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APO The Republic of Indonesia Health System Review (Health in Transition)

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APO The Republic of Indonesia Health System Review (Health in Transition)

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The Indonesia HiT reports the significant improvement in the health status of the population over the last 25 years through transitional period in all fields. However, the country faces remaining and foreseeing challenges in communicable diseases and emerging NCDs. The HiT concludes with the future challenges of expanding coverage of National health insurance scheme (JKN), reducing regional disparities in health-care services, managing resources and engaging private sector.

The Indonesia HiT reports the significant improvement in the health status of the population over the last 25 years through transitional period in all fields. However, the country faces remaining and foreseeing challenges in communicable diseases and emerging NCDs. The HiT concludes with the future challenges of expanding coverage of National health insurance scheme (JKN), reducing regional disparities in health-care services, managing resources and engaging private sector.

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APO The Republic of Indonesia Health System Review (Health in Transition)

  1. 1. Health Systems in Transition The Republic of Indonesia Health System Review
  2. 2. Health Systems in Transition: Indonesia Health System Review 2 Authors: Technical editors: Krishna Hort Walaiporn Patcharanarumol Note: Updated with data from Legido-Quigley H, Asgari-Jirhandeh N, editors. Resilient and people-centred health systems: Progress, challenges and future directions in Asia. New Delhi: World Health Organization, Regional Office for South-East Asia; 2018 Yodi Mahendradhata Laksono Trisnantoro Shita Listyadewi Prastuti Soewondo Tiara Marthias Pandu Harimurti John Prawira Suggested citation: Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Harimurti P, Prawira J, et al. The Republic of Indonesia Health System Review. Vol.7 No.1. New Delhi: World Health Organization, Regional Office for South-East Asia, 2017.
  3. 3. Indonesia: Socio-demographic profile  Overview of health system  Service delivery network  Governance and administration  Health financing  Infrastructure  Human Resources  Initial & recent reforms  Main findings  Progress made  Remaining challenges  Future prospects 3 Presentation outline: This map is an approximation of actual country borders. Source: https://www.who.int/countries/idn/en/
  4. 4. 4 Socio-demographic profile Area 1811942* sq. km Largest archipelago in the world Population • 264 Million (2017) • 49.9% Urban population • 2.4 TFR (2016) Life expectancy at birth m/f 67/71 (2016) GDP per capita: USD 3846.9 HDI 19 Expenditure on health % GDP 3.3 (2015) Source: World Bank, 2018 Indonesia socioeconomic indicators, selected years
  5. 5. 5 Mixed health system 1.1. Ministry of Health (MoH) & Ministry of Home Affairs key in HS organization 2.2. Public and private provision of care, and financing 3.3. National health insurance (for the poor/very poor) 4.4. UHC goal by 2019 5.5. Decentralized planning, and managing service delivery 6.6. MoH: operate tertiary and specialist hospitals; regulation, management of resources, supervision of SHIs Overview: Health system 1. Private sector a major player in health system 2. High OOP expenditures – 46% of THE 3. Limited health workforce numbers 4. Complex level of health burdens
  6. 6. Overview: Service delivery Provincial level: PHOs and provincial hospitals District level: DHOs and district hospitals Other:  Professional and institutional organizations  NGO and Development partners Patient pathways: Begins at primary care facilities  puskesmas and network as gatekeepers for JKN patients for referral treatment Outpatient care: Public sector primary care centralized around puskesmas and affiliated networks  Challenge of supplies and limited primary care across public sector  Primary care also provided private sector – 80% of GPs have private practices (2008) Inpatient care Delivered by public and private hospitals with limited services from private clinics  JKN offers a benefit package (outpatient & inpatient care) 6
  7. 7. 7 Central • Ministry of Health – limited service delivery, strategy, regulation, finances, increasing role in social insurance scheme Local (Provincial, district) • Decentralized – Financial and decision-making autonomy shifted to local government • Service delivery Other • Professional Organizations: Hospital, local government and for every health profession • Develop and regulate minimum competency standards for their respective professions • Civil society and external donors work with government across various health issues and health sector development Overview: Governance and Administration
  8. 8. 8 Overview: Health Financing Source: Indonesia National Health Accounts (WHO, 2017). Available from http://www.who.int/nha/en/ * System of Health Accounts 1.0 based. ** Including parastatal companies • THE has increased almost four fold between 1995-2014 to USD $299.41 per capita (purchasing power parity) • Private expenditure has remained high ~62% between 1995-2014 with OOP payments forming 46.9% of THE in 2014 • Overall health spending was 3.3% of GDP in 2015, ↑ from 2% in 1995 6% 6% 13% 13% 2% 47% 1% 11% 1% Percentage of total expenditure on health according to source of revenue, 2014 Central government Provincial government District government Social security funds Private insurance enterprise Private households OOPE Non-profit institutions serving households Corporations (other than health insurance) Rest of the world
  9. 9. 9 Overview: Health Financing – Health Insurance Schemes Indonesia’s National Health Insurance (Jaminan Kesehatan Nasional or JKN) • Introduced in 2014. Now includes all existing public health insurance programmes • Early focus on poor: 70% of members were subsidized poor in 2014 • 172m members in 2016. Universal health coverage aimed by 2019 • No co-payments under JKN • Ward class benefits determined by level of service (employment) and fees paid Benefits • Poor subsidized IDR 23000, Employer/Employee contribute combined 5% worker salary, informal/pension: premium based/rank Fees • USD $628m in 2017 due to low contributions from non-subsidized members and high expenses of medical costs Debt
  10. 10. Source: Mahendradhata et al., 2017 Number of beds in acute care settings Overview: Infrastructure • Private hospitals have increased from 352 in 1990 to 1553 (64.4% of all hospitals) • Only 51% of public hospitals accredited • Hospital beds increased by 84% since 1990 | Low ratio of inpatient beds to population • Hospitals distributed by population ratios: • 53.3% of hospitals are in Java-Bali regions cover 59.1% of the population and 7% land area • Rural areas have larger catchment areas creating barriers to care. • 9% of hospitals cover 9% of the population in eastern Indonesia but 29% of land area • Majority of private hospitals in Java-Bali, only 12.9% in central & eastern Indonesia 10
  11. 11. Overview: Human resources for Health Increase in health workers over the past decade Dual practice: Doctors (incl. specialists) less inclined to move to areas with less equipped facilities and lower income. 65.6% of surgeon and 81.2% of obstetrician income comes from private sectors Doctor, nurse, pharmacist and dentist to population ratios lowest in region:  Doctor: 0.25/1000 population  Nurse: 0.7/1000 pop.  Pharmacist: 0.05/1000 pop.  Dentist: 0.02/1000 pop. Source: WHO Regional Office for South-East Asia (2018) Trends in health worker density, per 10000 population 11
  12. 12. Overview: Major reforms • Increased authority and budget for local governments •Challenges: limited reporting to and lack of support from central government, low local capacity to supervise services Decentralization 1999 • Public sector: traditional to performance-based budgeting • Public facilities: puskesmas, hospitals developing more autonomy on recruitment, investment and LT planning Public sector reform, 2003 •To regulate medical education quality and boost numbers of physicians in remote areas and ‘primary doctor’ specialists •Challenges: limited primary doctor graduates, no salaries for graduate interns. Medical education reform, 2013 National Strategic Plan 2015-2019 12 •12 health sector objectives: including improving elderly and MCH, nutritional status, controlling disease and environmental health and increase access to quality basic health services 12
  13. 13. Overview: Reforms in Social Health Insurance 1998-2001: Health Card Programme and Social Safety Net for Health (JPS-BK) 2004: ‘Askeskin’ pro-poor social insurance programme 2008: Jamkesmas tax-based fee waiver scheme for the poor  Almost unlimited use of available health services in puskesmas and select hospitals Concurrent district government programme for near-poor and maternal health insurance scheme introduced 2014: JKN national social health insurance scheme  Shift to premium-based cover, members of other insurances now merged 13
  14. 14. 14 Achievements and progress made Significant increase in life expectancy Notable decrease in incidences and mortality rates of certain communicable diseases Strong primary and public health efforts through ‘puskesmas’ Infant and under-5 mortality rates reduced in line with MDG 4
  15. 15. 15 Achievements & progress: Puskesmas Central to primary health care strategy High basic utility, equipment Free drugs, vaccines to the poor Basic immunization programme Community- driven programme addressing NCD risk factors • Community-level primary health centres: central to primary care strategy • High levels of basic utilities and equipment: • 72% had clean water supply • 87% had 24hr access to electricity • 96% had stethoscopes • 94% had examination beds Community-led early detection, monitoring, follow up of NCD risk factors • Manages and delivers basic immunization programme
  16. 16. 16 Achievements & progress: Local and national programmes Healthy Indonesia Decentralization Desa Siaga National Programmes • Healthy Indonesia Program: National strategy to develop healthy communities with access to care. Consists of: • Paradigm of health, primary health care strengthening, national health insurance • Decentralization: locally led programmes, community partnerships including: • Water and sanitation services for low income communities • TB program: public-private coordination • TB mortality rate reduced by half
  17. 17. 17 • Dual burden of disease: Increasing NCD mortality, CD mortality still significant • Leading causes of death: Ischaemic heart disease, stroke and cancer • Indonesia has one of the highest rates of TB in the world • Neglected tropical diseases lead 111 million in poverty Remaining challenges: Dual burden of disease Source: Institute for Health Metrics and Evaluation, 2018 Main causes of death (%)
  18. 18. 18 • Leading causes of DALYs lost are the same as the leading causes of mortality: ischaemic heart disease, stroke and TB among communicable diseases • Higher obesity levels and ageing population contributed to tripling of diabetes incidence from 2011 to 2016 • 4 of 5 major risk factors contributing to DALYs have increased since 1990 • Indonesia the only nation in Asia not to ratify WHO Framework Convention on Tobacco Control Remaining challenges: Morbidity and DALYs Source: Institute for Health Metrics and Evaluation, 2018 Major risk factors contributing to DALYs lost (%)
  19. 19. 19 Remaining challenges: Natural and manmade disasters Source for both tables: Nomura S et al., 2017 Source: Center for Research on the Epidemiology of Disasters, 2018 Natural disasters, 1997-2017
  20. 20. 20 Remaining challenges: Health Information Systems Decentralization Weakened reporting: facilities building own reporting systems leading to duplication, redundancy and challenge of integration Non-compliance in reporting due to perceived voluntary nature| Private sector data not available Reporting systems Mortality reporting only completed if death certificate required Multiple separate reporting systems at central level: overlap, discrepancies created Road to effective HIS All puskesmas and hospitals to have online HIS linked centrally, interoperable Supplement incomplete data sets with national health surveys Early warning and response system: SMS based communication
  21. 21. 21 Remaining challenges: Quality of Care • Limited data to measure quality of care • Despite establishing policies on quality and safety of health care, implementation, monitoring and evaluation of their impact remains weak. • Existing evidence suggests: • Anecdotal evidence suggests low QoC • Quality scores low in public & private facilities recorded during ANC • Poor service readiness for immunization • Limited capacity of puskesmas to serve the needs of managing NCDs
  22. 22. 22 Remaining challenges: Maternal and child health High maternal mortality rate 98% of maternal deaths in Java/Bali hospitals Less than 40% quality rating for antenatal care in puskesmas and clinics Infant and child mortality double in the poorest quintile 61% of provinces had above average under-5 stunting rate Indonesia has among the highest maternal and child mortality rates regionally 23
  23. 23. 23 Remaining challenges: High OOPE Source: Ministry of National Development Planning, 2014b Percentage of households experiencing catastrophic levels of expenditure by province • No notable change in OOPE following JKN introduction • Rates of catastrophic expenditure higher when health service access is higher
  24. 24. 24 • 97% of medical equipment imported • Lower equipment ratios than most developing countries in South-East Asia • 56% of CT and all PET scanners in Java-Bali region • Incomplete equipment in public sector: • 65.6% of puskesmas had no working incubator • 83.4% had no laboratory facility • 35% of hospitals had complete medical equipment for obstetrics, paediatrics, internal medicine and surgery Remaining challenges: Equipment Source: (a) MoH registry/database (includes private and public health facilities). (b) Telephone survey of major hospitals by the Centre for Health Policy and Health Service Management/UGM, 2013 Number of functioning diagnostic imaging technologies, 2013
  25. 25. 25 Remaining challenges: Medicines • Self-medical using OTC medicines common • Estimated 5000 unlicensed drug stores, 90000 small stores and hawkers, doctors and other health workers [allegedly] participate in illegal sale of prescription drugs • Branded drugs three times the price of generic drugs. Innovator brand names are 20 times the international indicator price. • Private sector dominates sales with 75% of the market offering 16000 types of drugs, 10% of which are generic leading to higher OOP payments • Locals are usually unaware of substitutability of generic drugs • Limited action taken on suspected misuse and overuse of antibiotics in human, and livestock
  26. 26. Use of telemedicine Incentives for even workforce distribution Decrease barriers for foreign health workers Greater regulatory functions for health offices More legislation for clearer health system framework 26 Future prospects: Indonesia
  27. 27. Based on the Health Systems in Transition The Republic of Indonesia Health System Review, 2017 27
  28. 28. http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/Indonesia_HIT/en/ Access full publication at: THANK YOU

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