ndin

g (%

GD

P)

100 250 1000 10000 25000GDP per capita

Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale

TOTAL HEALTH SPENDING VS INCOME, 2008

ChinaCambodia

Lao PDR

Malaysia

ThailandVietnam

Samoa

Indonesia

05

1015

Gov

ernm

ent

Hea

lth S

pend

ing

(% G

DP

)

10 100 250 1000 10000 25000GDP per capita


GOVERNMENT HEALTH SPENDING VS INCOME,2008

And government health spending as a share of the budget is even lower than total government expenditures as a share of GDP.


Indonesia

Indonesia

1020

3040

50

Gov

ernm

ent sp

endi

ng (%

GD

P)

Gov

ernm

ent he

alth

spe

ndin

g (%

bud

get)

100 250 1000 2500 10000 25000GNI per capita (US$)

Source: WDI

Government spending vs income, 2004-2006

Government spending (% GDP)

Government health spending (% budget)

24

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13

OOP spending, a measure of financial protection, is about average relative to comparators.

25


China

Lao PDR

Malaysia

Philippines

Thailand

Samoa

Indonesia

Cambodia

Vietnam

020

4060

80

Out

-of-

pock

et h

ealth

spe

ndin

g(%

tot

al h

ealth

spe

ndin

g)

100 250 1000 10000 25000GDP per capita, current US$


OOP spending as share of total health spendingvs Income per capita, 2008

Financial protection, measured as the OOP share of nonfood spending has improved.

Source: Equitap Update 2009.

26

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14

27

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

Malaysia (1999) Taiwan (2000) Indonesia(2006)

Thailand(2002)

Hong Kong(2000)

Sri Lanka(1997)

Philippines(1999)

Indonesia(2001)

Korea (2000) Nepal (1996) India (2000) China (2000) Bangladesh(2000)

Vietnam (1998)

% o

f hou

seh

old

s ex

ceed

ing

thre

shol

d

Greater than 25 percent of nonfood expenditures Greater than 10 percent of total expenditures

Catastrophic payments for health care are defined as OOP payments in excess of a substantial proportion of the household budget, usually 10-40 percent (Van Doorslaer et al. 2006; Xu et al, 2003)

By regional standards, the incidence of catastrophic health spending is low in Indonesia.


Equity of public spending on health could be improved; it is low in international comparisons and has not changed much since 2001.

28

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Shanxi province (C

hina) 2003

Heilongjiang (C

hina) 2003

Zhejiang (C

hina) 2003

Gansu (C

hina) 2003

Indonesia 2001

Indonesia 2006

India 1996

Mongolia*

Bangladesh 2000

Vietnam

2003

Malaysia 1996

Thailand 2002

Sri L

anka 2004

Hong K

ong 2002P

oore

st q

uin

tile

sh

are

of s

ub

sid

y

Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region


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15

Inequities between provinces are also evident from differences in health expenditures.

29


District Public Health Expenditures by Province (2005)

Technical efficiency is low in Indonesia in global comparisons and there are large differences between provinces.

30

AusA

B

C

Cdn

CN

CZ

F

D

G

HKHIdn

Irl

I

JRok

LMys

M

MngNl

N

PS

ECh

Tw

T

Tk

UK

US

V

averagecase- f low

averagebed occupancy

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

percent bed occupancy rate

case

-flo

w (

case

s pe

r be

d pe

r ye

ar)

A : high case-flow low occupancy

C: high case-flow high occupancy

B: low case-flow low occupancy

D: low case-flow high occupancy

N A D

Sumut

Sumbar R i a u

J a m b i

Sumsel Bengkulu Lampung

Bangka Belitung DKI Jakarta

JabarJatengDIYJatim

Banten

B a l iNTB

NTT

KalBarKalseng

Kaltim

Sulut

SultengSulselSulteng Irian Jaya Tengah

Irian Jaya Timur

average case- f lo w

average b ed occup ancy

Kalteng

Maluku

Irian Jaya Barat

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

percent bed occupancy rate

case

-flo

w (

case

per

bed

per

yea

r)

A : high case-flow low occupancy

C: high case-flow high occupancy

B: low case-flow low occupancy

D: low case-flow high occupancy

Technical efficiency is ideally measured using case-mix unit cost data, however these are not available in Indonesia. Instead case-flow and average bed occupancy are used.


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A n a l r e a d y s t r e t c h e d h e a l t h s y s t e m w i l l i n c u r f u r t h e r p r e s s u r e d u e t o i n c r e a s e d d e m a n d f r o m o n g o i n g d e m o g r a p h i c , n u t r i t i o n a n d e p i d e m i o l o g i c a l t r a n s i t i o n s a s w e l l a s t h e i n t r o d u c t i o n o f u n i v e r s a l h e a l t h i n s u r a n c e c o v e r a g e .

I n d o n e s i a ’ s h e a l t h i n f r a s t r u c t u r e , a l t h o u g h w i d e l y a v a i l a b l e f o r p r i m a r y c a r e , d o e s n o t h a v e s u f f i c i e n t b e d s o r h e a l t h w o r k e r s t o r e s p o n d t o t h e s e i n c r e a s e d n e e d s .

P h a r m a c e u t i c a l s u p p l i e s a r e r e a s o n a b l e b u t m o s t I n d o n e s i a n p a y m o r e t h a n t h e y n e e d t o a n d m o s t e x p e n d i t u r e s a r e o u t o f p o c k e t .

T h e r e i s a p r e s s i n g n e e d t o a d d r e s s h u m a n r e s o u r c e s d i s t r i b u t i o n i n e q u i t i e s a n d q u a l i t y .

S a t i s f a c t i o n l e v e l s o v e r a l l a r e g o o d a l t h o u g h t h e r e i s a h i g h l e v e l o f d i s s a t i s f a c t i o n w i t h v a r i o u s a s p e c t s o f h e a l t h c a r e .

31

Indonesia’s Health Delivery System

Indonesia’s primary public health care system is extensive: more than 90percent of the population has access to primary care facilities.

Source: MoH. 2010. Health Profile.

32

Ratio Puskesmas per 100,000 Population

3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9

2002 2003 2004 2005 2006 2007 2008 2009 2010

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While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators.

33


China

Cambodia

Lao PDRMalaysia

Philippines

ThailandVietnam

SamoaIndonesia

05

1015

Hos

pita

l Bed

s pe

r 1,

000



HOSPITAL BED SUPPLY VS INCOME, 2000-2010

And Also Fewer Health Workers

34

World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.

China

CambodiaLao PDR

MalaysiaPhilippines

ThailandVietnam

SamoaIndonesia02

46

8D

octo

r pe

r 1,

000



DOCTOR SUPPLY VS INCOME, 2000-2010

CambodiaLao PDRMalaysia

Philippines

ThailandVietnam

SamoaIndonesia

05

1015

20M

idw

ives

/Nur

ses

per

1,00

0



MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010

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18

At the Puskesmas level most basic services are available.

35

Quality Measures Public Settings Private Settings

Puskesmas Pustu Private Nurse

Private Midwife

Private MDs

All Settings

Structural qualityInternal water source (%) 89 71 80 84 89 84

Inpatient beds (%) 28 3 3 28 3 18Functioning microscope (%) 79 5 1 3 7 25

Tuberculosis service (%) 95 30 8 2 44 38Measles vaccines in stock (%) 97 51 5 48 11 51

Tetanus toxoid vaccine in stock (%)

97 55 9 59 12 55

Hepatitis B vaccine in stock (%) 92 52 6 54 16 52

Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult Curative Care (by Clinical Setting)(2007)


Secondary and tertiary care have not progressed equally: thenumber of hospitals and hospital beds has grown slowly.

0

20000

40000

60000

80000

100000

120000

140000

1995 1997 2000 2003 2005 2006

MoH Province, district, municipal Armed forces, police State-owned Private

Increase in numbers of hospital beds between 1995 and 2006 by ownership

36


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19

There are 3 beds per 10,000, 3.8 Puskesmas per 100,000 and 6.9 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.

37

0

2

4

6

8

10

12

14

16

0

200

400

600

800

1,000

1,200N

ort

h S

ulaw

esi

No

rth

Mal

uku

Mal

uku

Wes

t Pap

ua

Eas

t Kal

iman

tan

Cen

tral

Kal

iman

tan

Go

ront

alo

Wes

t Sum

atra

Bal

i

Ban

gka

Bel

itung

Arc

hipe

lago

Nan

ggr

oe A

ceh

Dar

ussa

lam

Ben

gku

lu

Pap

ua

So

uth

Kal

iman

tan

Cen

tral

Sul

awes

i

So

uth

Sul

awes

i

Jam

bi

D I

Yo

gya

kart

a

So

uth

Eas

t Sul

awes

i

DK

I Jak

arta

Eas

t Nus

a T

eng

gara

Cen

tral

Jav

a

Ria

u A

rch

ipel

ago

So

uth

Sum

ater

a

Ria

u

Wes

t Kal

iman

tan

No

rth

Sum

atra

Eas

t Jav

a

Wes

t Nus

a T

engg

ara

Lam

pun

g

Wes

t Sul

awes

i

Wes

t Jav

a

Ratio

# Health center

Puskesmas Hospital Bed per 10,000 pop Puskesmas per 100,000 popSource : IndonesiaHealth Profile, 2010

The ratio of physicians to population also masks significantinequities among urban and rural areas.

Source: KKI 2008.

38

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20

DPT3 immunization, often considered a good indicator of health system coverage, is low for Indonesia’s health expenditure level and may indicate low levels of efficiency.

Country Total health expenditure pc

(US$)

DPT3immunization

coverage

Indonesia 26 70

Uganda 22 84

Rwanda 19 95

Tajikistan 18 85

Tanzania 17 90

Nepal 16 75

Pakistan 15 80

Bangladesh 12 88

39


Analysis of the number of staff per primary care facility illustrates inequalities at the facility level…

Facility

National Java‐Bali SumatraOther

Provinces

1997 2007 1997 2007 1997 2007 1997 2007

Puskesmas

Number of Doctors 1.51 1.90 1.68 1.96 1.19 1.85 1.09 1.62

Number of Doctors (%) 3.4 7.0 1.5 5.9 2.0 6.8 15.9 11.3

Number of Midwives 5.85 3.69 5.76 3.44 6.33 5.28 5.62 3.18

Number of Nurses 5.05 6.14 4.58 5.60 6.16 7.16 5.84 7.61

Pustu

Number of Midwives 0.98 0.81 1.06 0.76 1.13 1.17 0.44 0.21

Number of Nurses 1.08 1.06 1.02 1.09 1.16 1.08 1.16 0.89

Source: IFLS 1997; 2007.

40

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21

…and quality, measured as diagnostic and treatment ability, varies between regions and geographic areas and has not improved much over time.

41

ServiceNational Java/Bali Sumatra Other Provinces

1997 2007 P= 1997 2007 P= 1997 2007 P= 1997 2007 P=

Prenatal Care

Public 42 46 *** 45 47 ** 35 39 ** 38 49 ***

Private 40 44 *** 43 46 *** 34 37 ** 39 46 ***

Child Curative Care

Public 56 64 *** 58 66 *** 48 56 *** 55 65 ***

Private 55 59 *** 57 62 *** 50 52 54 60 ***

Adult Curative Care

Public 49 56 *** 52 59 *** 43 48 *** 44 53 ***

Private 46 53 *** 48 56 *** 40 51 *** 44 51 ***

Quality of Public Health Services in Indonesia 1997-2007 (by Region)

*** p<0.01, **p<0.05


In international comparisons Indonesia spends little on medicine per capita, and most expenses are out-of-pocket.

0 5 10 15 20 25

India

Indonesia

Cambodia

Philippines

Vietnam

Malaysia

Thailand

Government Private

Source: WHO. 2004. The World Medicines Situation.

42

Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less thanUS$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming thecentral government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide allthe primary care medicines recommended by WHO.

Spending on drugs per capita in US$

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22

But most Indonesians pay more than they need to for their medicines when they buy from the private sector or from public hospitals.

Price ratio to median international indicator price

Originatorbrands

Most sold brandedgeneric

Lowest price generic

Private pharmacies

22-26 6-7 2.6

Public hospitals 22 1.7-6 2.15

Source: National Institute for Health Research and Development (NIHRD) Survey 2004.

43

Provision of health services by private health providers has grown significantly over the past decade.

At the national level, physician practices per 1,000 of population grew at 38.5 percent

The number of midwife practices per 1,000 population increased by 4.64 percent.

And the majority of

physicians working in a

Puskesmas supplement

their income through

private service provision


44

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23

And utilization of private health providers fell after Askeskin was introduced and the utilization of Puskesmas increased.

45

Changes in choice between public and private sector between 2004 and 2009

Various Susenas : Worldbank staff calculation

43.3 43 47.740.1 38.5 39.9 41

50 50.9 47.453.7 55.8 55.3 54.1

1.8 2.6 2.8 2.6 2.7 2.3 2.34.9 3.2 4.5 3.8 2.9 2.8 2.5

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2004 2005 2006 2007 2008 2009 2010

Public Private Traditional Other

However, most Indonesians continue to seek ambulatory care from private providers when ill.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2007

1997

Source: IFLS 1997 & 2007.

46

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24

Overall consumer satisfaction with inpatient and outpatient services appears good…

47

58.1

65.2

59.7

32.2 31.3 32.3

7.7

3.37.2

1.2 0.2 0.90.9 0.0 0.00

10

20

30

40

50

60

70

GDS2 (N=7.916) Susenas-Inpat ient (N=19.294) Susenas-Outpat ient (N=2.657)

Satisf ied Somewhat sat isf ied Somewhat unsat isf ied Unsat isf ied No response

Source: GSD2 and Susenas.

…although there is a high level of dissatisfaction with variousaspects of the provision of health care…

18.3

26.8

27.3

32.8

24.1

13.6

26.1

11.6

21.7

27.9

25.6

29.7

24.2

17.2

21.7

0 10 20 30 40

family visit

cleanliness

freedom of choice

private consultation

involvement in…

information availability

hospitality

waiting time

percent

inpatient outpatient

Source: Sakernas National Health Survey 2004.

48

Dissatisfaction With Various Aspects of Health Services (%)

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25

…and many people continue to opt for self-treatment or forego treatment altogether.

49

Source: Susenas various years.

38.2 34.4 34.144.1 44.4 44.7 44.0

51.750.9 51.2

44.2 45.1 46.5 46.2

10.1 14.7 14.6 11.7 10.6 8.8 9.8

0%

20%

40%

60%

80%

100%

2004 2005 2006 2007 2008 2009 2010

Facility visit, any Self treatment only No treatment

T h e n e w g o v e r n m e n t i s c o m m i t t e d t o i m p l e m e n t i n g t h e r e f o r m a n d a s s u r i n g a l l I n d o n e s i a n c i t i z e n s a c c e s s t o q u a l i t y h e a l t h s e r v i c e s a n d f i n a n c i a l p r o t e c t i o n a g a i n s t t h e i m p o v e r i s h i n g e f f e c t s o f l a r g e u n p r e d i c t a b l e m e d i c a l c a r e c o s t s .

F u l f i l l i n g t h i s c o m m i t m e n t w i l l r e q u i r e t h e d e v e l o p m e n t , i m p l e m e n t a t i o n , a n d m o n i t o r i n g o f p o l i c i e s a f f e c t i n g a l l a s p e c t s o f t h e h e a l t h s y s t e m – b a s i c p u b l i c h e a l t h p r o g r a m s ; d e l i v e r y s y s t e m s a n d l o g i s t i c a l c a p a c i t y ; q u a l i t y a n d d i s t r i b u t i o n ; o r g a n i z a t i o n , m a n a g e m e n t , a n d a c c o u n t a b i l i t y ; p h a r m a c e u t i c a l s ; f i n a n c i n g ; p u b l i c — p r i v a t e p a r t n e r s h i p s a n d a l l l e v e l s o f g o v e r n m e n t .

50

Health Financing Reform

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26

Background51

The 2004 Social Security legislation (Law No. 40) envisages coverage of the entire population through a mandatory health insurance system evolving from the existing insurance programs.

As of 2009 the government has covered some 76 million poor and near poor through the Jamkesmas program, funded through the central government budget.

However, progress over the last five years has been slow in developing the final configuration of the health insurance system and the transition plan to provide health insurance to the remaining 50+ percent of the population who currently lack coverage remains to be developed.

Many local governments have developed their own financing schemes, some for the uncovered non-poor.

The health insurance reform is complicated by the big bang decentralization reform that took place in 2001 which transferred most of the authority and responsibility for assuring service delivery capacity to local governments.


Health insurance systems in Indonesia since 2008.

Current Insurance Systems

Ministry of Labor

Ministry of Finance

Ministry of Health

Ministry of Defense

JamsostekPrivate

insuranceAskes, HMOs

Military personnel

Social security Social HMO

Commercial health insurance

PT Askes:-Civil servants-Commercial HMOs

Jamkesmas(scheme for the poor)

Types:

Coverage(millions of

people)

Free health services

Technical oversightFinancial oversight

4.16.6. including

personal accident

Civil servant: 14Commercial HMOs: 2

276.4

Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.

52

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27

The Current Health Policy Baseline for Health Financing Reform: System Strengths.

53

The country has favorable demographic circumstances with dependency ratios falling over the next 30 years

There are high educational and literacy levels

The government is committed to reform

Health spending levels are not excessive

The country achieves reasonable health outcomes, financial protection and consumer satisfaction

There is substantial experience with health insurance programs

There is an extensive primary care delivery system

Pharmaceuticals are generally available


54

Half the population lacks health insurance coverage

Health financing and delivery systems are highly fragmented

Human and physical infrastructures are limited and face quality and efficiency problems

Salary and capital subsidies to public health providers preclude the development of a ‘level playing field’ for both public and private providers to compete on the basis of price

Critical data for decision making are lacking, including national and subnational health accounts, detailed information on the numbers, risk profiles of the insured and the uninsured, and unit cost information

Design features of the Jamsostek and Askes programs result in high OOP costs for program beneficiaries and limit operational effectiveness and sustainability

Local contributions vary widely, current intergovernmental fiscal redistributions may not adequately reflect local fiscal capacity and need, and the fiscal capacity of districts vary widely.

The Current Health Policy Baseline for Health Financing Reform: System Challenges.


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28

55

Framework to Assess HI Financing Options.

What is the ‘ultimate’ HI system of Universal Coverage (UC) under Law No. 40: single unitary Social Health Insurance (SHI); or multiple systems under a single set of rules; or a unitary general revenue funded system (e.g., Jamkesmas for all)?

What are the specific details of this system with respect to: single or multiple funds; eligibility of different groups including informal sector workers; benefits covered including cost sharing and referral requirements; financing including public subsidies and regional contributions; provider payment and cost containment; quality assurance; Administration; and the role of the private sector.

What are the transition policies to get to (UC)?


56

Future Vision 1: Jamkesmas for All: An Indonesian NHS.

This approach approximates a National Health Service like that in Sri Lanka.

It reflects the fact that more than half of the population is currently poor or near poor, and thus has a very limited ability to pay.

It also recognizes the inherent difficulty of identifying the 61 percent of workers who are in the informal sector and having them pay premiums.

By picking up formal sector workers through general revenues, firms might be more competitive as their 3-6 percent payroll contributions would be eliminated and/or could be replaced by more efficient and equitable broad-based taxes.


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29

57

Future Vision 2: A Single Integrated SHI Fund.

This approach approximates the ‘new’ national SHI model (now called Mandatory Health Insurance (MHI)) where the SHI is funded through both wage-based contributions for public and private sector workers (and retirees) and government general revenue contributions for the poor and other disadvantaged groups.

Under this approach there would be a single standardized national HI fund (although one could also establish multiple funds as in Germany or Japan).

The poor would be financed through the GoI budget, while government and private sector workers would be funded as now through wage-based contributions.

The GoI would need to decide if informal sector workers would be covered by the GoI like the poor (as in Thailand) or whether mechanisms can be developed to make them contribute some share of their earnings.


58

Future Vision 3: MHI through a Single Set of Rules Applying to Multiple SHI and NHS Type Programs.

This approach could be considered as a variant of Option 2 or a combination of Options 1 and 2.

Existing programs would be scaled up to include the entire population. All the poor and other disadvantaged groups would be covered through

Jamkesmas. All private sector workers would be covered through Jamsostek (possibly

though elimination of the opt out, employer size, and wage ceiling restrictions and adding requirements to cover retirees).

Civil servants and civil service retirees would be covered through Askes (or the Askes program could be folded into Jamsostek, or conversely).

A decision would need to be made about how to handle informal sector workers.

The three programs would have separate administrative structures but would operate under the same set of rules concerning issues such as benefits and contracting/provider payment.

There might be cross-subsidies required across programs on the financing side.


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30

59

No Matter Which Option is Chosen, The Devil Will Be in The Detail.

Administrative and governance arrangements Defining the benefit package Determining eligible groups Determining purchasing/contracting arrangements and cost

containment policies Estimating actuarially sound premium levels Determining financing sources Defining revenue collection mechanisms Defining transition steps to new system Developing and implementing monitoring and evaluation procedures


T h e p u r p o s e o f t h e a c t u a r i a l e s t i m a t e s w a s t o r e s p o n d t o t h e G o I r e q u e s t t o a s s i s t i n d e v e l o p i n g b a s e l i n e e s t i m a t e s f o r t h e c o s t o f e x i s t i n g h e a l t h i n s u r a n c e p r o g r a m s a n d t o p e r f o r m a n a c t u a r i a l a n a l y s i s t o c o s t d i f f e r e n t o p t i o n s f o r a t t a i n i n g U H I C .

I t d e m o n s t r a t e s t h e i m p o r t a n c e o f t h e d e c i s i o n s t o b e t a k e n r e g a r d i n g t h e d e t a i l a s e a c h d e c i s i o n i n f l u e n c e s t h e l e v e l o f f i n a n c i n g n e e d e d .

T h e e x e r c i s e i n c l u d e d t h e d e v e l o p m e n t o f a b a s e l i n e b a s e d o n t h e 2 0 0 8 A s k e s c l a i m s d a t a , t h e c r e a t i o n o f a r a n g e o f b a s e l i n e s a n d t h e c r e a t i o n o f v a r i o u s s c e n a r i o s .

60

Actuary Estimates

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31

CMPM estimation which include out-of-pocket (OOP) expenses, subsidies to thepublic system and supply constraints assumption in various scenarios, provides amore realistic expenditure estimate ranging from Rp 20,542 CMPM to Rp 36,029.

61

Source : Actuarial costing of Universal Health Insurance Coverage in Indonesia : Options and Preliminary results, Worldbank 2011

Projecting costs forward to 2020 suggests that UC in Indonesia is likely to require anexpenditure range between Rp 127 trillion (6.66 percent of total public expenditures and 1.17percent of GDP) and Rp 221 trillion (11.58 percent and 2.03 percent).

62

Source : Actuarial costing of Universal Health Insurance Coverage in Indonesia : Options and Preliminary results, Worldbank 2011

4/16/2013

32

I n a l l l i k e l i h o o d , a n d f o r a v a r i e t y o f r e a s o n s , I n d o n e s i a w i l l n e e d t o b o o s t h e a l t h s p e n d i n g i n t h e n e a r f u t u r e a s i t e x p a n d s a c c e s s t o c a r e t h r o u g h t h e e x p a n s i o n o f J a m k e s m a s , t h e h e a l t h i n s u r a n c e s c h e m e f o r t h e p o o r a n d t h e n e a r p o o r .

I n a d d i t i o n , p r o j e c t i o n s b a s e d o n d e m o g r a p h i c a n d e p i d e m i o l o g i c a l c h a n g e s i n t h e c o u n t r y i n d i c a t e t h e r e i s l i k e l y t o b e a s i g n i f i c a n t i n c r e a s e i n t h e d e m a n d a n d n e e d f o r h e a l t h s e r v i c e s a n d m o r e s o p h i s t i c a t e d c a r e .

D e s p i t e a t r i p l i n g o f t h e p u b l i c b u d g e t f o r h e a l t h o v e r t h e p a s t f i v e y e a r s , t h i s i n c r e a s e d n e e d , c o m b i n e d w i t h t h e f a c t t h a t I n d o n e s i a r e m a i n s a c o m p a r a t i v e l y l o w s p e n d e r o n h e a l t h , i n d i c a t e s t h a t t h e r e w i l l c o n t i n u e t o b e u p w a r d p r e s s u r e o n r e s o u r c e s f o r t h e h e a l t h s e c t o r i n t h e n e a r f u t u r e .

63

More Resources for Health; Assessing Fiscal Space

Visualizing fiscal space for Indonesia: different means by which government spending on health can increase.

World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

64

Conducive macroeconomic conditions

Reprioritization

Sector-specific foreign aidOther sector-specific resources

Efficiency

1

2

3

4

5

6

7

8

Fiscal space for health(increase as % of government health spending)

4/16/2013

33

One of the most important determinants of fiscal space for health is economic growth which has a positive outlook in Indonesia.

65

Pre-crisis forecast

Post-crisis forecast

45

67

8

Rea

l GDP g

rowth

rate

2003 2005 2007 2009 2011 2013Year

Source: IMF

Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for thecountry, although growth remains in the 6-7 percent range per annum over the period 2008-2013.


Higher revenues provide extra resources, but Indonesia’s revenues as a percentage of GDP (19 percent) are low in comparison with other lower-middle-income countries.

0 5 10 15 20 25 30 35 40

Lower income

Middle income

Upper middle

Higher income

Revenue (% of GDP), 2003-2006

66


4/16/2013

34

Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.

Agriculture

Education

Health

Govt Apparatus National Defense

Infrastructure

Subsidies

Interest payments

0%

1%

2%

3%

4%

5%

6%

7%

1994 1996 1998 2000 2002 2004 2006 2008*

% o

f G

DP

With subsidies declining again (in 2009) there might be increased space for the health sector

67

World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

Indonesia’s has not depended significantly on external resources for health in recent years.

0

2

4

6

8

10

12

1995 1997 1999 2001 2003 2005

External resources (% of total health spending)

Source: WHO.

68

4/16/2013

35

In addition to increasing budgets for health, effective fiscal space may be generated by increasing the efficiency of spending.

Sri Lanka is often presented as an example of a country that has been able to attain excellenthealth outcomes with relatively low levels of resources, in part because of the underlyingefficiency of its health system.

69


Indonesia

Sri Lanka

Abo

ve a

vera

geB

elow

ave

rage

Above average Below average-3-2

-10

12

3P

erfo

rman

ce rel

ativ

e to

per

cap

ita h

ealth

spe

ndin

g

-3 -2 -1 0 1 2 3Performance relative to income percapita

Under-five mortality

Indonesia

Sri Lanka

Abo

ve a

vera

geB

elow

ave

rage

Above average Below average-3-2

-10

12

3P

erfo

rman

ce rel

ativ

e to

per

cap

ita h

ealth

spe

ndin

g

-3 -2 -1 0 1 2 3Performance relative to income percapita

Maternal mortality

Source: WDI 2009

Performance relative to income and health spending, 2008

Local variation in performance across districts further indicates potential efficiency gains.

Kota Padang Panjang

Kab. Kediri

Kab. Bantul

Kab. Barito Selatan

Kab. Hulu Sungai Utara

Kab. Nias Selatan

Kab. Yahukimo

Kota Kediri

Kab. Semarang

Kab. Kuningan

Kab. Barru

Kab. Purbalingga

Kab. Wonosobo Burundi

Bangladesh

Pakistan

Senegal

Ukraine

Bhutan

China

Ethiopia

Indonesia

CambodiaTanzania

020

4060

8010

0

Skille

d birth atten

danc

e

Indonesia Other countries

Skilled birth attendance

Kab. Tana Toraja

Kab. Ciamis

Kab. Morowali

Kab. Subang

Kab. Parigi Moutong

Kab. Bombana

Kab. Pakpak Bharat

Kab. Madiun

Kota Ambon

Kab. Lombok Barat

Kab. Asmat

Kota Singkawang

Kab. Bangka Tengah

Bangladesh

Japan

Nepal

Papua New Guin

Somalia

Timor-Leste

Indonesia

India

Niger

Pakistan

Chad

Turkey

Uganda

Vietnam

020

4060

8010

0

Indonesia Other countries

DPT3 immunization

Source: Susenas and WDI.

70

4/16/2013

36

A t l e a s t 1 0 , 0 0 0 w o m e n c o n t i n u e t o d i e o f c h i l d b i r t h - r e l a t e d c a u s e s e v e r y y e a r i n I n d o n e s i a . E v e n t h o u g h s k i l l e d b i r t h a t t e n d a n c e h a s i n c r e a s e d s i g n i f i c a n t l y , m o r e n e e d s t o b e d o n e t o a c c e l e r a t e a r e d u c t i o n i n d e a t h s a n d a c h i e v e M D G 5 .A l a r g e n u m b e r o f w o m e n c o n t i n u e t o d e l i v e r a t h o m e w i t h o u t p r o f e s s i o n a l h e l p . H i g h l e v e l s o f u n c e r t a i n t y a b o u t m e d i c a l e x p e n s e s c o n t i n u e t o d e l a y t h e d e c i s i o n t o s e e k c a r e a t a f a c i l i t y . E v e n w h e n w o m e n r e a c h a f a c i l i t y o n t i m e , q u a l i t y o f m a n a g e m e n t i s p o o r a n d d e a t h r a t e s a t f a c i l i t i e s r e m a i n h i g h , e s p e c i a l l y , b u t n o t o n l y , i n p o o r a r e a s .

71

Focus on MDG 5: Reducing Maternal Death

There has been an impressive improvement in skilled birth attendance since 1987, but the poor continue to lag behind.

72

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37

Disparities exist between province, economic quintiles, and education levels.

0

20

40

60

80

100Maluku

WestSulaw

esi

NorthMaluku

EastNusaTenggara

Papua

Banten

Gorontalo

SoutheastSulaw

esi

WestPapua

SouthSulawesi

CentralSulaw

esi

WestKalimantan

WestNusaTenggara

SouthSumatra

CentralKalimantan

WestJava

Jambi

Lampung

Bengkulu

DIAceh

EastKalimantan

SouthKalimantan

EastJava

WestSum

atra

BangkaBelitung

CentralJava

NorthSum

atra

Riau

NorthSulaw

esi

RiauIslands

Bali

DIYogyakarta

DKIJakarta

percentage

Deliveryassistant&placebyprovince

%SBA %FacilitybasedeliveryData source : IDHS 2007

73

Most poor women continue to deliver their babies at home with traditional birth attendants (TBAs) where the risk of maternal death is highest…

74

-

100

200

300

400

500

600

700

800

0102030405060708090

100

Poorest Poorer Middle Richer Richest

Ma

tern

al

De

ath

p

er

100

,00

0 L

ive

Bir

ths

% A

NC

/Pro

fess

ion

al

de

liv

ery

ANC/Prof del ANC/No prof delNo care (No ANC/No prof del) No ANC/Prof delMMR

Source: DHS 2007.

4/16/2013

38

…even though midwives are almost everywhere and are equally distributed.

Note: All types of midwives included. Source: Indonesia Health Profile 2008.

Government target is 100 midwives per 100,000 population by 2010.

75

Midwife availability has increased significantly, however, TBAremains the preferred choice of provider for childbirth.

World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.

76

DIY

WJ

CJ

DKI

EJ

DKI

WJ

CJ

DIY

EJ

4060

8010

012

0%

Del

iver

y by

hea

lth p

rofe

ssio

nal

20 40 60 80100Ratio midwife per 100000 pop

SBA VS Ratio midwife, 2007

DKI DIY

EJ

WJ

CJ

DKI

WJ

CJ

DIY

EJ

4060

8010

012

0%

Del

iver

y by

hea

lth p

rofe

ssio

nal

200 400600Ratio TBA per 100000 pop

SBA VS Ratio TBA, 2007

Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007)Ratio Traditional Birth Attendant (TBA) (PODES, 2008)Note Abbreviation: DKI=DKI Jakarta, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java

4/16/2013

39

There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.

77

Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.

78

World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.

Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers

4/16/2013

40

Ob-Gyns provide the most comprehensive services but reach only a limited population.

79

Antenatal Care Services by Type of Assistance in West Java (DHS 2007)

World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.

Four areas for priority action to improve the health status of Indonesian mothers: Being implemented in ongoing pilots.

1. Improving coordination between public and private sector services at provincial and district levels

2. Strengthening coordination between community-based services and hospital services

3.Reducing financial barriers to utilization of maternal health services

4. Improving clinical skills and quality assurance

Increase research into near miss and maternal death for better understanding of the local contributing factors. Use this analysis to determine whether factors such as access to SHI, ANC, and place of delivery had an impact on outcomes

•Improve vital statistics registration, particularly for deaths among women of reproductive age•Address the unmet need for access to emergency obstetric care among the large majority of the female population•Conduct a hospital assessment for maternal health to identify barriers to care within the facility context

•Review the social insurance coverage amounts to expand what is reimbursed and to cover the true cost of having a delivery with a skilled provider.•Review reimbursement mechanisms in the case of referral upwards to a hospital for complications.

•Improve the quality of the skilled provider, particularly the Bidan di Desa by building on existing initiatives (such as Bidan Delima) and linking quality of care to accreditation and certification.•Look at the implementation of the comprehensive emergency obstetric services to find areas of improvement.

World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.

80

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41

81

CONTINUUM OF CARE

Increasing the DEMAND

PUSKESMAS+Private Clinic

HOSPITAL (pub;priv)

MOTHER AND BABY SURVIVEDAND WELL

Quality of Obstetric Care• Quality assurance in health facilities• Accreditation• Referral network• Recording and reporting system

Pregnant women & Comm.

Access• Financing

• Transportation

Logical Framework(intervention model)

I M P A C T S T O D A T E :C o v e r a g e h a s e f f e c t i v e l y b e e n i n c r e a s e d a n d a n e s t i m a t e d o n e -t h i r d o f t h e p o p u l a t i o n i s c u r r e n t l y b e i n g c o v e r e d , a c c o r d i n g t o o f f i c i a l d a t a ( S u s e n a s s u r v e y d a t a i n d i c a t e s l o w e r c o v e r a g e r a t e s ) .F o r t y - t h r e e p e r c e n t o f t h o s e c o v e r e d a r e p o o r a n d n e a r - p o o r h o u s e h o l d s .U t i l i z a t i o n o f h e a l t h s e r v i c e s a m o n g J a m k e s m a s b e n e f i c i a r i e s h a s i n c r e a s e d , e s p e c i a l l y f o r i n p a t i e n t s e r v i c e s .J a m k e s m a s h a s a p r o t e c t i v e e f f e c t o n t h e O O P h e a l t h e x p e n d i t u r e s o f t h e p o o r a n d n e a r - p o o r ; t h o s e w i t h J a m k e s m a s c o v e r a g e h a v e l o w e r O O P p a y m e n t s ( a m e a s u r e o f f i n a n c i a l p r o t e c t i o n ) a n d J a m k e s m a s b e n e f i c i a r i e s h a v e a l o w e r i n c i d e n c e o f c a t a s t r o p h i c m e d i c a l e x p e n d i t u r e s w h e n c o m p a r e d w i t h t h o s e w i t h n o i n s u r a n c e o r t h o s e w i t h o t h e r f o r m s o f i n s u r a n c e .G e o g r a p h i c a n a l y s i s s h o w s s i g n i f i c a n t i n c r e a s e s i n i n p a t i e n t u t i l i z a t i o n i n t h e p o o r e s t p r o v i n c e s ( N T T , P a p u a , M a l u k u ) .

82

Focus on JamkesmasUpdate in December 2011

4/16/2013

42

Almost half of population covered by health insurance, and nearly 30% of population covered by Jamkesmas

83

5.7

4.32.91.92.3

40

6

4.22.93.1.9

43

11

4.52.831

36

10

4.82.62.61.1

37

9.9

5.13.12.52.2

37

16

5.2

3.72.31.3

34

13

5

4.52.81.7

36

020

4060

Num

ber

of hou

sehol

ds (

mill

ion)

2004 2005 2006 2007 2008 2009 2010

Data source : Susenas 2004-2010

Household-level insurance coverage, 2004-2010

Jamkesmas/Askeskin/Health Card Askes

Jamsostek Private

Other No insurance

High utilization of outpatient care among those who covered by Jamkesmas, increase used of Jamkesmas for outpatient and inpatient care

84

No insurance

Jamkesmas/Askeskin/Health Card

Other insurance

0.0

5.1

.15

.2U

tiliz

atio

n ra

te

2003 2004 2005 2006 2007 2008 2009 2010 2011Year

All

No insurance


Other insurance

0.0

5.1

.15

.2U

tiliz

atio

n ra

te

2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Bottom 3 deciles

Source: SUSENAS 2004-2010

Outpatient utilization rate, 2004-2010by insurance type

No insurance


Other insurance

01

23

4pe

rcen

tage

2003 2004 2005 2006 2007 2008 2009 2010 2011Year

All

No insurance


Other insurance

0.5

11.

52

2.5

33.

54

perc

enta

ge

2003 2004 2005 2006 2007 2008 2009 2010 2011Year

Bottom 3 deciles

Source: SUSENAS 2004-2010

Inpatient utilization rate, 2004-2010by insurance type

4/16/2013

43

health spending is highest among households that had at least one inpatient utilization visit among any of the family members

85

01.

0e+

062.

0e+

063.

0e+

064.

0e+

065.

0e+

06

Hou

seho

ld h

ealth

exp

endi

ture

in p

ast

year

(Rup

iah)

00 10 01 11Utilization pattern

OOP health expenditureby utilization pattern

0.0

5.1

.15

Hou

seho

ld h

ealth

exp

endi

ture

sha

reof

tot

al c

onsu

mpt

ion

expe

nditu

re

00 10 01 11Utilization pattern

As share of total consumptionby utilization pattern

Source: SUSENAS 2010Utilization pattern: 00=0 outpatient and 0 inpatient visits; 10=1 or more outpatient and 0 inpatient visits01=0 outpatient and 1 or more inpatient visits; 11=1 or more outpatient and 1 or more inpatient visits

the share of health in total consumption expenditures – when conditioned on those utilizing inpatient care – are generally lower among

Jamkesmas/Askeskin/Kartu Sehat households across 2004-201086

Health expenditure and health share of household expenditure among those with at least one inpatient visit, 2004-2010

All No insurance Jamkesmas/Askeskin/

Kartu Sehat

Other insurance

Year Healthexpenditure

(share of totalexpenditure %)

Healthexpenditure


Healthexpenditure


Healthexpenditure


2004 Rp 1,629,763(10.9%)

Rp 1,626,499(11.9%)

Rp 1,006,313(9.5%)

Rp 1,898,414(9.8%)

2005 Rp 1,881,057(10.0%)

Rp 1,856,633(11.3%)

Rp 1,155,444(8.9%)

Rp 2,308,581(8.3%)

2006 Rp 1,653,611(8.3%)

Rp 1,867,575(9.9%)

Rp 893,536(6.7%)

Rp 1,944,168(7.2%)

2007 Rp 1,738,784(8.1%)

Rp 1,846,480(9.1%)

Rp 1,104,266(7.6%)

Rp 2,126,047(6.9%)

2009 Rp 3,066,949(10.3%)

Rp 3,171,209(11.3%)

Rp 1,959,415(9.2%)

Rp 4,054,062(9.6%)

2010 4,151,826 (11.9%)

4,145,972 (13.2%)

1,955,121 (9.9%)

6,152,485 (11.5%)

Source: 2008 data not included due to problems with expenditure module

4/16/2013

44

I n v e s t i n g i n I n d o n e s i a ’ s H e a l t h : C h a l l e n g e s a n d O p p o r t u n i t i e s f o r F u t u r e P u b l i c S p e n d i n g . H e a l t h P u b l i c E x p e n d i t u r e R e v i e w – J u n e 2 0 0 8

I n d o n e s i a ’ s D o c t o r s , M i d w i v e s a n d N u r s e s : C u r r e n t S t o c k , I n c r e a s i n g N e e d s , F u t u r e C h a l l e n g e s a n d O p t i o n s . H e a l t h H u m a n R e s o u r c e s R e v i e w – J a n u a r y 2 0 0 9

G i v i n g M o r e W e i g h t t o H e a l t h : A s s e s s i n g F i s c a l S p a c e f o r H e a l t h i n I n d o n e s i a – J a n u a r y 2 0 0 9

H e a l t h F i n a n c i n g i n I n d o n e s i a : a R e f o r m R o a d M a p – J u n e 2 0 0 9

N e w I n s i g h t s i n t o t h e P r o v i s i o n o f H e a l t h S e r v i c e s i n I n d o n e s i a : a H e a l t h W o r k F o r c e S t u d y – O c t o b e r 2 0 0 9

‘ a n d t h e n s h e d i e d ’ : I n d o n e s i a M a t e r n a l H e a l t h A s s e s s m e n t –D e c e m b e r 2 0 0 9

A c t u a r i a l C o s t i n g o f U n i v e r s a l H e a l t h I n s u r a n c e C o v e r a g e i n I n d o n e s i a : O p t i o n s a n d P r e l i m i n a r y R e s u l t s – J a n u a r y 2 0 1 1

Annex: World Bank Studies for the HSR

87

F o r t h c o m i n g :

E n h a n c i n g H e a l t h E q u i t y a n d F i n a n c i a l P r o t e c t i o n i n I n d o n e s i a : H o w W e l l D o e s J a m k e s m a s d o ? J a m k e s m a sR e v i e w P a p e r

- M a r c h 2 0 1 2

88

Annex: Forthcoming World Bank Studies

4/16/2013

45

P h a r m a c e u t i c a l s : W h y R e f o r m i s N e e d e d – M a r c h 2 0 0 9 A c c e l e r a t i n g I m p r o v e m e n t i n M a t e r n a l H e a l t h : W h y R e f o r m i s N e e d e d – J u n e 2 0 1 0 F i n a n c i n g U n i v e r s a l C o v e r a g e : A s s e s s i n g F i s c a l S p a c e i n I n d o n e s i a – J u l y 2 0 1 0 A c h i e v i n g U n i v e r s a l C o v e r a g e : D i f f e r e n t S t a g e s o f H a r m o n i z a t i o n o f I m p l e m e n t i n g H e a l t h I n s u r a n c e I n f o r m a t i o n S y s t e m s – A u g u s t 2 0 1 0H e a l t h P r o f e s s i o n a l E d u c a t i o n i n I n d o n e s i a : W h y R e f o r m i s N e e d e dM a t e r n a l H e a l t h M e e t s H e a l t h F i n a n c i n gA c t u a r i a l E s t i m a t e s : W h a t w o u l d U n i v e r s a l H e a l t h I n s u r a n c e C o v e r a g e b y 2 0 2 0 C o s t ?

F o r t h c o m i n g :

89

Annex: World Bank Policy Notes Series

indonesia’s health sector review · updated june 2012 indonesia’s health sector review 1...

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