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Indonesia’s Health Sector Review
1
OVERVIEW
DATA, GRAPHS AND TABLES
UPDATED JUNE 2012
Background
2
The WB received requests for electronic copies of the various charts, tables and graphs included in the reports and papers produced for the Indonesia Health Sector Review In response, this synthesis report has been created. It includes the key charts, tables and graphs that can be downloaded This is a living document and updates will be inserted when new data become available This document does not summarize all the work that was carried out, rather it includes mainly the data and graphs. For summaries and details please refer to the documents listed in the annex. Each slide includes the source document for easy reference
This review was put together by the World Bank Jakarta-based health team including Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi, George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved in earlier versions.
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Indonesia’s Dynamic Environment
3
Indonesia’s health system performance is challenged by a changing environment: Ongoing demographic and epidemiological transitions that are likely to increase demand and result in more costly and more diverse health care. Additional pressure will come from emerging diseases and epidemics such as HIV/AIDS, H5N1 (Avian Influenza) and H1N1 (Swine Influenza). The implementation of Law No. 40/2004 on Universal Health Insurance Coverage (UHIC) will further increase demand and utilization.
Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million. 4
75+ 75+ Males 70-74 70-74 Females 65-69 65-69 60-64 60-64 55-59 55-59 50-54 50-54 45-49 45-49 40-44 40-44 35-39 35-39 30-34 30-34 25-29 25-29 20-24 20-24 15-19 15-19 10-14 10-14 5-9 5-9 0-4 0-4
-15,000 -10,000 -5,000 0 5,000 10,000 15,000 -15,000 -10,000 -5,000 0 5,000 10,000 15,000 Population in Thousands 2000 Population In Thousands 2025
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
Dependency ratio, 1950-2050
90 total 80 demographic bonus 70 young window of opportunity 60
50
40
30
20 ratio to working-age population ratio to working-age 10 eldery
0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 year
Source: Adioetomo 2007.
…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. 7
Changes in Burden of Disease in Indonesia
70
60
50 SKRT'95
40 SKRT'01
Riskesdas07 30
20
10
0 Perinatal / Maternal Communicable Disease Non-communicable Injuries Disease
Source: Riskesdas Survey 2007.
The obesity rate is rising and increased prevalence of risk factors will change the burden of disease – increasing the need for preventive measures. 8
Adult Obesity in Indonesia (%)
Richest 23.2
Quintile 4 19.9
Quintile 3 17.8
Quintile 2 16.8
Poorest 15
Rural 15.7
Urban 23.6
Females 29
Male 7.7
0 5 10 15 20 25 30 35
Source: Riskesdas Survey 2007.
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Increased need will demand more resources for health. Fortunately, despite the global economic crisis, the macroeconomic picture is still favorable. 9 8
7 Pre-crisis forecast
6 Post-crisis forecast Real GDP growth rate 5 4
2003 2005 2007 2009 2011 2013 year Source : IMF
World Bank. 2009. Giving More Weight to Health in Indonesia.
Health System Performance
10
Indonesia’s health system performance measured in terms of health outcomes, financial protection, consumer awareness and equity and efficiency is mixed: Indonesia scores highly on reducing child mortality but low on reducing maternal mortality. Inequities in health outcomes between income levels and geographic areas are very large and constitute a major problem for the health sector overall.
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Indonesians live longer in 2010 and child mortality has fallen dramatically since the 1960s. 11
70 Under-five mortality 200 150 60 Infant mortality 100 Life expectancy 50 50 Infant/underfive mortalityrate Life expectancy 0 40 1960 1970 1980 1990 2000 2010 year Source : WDI 2009
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
But geographic inequities remain large: life expectancy varies between 60 in West Nusa Tenggara and 75 in Yogyakarta.
12
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
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Indonesia performs well in terms of infant mortality relative to other comparable health spending level countries but less well for its income.
13
INFANT MORTALITY (2008)
MalaysiaVietnam Thailand Sri Lanka ChinaBangladesh IndonesiaLao PDR India Attainment relative to income to relative Attainment Below average Aboveaverage Below average Above average
Attainment relative to health spending per capita Source: WDI 2009, WHO 2008
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
Despite significant reduction in IMR over time, some neighboring countries have performed better.
14
Infant mortality, 1960-2009 250
Indonesia India 100
Vietnam Thailand
25 China
Infant mortality Sri Lanka 5
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year Source: WDI 2009 Note: y-axis log scale
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
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And there are large inequalities between provinces and income levels.
15
120
h 100
80
60
40
Death forevery 1000live birt 20
0 Riau Bali Bali Jambi Papua Banten DI Aceh Maluku Lampung Bengkulu East Java East Gorontalo West Java West DKI Jakarta DKI Riau IslandsRiau West Papua Central Java Central North Maluku DI Yogyakarta West Sumatra West North Sumatra South Sumatra West Sulawesi North Sulawesi East Kalimantan South Sulawesi Bangka Belitung West Kalimantan West Central Sulawesi South Kalimantan South Central Kalimantan East Nusa Tenggara South-east Sulawesi West NusaTenggara
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
Infant mortality, 2008 150 100
Congo,Niger Rep. Uganda West Sulawesi West Nusa TenggaraTanzania Cambodia Zimbabwe North Maluku Timor-LesteIndia Papua New Guinea 50 West Sumatra Riau Islands South Sumatra Bangladesh West Java Riau DKI Jakarta East Kalimantan Infantmortality per 1000 livebirth DI Yogyakarta VietnamChina Ukraine
San Marino 0
Indonesia Other countries Source: IDHS (2007) & WDI 2009
World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.
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Indonesia also performs less well on maternal mortality for its income level in international comparisons.
17
MATERNAL MORTALITY, 2008
Vietnam Sri Lanka
China Thailand Malaysia Bangladesh India
Lao PDR Indonesia Attainment relative to income to relative Attainment Below average Above average Below average Above average
Attainment relative to health spending per capita Source: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008
World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.
And will need extra efforts to achieve the MDG of reducing maternal deaths by 75 percent by 2015. 18
The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.
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Underweight among children under five years of age has declined significantly… 19
40 Moderate 37.5 Severe 35 35.5 Underweight 31.6 30 29.5 28.2 27.3 27.5 28 26.4 26.1 25 24.6 31.2 28.3 20 20 19
Percentage 19.6 19.2 18.4 18.3 19.3 19.2 17.9 17.1 19.8 15
13 13 10
5 11.6 10.5 7.2 8.1 7.5 8 8.3 8.6 8.8 6.3 6.3 5.4 4.9 0 1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007 2010
Source : Susenas 1989-2005, Riskesdas 2007-2010
…however, stunting rates, which are an indicator of chronic malnutrition, remain very high.
20
Stunting Among Children under 5 years old, 2000-2009
Sri Lanka Thailand Bangladesh Vietnam ChinaIndonesia IndiaLao PDR Attainment relative to income to relative Attainment Below average Above average Below average Above average Attainment relative to health spending per capita Source: WDI 2009, WHO 2008
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Health Spending Trends
21 By any measure Indonesia’s public spending on health is low and inequitably distributed:
Indonesia’s public health spending as a proportion of GDP has stagnated in recent years and compares unfavorably with other comparable income countries. Indonesia’s Out-of-Pocket (OOP) spending is about average for its income level and has improved in recent years. Indonesia does reasonably well on reducing catastrophic spending incidence but less well on health insurance coverage and equity. Public spending on health is inequitably distributed across provinces and income quintiles.
Despite substantial increases in government health expenditures as a share of GDP over recent years, Indonesian governments barely spends 1 percent of GDP on health. 22
Government health expenditures by level of government (2001-2009)
45 1.2%
40 1.0% 35
30 0.8%
25 0.6% 20
15 0.4%
10
IDR Trillions (constant2007 prices) 0.2% 5
0 0.0% 2001 2002 2003 2004 2005 2006 2007* 2008* 2009**
Central Province District Share of GDP
World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.
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Total and public health spending in Indonesia is low relative to other comparable income countries.
23
TOTAL HEALTH SPENDING VS INCOME, 2008 GOVERNMENT HEALTH SPENDING VS INCOME,2008 15 15 10 10
Vietnam Cambodia 5
5 Samoa Samoa Lao PDR ChinaThailand Malaysia Vietnam Thailand
Total Health Spending (% GDP) (%Total Health Spending Indonesia China Malaysia Cambodia Indonesia GovernmentGDP)(% Health Spending Lao PDR 0 0
100 250 1000 10000 25000 10 100 250 1000 10000 25000 GDP per capita GDP per capita Source: World Development Indicators 2009, WHO 2008 Source: World Development Indicators 2009, WHO 2008 Note: GDP per capita in current US$; Log scale Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
And government health spending as a share of the budget is even lower than total government expenditures as a share of GDP. 24
Government spending vs income, 2004-2006 50 40 Government spending (% GDP) 30 20 Indonesia
Government health spending (% budget) 10
Indonesia Governmentspending GDP) (% Government health budget) spending (%
100 250 1000 2500 10000 25000 GNI per capita (US$) Source: WDI
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
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OOP spending, a measure of financial protection, is about average relative to comparators.
25
OOP spending as share of total health spending vs Income per capita, 2008 80
Cambodia Lao PDR 60 Vietnam Philippines China
Malaysia 40
Indonesia 20 (% total health spending) Thailand
Out-of-pocket healthspending Samoa 0
100 250 1000 10000 25000 GDP per capita, current US$ Source: World Development Indicators 2009, WHO 2008 Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Financial protection, measured as the OOP share of nonfood spending has improved. 26
Source: Equitap Update 2009.
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By regional standards, the incidence of catastrophic health spending is low in Indonesia.
27
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0 % of households exceeding threshold
0.0 Malaysia (1999) Taiwan (2000) Indonesia Thailand Hong Kong Sri Lanka Philippines Indonesia Korea (2000) Nepal (1996) India (2000) China (2000) Bangladesh Vietnam (1998) (2006) (2002) (2000) (1997) (1999) (2001) (2000)
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)
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Equity of public spending on health could be improved; it is low in international comparisons and has not changed much since 2001.
28
Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region
45%
y 40% 35% 30% 25% 20% 15% 10%
Poorest quintile share of subsidof share quintile Poorest 5% 0% Shanxi province(China) 2003 Heilongjiang (China) 2003 Zhejiang (China)2003 Gansu (China) 2003 Indonesia 2001 Indonesia 2006 India 1996 Mongolia* Bangladesh 2000 Vietnam 2003 Malaysia 1996 Thailand 2002 Sri Lanka 2004 Hong Kong 2002
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
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Inequities between provinces are also evident from differences in health expenditures.
29
District Public Health Expenditures by Province (2005)
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
Technical efficiency is low in Indonesia in global comparisons and there are large differences between provinces.
30
average average 100 case-flow 100 case-flow A: high case-flo w C: high case-flow A: high case-flow C: high case-flow low occupancy high occupancy low occupancy high o cc upancy
80 ) 80 ear
y Banten NTT
er er KalBar p Kalseng T 60 NTB 60 M N Bangka Belitung B a l i DKI Jakarta Sumsel SultengSulsel C UK Jatim Sulteng Irian Jaya Tengah
er bed er Bengkulu My s V R i a u JatengJabar p KaltimDIY F L Kalteng Lampung G A Ir l Sumbar average N A D TkUS HAus E average 40 J a m b i Irian Jaya Bar at bed occupancy 40 Idn HKI bed occupancy Sumut cases cases Ch ( PB Cdn Irian Jaya Timur S CZ Maluku Nl D Mng
case-flow (casecase-flow year) bed per per Sulut CN 20 20 Tw Rok case-flow case-flow J B: low case-flow D: low case-flow B: low case-flow D: low case-flow low occupancy high o cc upancy 0 low occupancy high occupancy 0 0 102030405060708090100 0 102030405060708090100 percent bed occupancy rate percent bed occupancy rate
Technical efficiency is ideally measured using case-mix unit cost data, however these are not available in Indonesia. Instead case-flow and average bed occupancy are used.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
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Indonesia’s Health Delivery System
31 An already stretched health system will incur further pressure due to increased demand from ongoing demographic, nutrition and epidemiological transitions as well as the introduction of universal health insurance coverage. Indonesia’s health infrastructure, although widely available for primary care, does not have sufficient beds or health workers to respond to these increased needs. Pharmaceutical supplies are reasonable but most Indonesian pay more than they need to and most expenditures are out of pocket. There is a pressing need to address human resources distribution inequities and quality. Satisfaction levels overall are good although there is a high level of dissatisfaction with various aspects of health care.
Indonesia’s primary public health care system is extensive: more than 90 percent of the population has access to primary care facilities. 32
Ratio Puskesmas per 100,000 Population
3.9
3.8
3.7
3.6
3.5
3.4
3.3
3.2 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: MoH. 2010. Health Profile.
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While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators.
33
HOSPITAL BED SUPPLY VS INCOME, 2000-2010 15 10 5 HospitalBeds per 1,000 Vietnam ThailandChina Malaysia Lao PDR PhilippinesSamoa Indonesia
0 Cambodia 100 250 1000 10000 25000 GDP per capita, current US$ Source: World Development Indicators 2009, WHO 2008 Note: GDP per capita in current US$; Log scale
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
And Also Fewer Health Workers
34
DOCTOR SUPPLY VS INCOME, 2000-2010 MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010 8 20 6 15 4 10
Doctor per 1,000 per Doctor Philippines 2 5
China 1,000 per Midwives/Nurses Philippines Malaysia Vietnam Malaysia SamoaThailand Lao PDR Thailand CambodiaLaoVietnam PDR Indonesia Cambodia IndonesiaSamoa 0 0
100 250 1000 10000 25000 100 250 1000 10000 25000 GDP per capita, current US$ GDP per capita, current US$ Source: World Development Indicators 2009, WHO 2008 Source: World Development Indicators 2009, WHO 2008 Note: GDP per capita in current US$; Log scale Note: GDP per capita in current US$; Log scale
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
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At the Puskesmas level most basic services are available.
35
Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult Curative Care (by Clinical Setting)(2007) Quality Measures Public Settings Private Settings Puskesmas Pustu Private Private Private All Nurse Midwife MDs Settings
Structural quality Internal water source (%) 89 71 80 84 89 84
Inpatient beds (%) 28 3 3 28 3 18 Functioning microscope (%) 79 5 1 3 7 25
Tuberculosis service (%) 95 30 8 2 44 38 Measles 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
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
Secondary and tertiary care have not progressed equally: the number of hospitals and hospital beds has grown slowly.
36
Increase in numbers of hospital beds between 1995 and 2006 by ownership
140000
120000
100000
80000
60000
40000
20000
0 1995 1997 2000 2003 2005 2006
MoH Province, district, municipal Armed forces, police State-owned Private
World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
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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
1,200 16 14 1,000 12 800 10 center 600 8 Ratio 6 Health 400 # 4 200 2 0 0 Bali Riau Jambi Papua Maluku Lampung Bengkulu East Java East Gorontalo West Java West DKI JakartaDKI West Papua West Central Java Central North Maluku West Sumatra West North Sumatra West Sulawesi West D I Yogyakarta North Sulawesi South Sulawesi South Sumatera East Kalimantan Central Sulawesi Central West Kalimantan West Riau Archipelago South Kalimantan Central Kalimantan South East Sulawesi East Nusa Tenggara Nusa East West Nusa Tenggara Nusa West NanggroeDarussalam Aceh Bangka Belitung Archipelago
Source : Indonesia Health Profile, 2010 Puskesmas Hospital Bed per 10,000 pop Puskesmas per 100,000 pop
The ratio of physicians to population also masks significant inequities among urban and rural areas.
38
Source: KKI 2008.
19 4/16/2013
DPT3 immunization, often considered a good indicator of health system coverage, is low for Indonesia’s health expenditure level and may indicate low levels of efficiency. 39
Country Total health DPT3 expenditure pc immunization (US$) coverage
Indonesia 26 70
Uganda 22 84
Rwanda 19 95
Tajikistan 18 85
Tanzania 17 90
Nepal 16 75
Pakistan 15 80
Bangladesh 12 88
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Analysis of the number of staff per primary care facility illustrates inequalities at the facility level…
40
Other National Java‐Bali Sumatra Provinces
Facility 1997 2007 1997 2007 1997 2007 1997 2007 Puskesmas Number of Doctors 1.51 1.90 1.68 1.96 1.19 1.85 1.09 1.62 Number of Doctors (%) 3.4 7.0 1.5 5.9 2.0 6.8 15.9 11.3 Number of Midwives 5.85 3.69 5.76 3.44 6.33 5.28 5.62 3.18 Number of Nurses 5.05 6.14 4.58 5.60 6.16 7.16 5.84 7.61 Pustu Number of Midwives 0.98 0.81 1.06 0.76 1.13 1.17 0.44 0.21 Number of Nurses 1.08 1.06 1.02 1.09 1.16 1.08 1.16 0.89
Source: IFLS 1997; 2007.
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…and quality, measured as diagnostic and treatment ability, varies between regions and geographic areas and has not improved much over time. 41
Quality of Public Health Services in Indonesia 1997-2007 (by Region)
National Java/Bali Sumatra Other Provinces Service 1997 2007 P= 1997 2007 P= 1997 2007 P= 1997 2007 P= Prenatal Care Public 42 46 *** 45 47 ** 35 39 ** 38 49 *** Private 40 44 *** 43 46 *** 34 37 ** 39 46 *** Child Curative Care Public 56 64 *** 58 66 *** 48 56 *** 55 65 *** Private 55 59 *** 57 62 *** 50 52 54 60 *** Adult Curative Care Public 49 56 *** 52 59 *** 43 48 *** 44 53 *** Private 46 53 *** 48 56 *** 40 51 *** 44 51 *** *** p<0.01, **p<0.05
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
In international comparisons Indonesia spends little on medicine per capita, and most expenses are out-of-pocket.
42
Spending on drugs per capita in US$
Thailand
Malaysia
Vietnam
Philippines
Cambodia
Indonesia
India Government Private
0 5 10 15 20 25
Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less than US$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming the central government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide all the primary care medicines recommended by WHO.
Source: WHO. 2004. The World Medicines Situation.
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But most Indonesians pay more than they need to for their medicines when they buy from the private sector or from public hospitals. 43
Price ratio to Originator Most sold Lowest price median brands branded generic international generic indicator price
Private 22-26 6-7 2.6 pharmacies
Public hospitals 22 1.7-6 2.15
Source: National Institute for Health Research and Development (NIHRD) Survey 2004.
Provision of health services by private health providers has grown significantly over the past decade. 44
At the national level, physician practices per 1,000 of population grew at 38.5 percent The number of midwife practices per 1,000 population increased by 4.64 percent.
And the majority of physicians working in a Puskesmas supplement their income through private service provision
World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.
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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
100% 4.9 3.2 4.5 3.8 2.9 2.8 2.5 1.8 2.6 2.8 2.6 2.7 2.3 2.3 90%
80%
70% 47.4 50 50.9 53.7 55.8 55.3 54.1 60%
50%
40%
30% 43.3 47.7 20% 43 40.1 38.5 39.9 41 10%
0% 2004 2005 2006 2007 2008 2009 2010 Public Private Traditional Other
Various Susenas : Worldbank staff calculation
However, most Indonesians continue to seek ambulatory care from private providers when ill. 46
100% 90% 80% 70% 60% 50% 40% 30% 2007 20% 1997 10% 0%
Source: IFLS 1997 & 2007.
23 4/16/2013
Overall consumer satisfaction with inpatient and outpatient services appears good…
47
70 65.2 59.7 60 58 .1
50
40 32.2 31.3 32.3 30
20
10 7.7 7.2 3.3 1. 2 0.9 0.2 0.00.9 0.0 0 GDS2 (N=7.916) Susenas-Inpat ient (N=19.294) Susenas-Out pat ient (N=2.657)
Satisf ied Somewhat satisfied Somewhat unsat isf ied Unsatisfied No response
Source: GSD2 and Susenas.
…although there is a high level of dissatisfaction with various aspects of the provision of health care… 48
Dissatisfaction With Various Aspects of Health Services (%)
21.7 waiting time 26.1 17.2 hospitality 13.6 24.2 information availability 24.1 29.7 involvement in… 32.8 25.6 private consultation 27.3 27.9 freedom of choice 26.8 21.7 cleanliness 18.3 family visit 11.6
0 10203040 percent
inpatient outpatient
Source: Sakernas National Health Survey 2004.
24 4/16/2013
…and many people continue to opt for self-treatment or forego treatment altogether.
49 100% 10.1 8.8 9.8 14.7 14.6 11.7 10.6
80%
45.1 46.5 46.2 51.7 44.2 60% 50.9 51.2
40%
20% 44.1 44.4 44.7 44.0 38.2 34.4 34.1
0% 2004 2005 2006 2007 2008 2009 2010 Facility visit, any Self treatment only No treatment
Source: Susenas various years.
Health Financing Reform
50
The new government is committed to implementing the reform and assuring all Indonesian citizens access to quality health services and financial protection against the impoverishing effects of large unpredictable medical care costs. Fulfilling this commitment will require the development, implementation, and monitoring of policies affecting all aspects of the health system – basic public health programs; delivery systems and logistical capacity; quality and distribution; organization, management, and accountability; pharmaceuticals; financing; public—private partnerships and all levels of government.
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Background
51
The 2004 Social Security legislation (Law No. 40) envisages coverage of the entire population through a mandatory health insurance system evolving from the existing insurance programs. As of 2009 the government has covered some 76 million poor and near poor through the Jamkesmas program, funded through the central government budget. However, progress over the last five years has been slow in developing the final configuration of the health insurance system and the transition plan to provide health insurance to the remaining 50+ percent of the population who currently lack coverage remains to be developed. Many local governments have developed their own financing schemes, some for the uncovered non-poor. The health insurance reform is complicated by the big bang decentralization reform that took place in 2001 which transferred most of the authority and responsibility for assuring service delivery capacity to local governments.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Health insurance systems in Indonesia since 2008.
52
Current Insurance Systems
Ministry of Ministry of Ministry of Ministry of Labor Finance Health Defense
Private Askes, Military Jamsostek insurance HMOs personnel
PT Askes: Jamkesmas Types: Social security Commercial Free health -Civil servants (scheme for Social HMO health insurance services -Commercial HMOs the poor)
Coverage 6.6. including Civil servant: 14 (millions of 4.1 personal 76.4 2 Commercial HMOs: 2 people) accident
Technical oversight Financial oversight
Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.
26 4/16/2013
The Current Health Policy Baseline for Health Financing Reform: System Strengths.
53
The country has favorable demographic circumstances with dependency ratios falling over the next 30 years There are high educational and literacy levels The government is committed to reform Health spending levels are not excessive The country achieves reasonable health outcomes, financial protection and consumer satisfaction There is substantial experience with health insurance programs There is an extensive primary care delivery system Pharmaceuticals are generally available
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
The Current Health Policy Baseline for Health Financing Reform: System Challenges.
54
Half the population lacks health insurance coverage Health financing and delivery systems are highly fragmented Human and physical infrastructures are limited and face quality and efficiency problems Salary and capital subsidies to public health providers preclude the development of a ‘level playing field’ for both public and private providers to compete on the basis of price Critical data for decision making are lacking, including national and subnational health accounts, detailed information on the numbers, risk profiles of the insured and the uninsured, and unit cost information Design features of the Jamsostek and Askes programs result in high OOP costs for program beneficiaries and limit operational effectiveness and sustainability Local contributions vary widely, current intergovernmental fiscal redistributions may not adequately reflect local fiscal capacity and need, and the fiscal capacity of districts vary widely.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
27 4/16/2013
Framework to Assess HI Financing Options. 55
What is the ‘ultimate’ HI system of Universal Coverage (UC) under Law No. 40: single unitary Social Health Insurance (SHI); or multiple systems under a single set of rules; or a unitary general revenue funded system (e.g., Jamkesmas for all)? What are the specific details of this system with respect to: single or multiple funds; eligibility of different groups including informal sector workers; benefits covered including cost sharing and referral requirements; financing including public subsidies and regional contributions; provider payment and cost containment; quality assurance; Administration; and the role of the private sector. What are the transition policies to get to (UC)?
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Future Vision 1: Jamkesmas for All: An Indonesian NHS. 56
This approach approximates a National Health Service like that in Sri Lanka. It reflects the fact that more than half of the population is currently poor or near poor, and thus has a very limited ability to pay. It also recognizes the inherent difficulty of identifying the 61 percent of workers who are in the informal sector and having them pay premiums. By picking up formal sector workers through general revenues, firms might be more competitive as their 3-6 percent payroll contributions would be eliminated and/or could be replaced by more efficient and equitable broad-based taxes.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
28 4/16/2013
Future Vision 2: A Single Integrated SHI Fund. 57
This approach approximates the ‘new’ national SHI model (now called Mandatory Health Insurance (MHI)) where the SHI is funded through both wage-based contributions for public and private sector workers (and retirees) and government general revenue contributions for the poor and other disadvantaged groups. Under this approach there would be a single standardized national HI fund (although one could also establish multiple funds as in Germany or Japan). The poor would be financed through the GoI budget, while government and private sector workers would be funded as now through wage-based contributions. The GoI would need to decide if informal sector workers would be covered by the GoI like the poor (as in Thailand) or whether mechanisms can be developed to make them contribute some share of their earnings.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Future Vision 3: MHI through a Single Set of Rules Applying to Multiple SHI and NHS Type Programs.
58
This approach could be considered as a variant of Option 2 or a combination of Options 1 and 2. Existing programs would be scaled up to include the entire population. All the poor and other disadvantaged groups would be covered through Jamkesmas. All private sector workers would be covered through Jamsostek (possibly though elimination of the opt out, employer size, and wage ceiling restrictions and adding requirements to cover retirees). Civil servants and civil service retirees would be covered through Askes (or the Askes program could be folded into Jamsostek, or conversely). A decision would need to be made about how to handle informal sector workers. The three programs would have separate administrative structures but would operate under the same set of rules concerning issues such as benefits and contracting/provider payment. There might be cross-subsidies required across programs on the financing side.
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
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No Matter Which Option is Chosen, The Devil Will Be in The Detail. 59
Administrative and governance arrangements Defining the benefit package Determining eligible groups Determining purchasing/contracting arrangements and cost containment policies Estimating actuarially sound premium levels Determining financing sources Defining revenue collection mechanisms Defining transition steps to new system Developing and implementing monitoring and evaluation procedures
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
Actuary Estimates
60
The purpose of the actuarial estimates was to respond to the GoI request to assist in developing baseline estimates for the cost of existing health insurance programs and to perform an actuarial analysis to cost different options for attaining UHIC.
It demonstrates the importance of the decisions to be taken regarding the detail as each decision influences the level of financing needed.
The exercise included the development of a baseline based on the 2008 Askes claims data, the creation of a range of baselines and the creation of various scenarios.
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CMPM estimation which include out-of-pocket (OOP) expenses, subsidies to the public system and supply constraints assumption in various scenarios, provides a more 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 an expenditure range between Rp 127 trillion (6.66 percent of total public expenditures and 1.17 percent of GDP) and Rp 221 trillion (11.58 percent and 2.03 percent).
62
Source : Actuarial costing of Universal Health Insurance Coverage in Indonesia : Options and Preliminary results, Worldbank 2011
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More Resources for Health; Assessing Fiscal Space
63
In all likelihood, and for a variety of reasons, Indonesia will need to boost health spending in the near future as it expands access to care through the expansion of Jamkesmas, the health insurance scheme for the poor and the near poor.
In addition, projections based on demographic and epidemiological changes in the country indicate there is likely to be a significant increase in the demand and need for health services and more sophisticated care.
Despite a tripling of the public budget for health over the past five years, this increased need, combined with the fact that Indonesia remains a comparatively low spender on health, indicates that there will continue to be upward pressure on resources for the health sector in the near future.
Visualizing fiscal space for Indonesia: different means by which government spending on health can increase.
64
Fiscal space for health (increase as % of government health spending)
Conducive macroeconomic conditions
Efficiency Reprioritization
1 2 3 4 5 6 7 8 Other sector-specific resources Sector-specific foreign aid
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
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One of the most important determinants of fiscal space for health is economic growth which has a positive outlook in Indonesia.
65
Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for the country, although growth remains in the 6-7 percent range per annum over the period 2008-2013. 8
Pre-crisis forecast 7 6
Post-crisis forecast Real GDP growth rate growth GDP Real 5 4
2003 2005 2007 2009 2011 2013 Year Source: IMF
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Higher revenues provide extra resources, but Indonesia’s revenues as a percentage of GDP (19 percent) are low in comparison with other lower- middle-income countries. 66
Higher income
Upper middle
Middle income
Lower income
0 5 10 15 20 25 30 35 40
Revenue (% of GDP), 2003-2006
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
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Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health. 67
With subsidies declining again (in 2009) there might be increased space for the health sector 7%
6%
5% Subsidies
4%
3% % of GDP % of
Interest payments 2% Education Infrastructure 1% National Defense Govt Apparatus Agriculture 0% Health 1994 1996 1998 2000 2002 2004 2006 2008*
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.
68
12
10
8
6
4
2
0 1995 1997 1999 2001 2003 2005 External resources (% of total health spending)
Source: WHO.
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In addition to increasing budgets for health, effective fiscal space may be generated by increasing the efficiency of spending.
69
Sri Lanka is often presented as an example of a country that has been able to attain excellent health outcomes with relatively low levels of resources, in part because of the underlying efficiency of its health system.
Performance relative to income and health spending, 2008
Under-five mortality Maternal mortality 3 3 2 2 1 1
0 0 Indonesia
Indonesia -1 -1 Sri Lanka Sri Lanka -2 -2 Above averageAbove Below average averageAbove Below average Performancerelative to per capita health spending Performancerelative to per capita health spending
-3 Above average Below average -3 Above average Below average -3 -2 -1 0 1 2 3 -3 -2 -1 0 1 2 3 Performance relative to income percapita Performance relative to income percapita
Source: WDI 2009
World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.
Local variation in performance across districts further indicates potential efficiency gains.
70
DPT3 immunization Skilled birth attendance Japan Kota Padang Panjang Kota Kediri Ukraine 100 100 China Kab. Tana Toraja Vietnam Kab. Kediri Kab. Semarang Turkey Kab. Madiun Bangladesh Uganda Pakistan 80 80 Kab. Bantul Kab. Kuningan Kab. Ciamis Kota Ambon Nepal Indonesia Kab. Morowali Kab. LombokIndonesia Barat Kab. Subang Kab. Barito Selatan Kab. Barru Kab. Asmat Papua New Guin 60 60 Kab. Parigi Moutong Kota SingkawangIndia Timor-Leste
attendance Senegal Kab. Hulu Sungai Utara Kab. PurbalinggaBhutan Tanzania
Kab. Bombana Kab. Bangka Tengah birth Cambodia
40 Niger 40 Somalia Kab. Nias Selatan Kab. Wonosobo Burundi Skilled Pakistan
Chad 20 20
Bangladesh Kab. Pakpak Bharat Ethiopia Kab. Yahukimo 0 0
Indonesia Other countries Indonesia Other countries
Source: Susenas and WDI.
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Focus on MDG 5: Reducing Maternal Death
71
At least 10,000 women continue to die of childbirth-related causes every year in Indonesia. Even though skilled birth attendance has increased significantly, more needs to be done to accelerate a reduction in deaths and achieve MDG5. A large number of women continue to deliver at home without professional help. High levels of uncertainty about medical expenses continue to delay the decision to seek care at a facility. Even when women reach a facility on time, quality of management is poor and death rates at facilities remain high, especially, but not only, in poor areas.
There has been an impressive improvement in skilled birth attendance since 1987, but the poor continue to lag behind.
72
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Disparities exist between province, economic quintiles, and education levels.
73
Delivery assistant & place by province 100
80
60
40 percentage
20
0 Bali Riau Jambi Papua Banten Maluku DI Aceh East Java Lampung Bengkulu West Java Gorontalo DKI Jakarta West Papua Central Java Riau Islands North Maluku West Sumatra DI Yogyakarta West Sulawesi South Sumatra North Sumatra South Sulawesi North Sulawesi East Kalimantan Bangka Belitung Central Sulawesi West Kalimantan South Kalimantan Southeast Sulawesi Central Kalimantan East Nusa Tenggara West Nusa Tenggara
Data source : IDHS 2007 % SBA % Facility base delivery
Most poor women continue to deliver their babies at home with traditional birth attendants (TBAs) where the risk of maternal death is highest… 74
100 800 90 700 80 600 70 60 500 50 400 40 300 30 Death Maternal 200 20 per 100,000 Live Births 10 100 % ANC/Professional delivery % ANC/Professional 0 - Poorest Poorer Middle Richer Richest
ANC/Prof del ANC/No prof del No care (No ANC/No prof del) No ANC/Prof del MMR
Source: DHS 2007.
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…even though midwives are almost everywhere and are equally distributed.
75
Government target is 100 midwives per 100,000 population by 2010.
Note: All types of midwives included. Source: Indonesia Health Profile 2008.
Midwife availability has increased significantly, however, TBA remains the preferred choice of provider for childbirth. 76
SBA VS Ratio midwife, 2007 SBA VS Ratio TBA, 2007 120 120
100 DKI 100 DKI DIY DIY
CJ CJ
80 EJ 80 EJ
WJ WJ 60 60 % Delivery% by health professional Delivery% by health professional 40 40
20 40 60 80100 200 400600 Ratio midwife per 100000 pop Ratio TBA per 100000 pop
Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007) Ratio Traditional Birth Attendant (TBA) (PODES, 2008) Note Abbreviation: DKI=DKI Jakarta, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java
World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.
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There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas. 77
Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.
78
Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
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Ob-Gyns provide the most comprehensive services but reach only a limited population.
79
Antenatal Care Services by Type of Assistance in West Java (DHS 2007)
World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.
Four areas for priority action to improve the health status of Indonesian mothers: Being implemented in ongoing pilots.
80
1. Improving coordination between public and Increase research into near miss and maternal death for private sector services at provincial and better understanding of the local contributing factors. Use district levels 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 2. Strengthening coordination between among women of reproductive age •Address the unmet need for access to emergency obstetric community-based services and hospital services 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
3.Reducing financial barriers to utilization of •Review the social insurance coverage amounts to expand maternal health services 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 4. Improving clinical skills and quality assurance Bidan di Desa by building on existing initiatives (such as Bidan Delima) and linking quality of care to accreditation and certification. •Look at the implementation of the comprehensive emergency obstetric services to find areas of improvement.
World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.
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Logical Framework (intervention model) 81
Access • Financing • Transportation
PUSKESMAS + Private Clinic
Increasing the Pregnant HOSPITAL MOTHER AND DEMAND women & (pub;priv) BABY Comm. SURVIVED CONTINUUM OF CARE AND WELL
Quality of Obstetric Care • Quality assurance in health facilities • Accreditation • Referral network • Recording and reporting system
Focus on Jamkesmas Update in December 2011
82
IMPACTS TO DATE: Coverage has effectively been increased and an estimated one- third of the population is currently being covered, according to official data (Susenas survey data indicates lower coverage rates). Forty-three percent of those covered are poor and near-poor households. Utilization of health services among Jamkesmas beneficiaries has increased, especially for inpatient services. Jamkesmas has a protective effect on the OOP health expenditures of the poor and near-poor; those with Jamkesmas coverage have lower OOP payments (a measure of financial protection) and Jamkesmas beneficiaries have a lower incidence of catastrophic medical expenditures when compared with those with no insurance or those with other forms of insurance. Geographic analysis shows significant increases in inpatient utilization in the poorest provinces (NTT, Papua, Maluku).
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Almost half of population covered by health insurance, and nearly 30% of population covered by Jamkesmas
83
Household-level insurance coverage, 2004-2010 60
34 36 36 37 37 40 43 40
1.3 2.3 1.7 3.7 2.8 1 1.1 2.2 4.5 20 3 2.6 2.5 5.2 2.3 .9 2.8 2.6 3.1 5 1.9 3.1 2.9 2.9 4.5 4.8 5.1
Number of households (million) 4.3 4.2 16 13 11 10 9.9 5.7 6 0 2004 2005 2006 2007 2008 2009 2010 Jamkesmas/Askeskin/Health Card Askes Jamsostek Private Other No insurance
Data source : Susenas 2004-2010
High utilization of outpatient care among those who covered by Jamkesmas, increase used of Jamkesmas for outpatient and inpatient care
84
Outpatient utilization rate, 2004-2010 Inpatient utilization rate, 2004-2010 by insurance type by insurance type
All Bottom 3 deciles All Bottom 3 deciles .2 .2 4 4
Jamkesmas/Askeskin/Health Card 3.5 Jamkesmas/Askeskin/Health Card Other insurance 3 3 .15 .15 2.5 Other insurance .1 .1 Other insurance 2 2 Other insurance Jamkesmas/Askeskin/Health Card No insurance percentage percentage Utilization rate Utilization rate
No insurance 1.5 1 1
.05 .05 Jamkesmas/Askeskin/Health Card No insurance
.5 No insurance 0 0 0 0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2003 2004 2005 2006 2007 2008 2009 2010 2011 2003 2004 2005 2006 2007 2008 2009 2010 2011 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year Year Year Year
Source: SUSENAS 2004-2010 Source: SUSENAS 2004-2010
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health spending is highest among households that had at least one inpatient utilization visit among any of the family members
85
OOP health expenditure As share of total consumption by utilization pattern by utilization pattern .15 5.0e+06 4.0e+06 .1 3.0e+06 (Rupiah) 2.0e+06 .05 of total consumption expenditure Household health expenditure share expenditure health Household Household health expenditure in past in year expenditure health Household 1.0e+06 0 0 00 10 01 11 00 10 01 11 Utilization pattern Utilization pattern
Source: SUSENAS 2010 Utilization pattern: 00=0 outpatient and 0 inpatient visits; 10=1 or more outpatient and 0 inpatient visits 01=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 2004-2010 86 Health expenditure and health share of household expenditure among those with at least one inpatient visit, 2004-2010
All No insurance Jamkesmas/Aske Other insurance skin/ Kartu Sehat Year Health Health Health Health expenditure expenditure expenditure expenditure (share of total (share of total (share of total (share of total expenditure %) expenditure %) expenditure %) expenditure %) 2004 Rp 1,629,763 Rp 1,626,499 Rp 1,006,313 Rp 1,898,414 (10.9%) (11.9%) (9.5%) (9.8%) 2005 Rp 1,881,057 Rp 1,856,633 Rp 1,155,444 Rp 2,308,581 (10.0%) (11.3%) (8.9%) (8.3%) 2006 Rp 1,653,611 Rp 1,867,575 Rp 893,536 Rp 1,944,168 (8.3%) (9.9%) (6.7%) (7.2%) 2007 Rp 1,738,784 Rp 1,846,480 Rp 1,104,266 Rp 2,126,047 (8.1%) (9.1%) (7.6%) (6.9%) 2009 Rp 3,066,949 Rp 3,171,209 Rp 1,959,415 Rp 4,054,062 (10.3%) (11.3%) (9.2%) (9.6%) 2010 4,151,826 4,145,972 1,955,121 6,152,485 (11.9%) (13.2%) (9.9%) (11.5%)
Source: 2008 data not included due to problems with expenditure module
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Annex: World Bank Studies for the HSR
87
Investing in Indonesia’s Health: Challenges and Opportunities for Future Public Spending. Health Public Expenditure Review – June 2008 Indonesia’s Doctors, Midwives and Nurses: Current Stock, Increasing Needs, Future Challenges and Options. Health Human Resources Review – January 2009 Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia– January 2009 Health Financing in Indonesia: a Reform Road Map – June 2009 New Insights into the Provision of Health Services in Indonesia: a Health Work Force Study – October 2009 ‘ and then she died’: Indonesia Maternal Health Assessment – December 2009 Actuarial Costing of Universal Health Insurance Coverage in Indonesia: Options and Preliminary Results – January 2011
Annex: Forthcoming World Bank Studies
88
Forthcoming:
Enhancing Health Equity and Financial Protection in Indonesia: How Well Does Jamkesmas do? Jamkesmas Review Paper -March 2012
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Annex: World Bank Policy Notes Series 89
Pharmaceuticals : Why Reform is Needed – March 2009 Accelerating Improvement in Maternal Health : Why Reform is Needed – June 2010 Financing Universal Coverage: Assessing Fiscal Space in Indonesia – July 2010 Achieving Universal Coverage: Different Stages of Harmonization of Implementing Health Insurance Information Systems – August 2010 Health Professional Education in Indonesia: Why Reform is Needed Maternal Health Meets Health Financing Actuarial Estimates : What would Universal Health Insurance Coverage by 2020 Cost?
Forthcoming:
45