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HF Efficiency Measures Indonesia CIMSA.pptx
- 1. Effectiveness on Health Financingfor Health Systems, Society and Solutions Health Financing / Health System Strengthening Unit WHO Country Office Indonesia
- 2. What is UniversalHealth Coverage (UHC)? 2 Benefit design and rationing along the three dimension of coverage • Universal Health Coverage is not (only) about JKN coverage • Three (3) dimension of coverage : • Provide all people with access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective (SDG 3.8.1) • Ensure that the use of these services does not expose the user to financial hardship (SDG 3.8.2). X: population coverage Y: cost coverage Z: service available x y z
- 3. WHO’s Response toHealth System Challenges: Source: Everybody business : strengthening health systems to improve health outcomes : WHO’s framework for action. World Health Organization. 2007 3 • Health system strengthening is defined as improving these six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes. It requires both technical and political knowledge and action.
- 4. 4 UHC Goals andIntermediate Objectives Influenced by Health Financing Policy Source: Health Financing Policy and UHC Pathways, WHO
- 5. 5 UHC Report -Global results overview “ The world is off track to make significant progress towards universal health coverage (UHC) (Sustainable Development Goals (SDGs) target 3.8) by 2030 as improvements to health services coverage have stagnated since 2015, and the proportion of the population that faced catastrophic levels of out-of-pocket (OOP) health spending has increased“
- 6. Indonesia Health Developmentthrough UHC Tracking Source: Global UHC Report 2023, WHO 20 40 60 80 100 0 5 10 15 20 2000 2005 2010 2015 2017 2019 2005 2010 2015 2017 2019 2021 2000 2005 2010 2015 2017 2019 Global Indonesia SE Asia Region UHC service coverage index (SDG indicator 3.8.1) Catastrophic out-of-pocket health spending (SDG indicator 3.8.2, 10% threshold) An increase in service coverage is better Less people with catastrophic health spending is better SDG 3.8.2 Financial Protection • Based on Catastrophic Health Spending in June 2021: 5.6 million people from poor households experienced catastrophic out-of-pocket (OOP) health expenditures (WHO, 2023). • In 2020, about 28.9% of total health expenditure came from OOP payments. The proportion of OOP to Total Health Expenditure (THE) continues to decline, although household contributions remain dominant (MOH, 2024). SDG 3.8.1 Service Delivery Tracer Indicator UHC SCI Index Reproductive, newborn, maternal and child health (RMNCH) Infectious Diseases (TB, HIV, Malaria, Sanitation) Non-Communicable Diseases (Hypertension, Diabetes, Tobacco non- use) Service Capacity and Access (Hospital bed, Health Workforce, IHR)
- 7. 7 Indonesia’s Health DevelopmentEnigma The National Health Insurance scheme or JKN has reached over 90% of the population or over 250 million Indonesians- making it one of the largest single payer programs in the world. Share of out-of-pocket health expenditure (in total health expenditure) has reduced considerably- from 45% (2014) to 32 % (2020) and catastrophic health expenditure to just 1.97% (2021). Domestic General Govt Health Expenditure (as % Current Health expenditure) has increased from 33% in 2014 to 55 % in 2020 (Source : GHED/GHO) Domestic Govt Health Expenditure as % of General Govt Expenditure has increased from 5 to 10 % (2014-2020) Impressive gains in economic growth and financial protection but key challenges remain at levels seen in low income and fragile countries Maternal mortality of 173 per 100,000 live births (2020) 3rd largest contributor to the global TB burden with 824,000 new cases (99,000 children) in 2020 and 93,000 TB deaths 1 in 4 stunted children, despite impressive improvements since 2018 Epidemiologic transition: emergence of non-communicable diseases and chronic conditions related to socio- demographic and lifestyle: underdiagnosed and undertreated • Performance (life expectancy, IMR, service coverage) below countries that invest same level of per capita • Many provinces (Maluku, Papua, West Papua) IMR worse than countries in Sub Saharan Africa (Somalia, Nigeria, Liberia) Source: WHO HSD SEARO 2023
- 8. Indonesia Heath FinancingLandscape 23,8% Formal Private Sector Poor/Near- Poor Informal Non-Poor Formal Public Sector General taxes 32,8% 41,4% Contributory, shared between employer (4%) and employee (1%) Public Private Line-item budget (salary, admin, medical goods) Ministry of Health (Central, Provincial, District) Capitation primary, DRG inpatient OOP Voluntary Health Insurance National Health Insurance (JKN) 2% Contributory, shared between employer (4%) and employee (1%) Contributory - flat-rates 1,2% Uncovered Health Service
- 9. 9 What is Efficiency? Whatit IS Doing the right things… …In the right places …In the right way The 3 R’s: a comprehensive, action-oriented approach to efficiency What it is NOT Balancing revenues and expenditures Cutting budgets These measures can actually reduce efficiency…
- 10. 10 Inefficiencies in theHealth Sector Series1 60-80% 20-40% Health resources Share wasted Sources of waste/inefficiency Wrong staff mix Under-use of generics Over- prescription Substandard and falsified products/medicines Hospital size Length of stay Corruption Fraud Excessive procedures Equipment overuse Poor quality care Medical error Absenteeism Ghost workers Lack of focus on public health and prevention
- 11. 11 Impact of HealthFinancing Inefficiency 1. To the Health Policy The impact to program planning and implementation, potentially leading to misalignment between government workplans and actual needs and increasing the risk of budget inefficiencies. 2. To the Health Program The negative impact to the service delivery and health outcomes of the population. Unavailability of fund affecting case finding, data quality, and program tracking. 3. To the Health Worker Delay of incentive, demotivation, low quality of service delivery, also potential of overwork. 4. To the People Unavailability of adequate health service (treatment, essential medicine and drugs) that will lead to out-of-pocket spending. For the poor and near-poor, even small out-of- pocket payments will represent financial hardship.
- 12. Indonesia Heath FinancingEfficiency Measure 23,8% Formal Private Sector Poor/Near- Poor Informal Non-Poor Formal Public Sector General taxes 32,8% 41,4% Contributory, shared between employer (4%) and employee (1%) Public Private Line-item budget (salary, admin, medical goods) Ministry of Health (Central, Provincial, District) Capitation primary, DRG inpatient OOP Voluntary Health Insurance National Health Insurance (JKN) 2% Contributory, shared between employer (4%) and employee (1%) Contributory - flat-rates 1,2% Uncovered Health Service Efficienc y Measure s Secure
- 13. 13 Australia Bangladesh Brazil Bhutan China Germany Egypt France UK India Japan Korea Sri LankaMaldives Myanmar Malaysia Nepal Philippines Thailand Turkiye USA Indonesia 0 10 20 30 40 50 60 70 80 90 100 SHI contributions shar 0 10 20 30 40 50 60 70 80 90 100 General taxation share of current health spending (%) Australia Bangladesh Brazil Bhutan China Germany Egypt France UK India Japan Korea Sri Lanka Maldives Myanmar Malaysia Nepal Philippines Thailand Timor-Leste Turkiye USA Viet Nam Indonesia 0 10 20 30 40 50 60 70 80 OOP share of health e 0 1 2 3 4 5 6 7 8 9 10 11 12 Public expenditure on health as share of GDP (%) Global Public Financing Landscape High OOP often consequence of low public financing for health Public financing largely SHI Public financing largely general taxation Public spending > 50% of total Public spending < 50% of total
- 14. 14 Health’s Share ofPublic Expenditures Region Health Educati on Defen se Intere st East Asia & Pacific 11% 15% 5% 4% Europe & Central Asia 10% 15% 8% 3% Latin America & Caribbean 14% 16% 4% 9% Middle East & North Africa 10% 15% 12% 10% South Asia 8% 12% 9% 12% Sub-Saharan Africa 9% 15% 7% 8% Global 11% 15% 7% 7%
- 15. 15 Health’s Share ofPublic Expenditures Globally, large variations in extent to which health is prioritized in government budgets: <3% to >25%. Political economy considerations key; results-focused reform efforts – in particular, efforts to explicitly expand coverage and improve quality of spending as opposed to efforts focused only on government budgetary targets – are more likely to result in sustained and politically-feasible reprioritization. Efficiency considerations are important: efficiency is in itself a source of effective fiscal space; but can also be important for attracting additional public resources from ministries of finance/planning. 22% 13% 10% 5% 51% 21% 7% 3% 1% 68% 20% 9% 3% 1% 67% 19% 11% 5% 2% 63% 17% 14% 5%2% 61% 15% 10% 3% 2% 70% 14% 14% 11% 0% 62% 13% 15% 5%2% 65% 11% 7% 3% 0% 79% 11% 16% 3% 8% 62% 11% 9% 4% 6% 70% 10% 19% 4% 11% 56% 9% 15% 9% 6% 60% 9% 15% 4% 7% 65% 9% 10% 9% 30% 43% 9% 20% 4% 7% 60% 8% 11% 5% 3% 74% 6% 12% 4%2% 75% 5% 12% 4% 34% 44% 4% 11% 14% 7% 64% 3% 17% 8% 18% 54% 3% 12% 8% 14% 63% 0 10 20 30 40 50 60 70 80 90 100 Percentage (%) USA Japan Germany UK Australia France Korea Thailand Timor-Leste Brazil Turkiye Indonesia Viet Nam Philippines Sri Lanka Malaysia China Nepal Egypt Myanmar India Bangladesh Share of public expenditure Health Education Defense Interest payments Other
- 16. 16 What to dofor Health Financing Efficiency? Efficiency of Health Budget Assess country’s economic situation – How much money available for health? Cross Program Efficiency Measure – Reprioritization Sector Specific Domestic Revenue Sources (tax, SHI, etc.) Improve Public Financial Management of Health Budget Evidence- based allocation for performance on equity and quality Strategic Purchasing Size of economy matters, but so does overall revenue effort, willingness/ability to manage the budget, and priority to health How much money a country spends on health depends on three things: 1. How much of the money they have goes to health (Health’s share). 2. How much money the country makes overall (Size of the economy ). 3. How much of that money the government collects and spends (Public spending ). Bigger economies can spend more, but it also depends on how much the government chooses to spend on health. Important to maximizing outputs/outcomes with available resources
- 17. Thank you For moreinformation, please contact: Name: Feby Oldfisra Title: National Professional Officer - Health Financing Email: oldfisraf@who.int
Editor's Notes
- #11 Families should not have to choose between spending on health or on other necessities such as food and education