indonesia’s health system hasbullah thabrany universitas indonesia

Universitas IndonesiaDepok. 16424 IndonesiaUniversitas IndonesiaDepok. 16424 Indonesia

Personal view. [email protected]

Indonesia’s Health System

Hasbullah Thabrany Universitas Indonesia

H Thabrany-- Indonesian Health System 2

Indonesia: Mangeable?

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Some Basic Indicators

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Population in 2010 (million) 238 GNI/cap in 2008 (PPP intl $)

2.010(3.830)

Adult literacy rate (%) 92Life expectancy in 2008 67

HALE in 2007 60

IMR (per 1.000 LB) 31

U5 MR (per 1.000 LB) 41

MMR (per 100.000 LB) 420

Adult MR (per 1.000 pop) 206

HDI in 2010(rank)

0.600(108)

THE (% of GDP) 2.0HE per capita (US$) 42Private exp (% THE) 45.5Gov HE (% Gov total exp) 6.2OOP (% Private exp) 66.2Physician (per 10.000 pop)

1

Nurse (per 10.000 pop) 8Dentist (per 10.000 pop) <0.5Pharmacist (per 10.000 pop)

<0.5

Hosp beds (per 10.000 pop)

6


Healh Care System During New Order: 1967-1998

1. Rapid expansion of public health centers, public hospitals, and mandatory doctor deployments

2. One health center, one doctor, plus paramedics for every 10.000 people

3. One public hospital in every district. with at least four specialists (internist, obgyn, surgeon, and pediatrician)

4. Almost all doctors were public servants receiving basic government salary.

5. Doctors were allowed to have private practices to supplement their basic salary.

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Health Care System

Public:1. Central: Theory—Policy and Quality Control.

Practices—still dominanating operation of financing and delivery of hospitals

2. Provinces: Coordinationg and supervising policy and implementation. Arm length of Central

3. Districts/Cities: Autonomous in local regulations and implmentation. Run and manage public health centers (7,000) and sub health centers (22,000), and district/city hospitals (about 600)

5

Health Care System

Private:1. Primary care: health center, midwive practices,

nurse pratices (legally not recognized), doctor-solo practices, group practices

2. Supporting out-patient services: Clinical laboratories, dispensaries, drug stores, radiologies, etc.

3. Secondary: specialized practices/clinics (solo/group)4. Tertiary: Private hospitals (about 700)

6


Health Financing1. Financing to operate public facilities (public health centers and

public hospitals) was mainly the responsibility of the Ministry of Health. Local governments supplements funding

2. Rigid bureacratic fund channelling resulted in poor perception of quality of services, inconsistent supplies of medicals, equipments, and drugs

3. User charges had been nominal amounts. small. but on the basis of fee for services. Cost-recoveries were too low. 20-30%. Public hospitals offered first and VIP rooms and services for private payers.

4. Complaints of poor quality in public hospitals.5. Efforts to mobilize fund via the US HMO models failed

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Transtition Period. 1998-Now

1. Early 1990s. public hospitals experiented some autonomy on financial management.

2. Late 1990s. accountability of revenues in public facilities was problematic. The government took back financial autonomy.

3. Private hospitals and private clinics mushroomed due to poor public health facilities.

4. The doctors. However, were mostly from public servants (AM/PM mix). AM (theory) worked for the public . PM for private. In Practice. it has been indistinguisable

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Decentralization started 2001

1. 1998 financial crisis. started with exchange crisis when IDR plunged 400%. followed by massive reforms in politics. governances. legals. and all sectors

2. Health sector was decentralized given the authonomy of districts to manage. finance. and monitor health services.

3. The results stimulate growth in health financing. health providers. health education institutions. and health regulations

4. National data and information then became fragmented

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Achievments and Current Conditions

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HEALTH SYSTEM OUTCOME : progress in reducing infant and child mortality

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1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

0

5

10

15

20

25

30

35

40

20

37.5

18.4 18.7

11

Severe malnut.Moderate Malnut.RPJM 2009MalnutritionMDG targetRPJM 2014

Perc

enta

geChild Nutrition Status

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Maternal Mortality 390

334307

228

226

102117.7

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

Dea

th p

er 1

00.0

00 li

ve b

irths

.

Tren AK I S D K IMD G targetR P J M 2009R P J M 2014

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1980 1985 1990 1995 2000 20050

20

40

60

80

Infect. Dis.

CVD

Neoplasm

Perinatal

Maternal

Injuries

Mortality Study. NHHS

Prop

ortio

n of

dea

thEpidemiologic Transition :

1980 -2001

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H Thabrany-- Indonesian Health System 1510/11/2010

HEALTH SYSTEM UTILIZATION


Population Pyramide and Health Risks: 1970 - 2025

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HEALTH STATUS :Geographic disparity

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HEALTH STATUS :Economic disparity

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HEALTH SYSTEM UTILIZATION

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Health Reform and Financing. The Future

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Trend of Health Expenditure form Public Sector. 2001-2008

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Trend of Per Capita Expenditure for Health from Public Sector. 2001-2008

4.14.7

6.86 5.7

8.79.8

9.1

2.63.2

3.9 3.6 3.54.4 4.8 4.4

0.5 0.6 0.8 0.7 0.7 0.9 1.1 1.1

0

2

4

6

8

10

12

2001 2002 2003 2004 2005 2006 2007 2008

E xpenditure per c apita(US D)

National E xpenditure forHealth (% )

G ov't HealthE xpenditure as % ofG DP


Government Spending of Health Budget by Level of Administration


Lack of Primary Care Allocation: MoH Budget for Health Care for the

Poor (Jamkesmas) 2005-2008Program

Budget (Rp trillion)

2005 2006 2007 2008Community Health

Center (Puskesmas) 1.00 0.78 1.05 1.00

Hospitals 1.26 1.63 3.40 3.60

Total 2.26 2.42 4.45 4.60 Target (million

population) 60 60 76.4 76.4


Outpatient Utilization

Types of Facilities # users Rate (%)Puskesmas (Health Center) 2,107 4.95Clinic 419 0.98Private Practices 1,500 3.53Public Hospitals 305 0.72Private Hospitals 298 0.70Nurses 2,117 4.98Traditional 674 1.58Others 17 0.04Total 6,956 16.35

(n=42.540)


The Road to Universal Coverage for Primary Care

1. Expanding coverage to universal maternity care Nationally. expansion of current Medicaid scheme using DRG payment.

2. Expanding coverage for maternity care3. Local government initiatives to finance universal

health coverage. 1. Free health care at primary care2. Establishing comprehensive coverage via

insurance mechanism4. Still underway: National Health Insurance10/11/2010


Problem of Public Primary Care

1. Public primary care is the responsibility of local governments. with large variations of capacity of human resources and finance

2. Previous achievements of primary care had been deteriorated due to lack of commitment of local governments

3. Health system financing does not provide incentives to the development of public primary care

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Problems of Private Primary Care

1. Lack of standards and financing mechanisms lead to more demand for specialized health care

2. Overproduction and maldistribution of general practitioners lead to huge disparities between large and small cities/districts

3. Lack of incentives to undertake promotion and prevention at primary care levels

4. MoH starts putting more attention to primary care doctors

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Franchised Clinics—One of the Solutions

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Challenges for Strengthening Primary Care. both Public and

Private. are bigger than for secondary and tertiary care

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indonesia’s health system hasbullah thabrany universitas indonesia

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