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Indonesia's Health Sector Review

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Indonesia's Health Sector Review 4/16/2013 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. 1 4/16/2013 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. 2 4/16/2013 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. 3 4/16/2013 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. 4 4/16/2013 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. 5 4/16/2013 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. 6 4/16/2013 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. 7 4/16/2013 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 Islands 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. 8 4/16/2013 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. 9 4/16/2013 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 10 4/16/2013 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.
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