Indonesia has a mixed health system with both public and private provision of care. Key achievements include increased life expectancy and reductions in communicable disease rates. However, challenges remain such as the dual burden of disease, natural disasters, weak health information systems, and high out-of-pocket expenditures. Future prospects include expanding the use of telemedicine, incentivizing an even workforce distribution, and passing more legislation to clarify the health system framework.

1. Health Systems in Transition
The Republic of Indonesia
Health System Review

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. 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
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
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. 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
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
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
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. 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. 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. 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. 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
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
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
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
• 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
• 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
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
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
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
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
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
• 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
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. 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. Based on the Health Systems in Transition
The Republic of Indonesia Health System Review, 2017
27

28. http://www.searo.who.int/entity/asia_pacific_observatory/publications/hits/Indonesia_HIT/en/
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