1. Universitas Indonesia Depok. 16424 Indonesia Universitas Indonesia Depok. 16424 Indonesia Personal view. hasbullah.thabrany@ui.edu Indonesia’s Health System Hasbullah Thabrany Universitas Indonesia

2. Indonesia: Mangeable? 10/11/2010H Thabrany-- Indonesian Health System2

3. Some Basic Indicators 10/11/2010H Thabrany-- Indonesian Health System3 Population in 2010 (million)238 GNI/cap in 2008 (PPP intl $) 2.010 (3.830) Adult literacy rate (%)92 Life expectancy in 200867 HALE in 200760 IMR (per 1.000 LB)31 U5 MR (per 1.000 LB)41 MMR (per 100.000 LB)420 Adult MR (per 1.000 pop)206 HDI in 2010 (rank) 0.600 (108) THE (% of GDP)2.0 HE per capita (US$)42 Private exp (% THE)45.5 Gov HE (% Gov total exp)6.2 OOP (% Private exp)66.2 Physician (per 10.000 pop)1 Nurse (per 10.000 pop)8 Dentist (per 10.000 pop)<0.5 Pharmacist (per 10.000 pop)<0.5 Hosp beds (per 10.000 pop)6

4. 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. 10/11/20104H Thabrany-- Indonesian Health System

5. 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

6. 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

7. Health Financing 1.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 10/11/20107H Thabrany-- Indonesian Health System

8. 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 10/11/20108H Thabrany-- Indonesian Health System

9. 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 10/11/20109H Thabrany-- Indonesian Health System

10. Achievments and Current Conditions 10/11/201010H Thabrany-- Indonesian Health System

11. HEALTH SYSTEM OUTCOME : progress in reducing infant and child mortality HEALTH SYSTEM OUTCOME : progress in reducing infant and child mortality 10/11/201011H Thabrany-- Indonesian Health System

12. Child Nutrition Status 10/11/201012H Thabrany-- Indonesian Health System

13. Maternal Mortality 10/11/201013H Thabrany-- Indonesian Health System

14. Epidemiologic Transition : 1980 -2001 10/11/201014H Thabrany-- Indonesian Health System

15. 10/11/2010H Thabrany-- Indonesian Health System15 HEALTH SYSTEM UTILIZATION

16. Population Pyramide and Health Risks: 1970 - 2025 10/11/201016H Thabrany-- Indonesian Health System

17. HEALTH STATUS : Geographic disparity 10/11/201017H Thabrany-- Indonesian Health System

18. HEALTH STATUS : Economic disparity 10/11/201018H Thabrany-- Indonesian Health System

19. HEALTH SYSTEM UTILIZATION 10/11/201019H Thabrany-- Indonesian Health System

20. Health Reform and Financing. The Future 10/11/201020H Thabrany-- Indonesian Health System

21. Trend of Health Expenditure form Public Sector. 2001-2008 10/11/201021H Thabrany-- Indonesian Health System

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25. 10/11/2010H Thabrany-- Indonesian Health System25 Trend of Per Capita Expenditure for Health from Public Sector. 2001-2008

26. 10/11/2010H Thabrany-- Indonesian Health System26 Government Spending of Health Budget by Level of Administration

27. 10/11/2010H Thabrany-- Indonesian Health System27 Lack of Primary Care Allocation: MoH Budget for Health Care for the Poor (Jamkesmas) 2005-2008 Program Budget (Rp trillion) 2005200620072008 Community Health Center (Puskesmas)1.000.781.051.00 Hospitals1.261.633.403.60 Total2.262.424.454.60 Target (million population)60 76.4

28. 10/11/2010H Thabrany-- Indonesian Health System28 Outpatient Utilization Types of Facilities# usersRate (%) Puskesmas (Health Center) 2,1074.95 Clinic 4190.98 Private Practices 1,5003.53 Public Hospitals 3050.72 Private Hospitals 2980.70 Nurses 2,1174.98 Traditional 6741.58 Others 170.04 Total 6,95616.35 (n=42.540)

29. 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 care 3.Local government initiatives to finance universal health coverage. 1.Free health care at primary care 2.Establishing comprehensive coverage via insurance mechanism 4.Still underway: National Health Insurance 10/11/201029H Thabrany-- Indonesian Health System

30. 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 10/11/2010H Thabrany-- Indonesian Health System30

31. 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 10/11/2010H Thabrany-- Indonesian Health System31

32. Franchised Clinics—One of the Solutions 10/11/2010H Thabrany-- Indonesian Health System32

33. Challenges for Strengthening Primary Care. both Public and Private. are bigger than for secondary and tertiary care 10/11/201033H Thabrany-- Indonesian Health System