Indonesia’s Health System Hasbullah Thabrany Universitas Indonesia

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

2. Indonesia: Mangeable? H Thabrany-- Indonesian Health System

3. Some Basic Indicators H Thabrany-- Indonesian Health System

4. Healh Care System During New Order: 1967-1998 • Rapid expansion of public health centers, public hospitals, and mandatory doctor deployments • One health center, one doctor, plus paramedics for every 10.000 people • One public hospital in every district. with at least four specialists (internist, obgyn, surgeon, and pediatrician) • Almost all doctors were public servants receiving basic government salary. • Doctors were allowed to have private practices to supplement their basic salary. H Thabrany-- Indonesian Health System

5. Health Care System Public: • Central: Theory—Policy and Quality Control. Practices—still dominanating operation of financing and delivery of hospitals • Provinces: Coordinationg and supervising policy and implementation. Arm length of Central • 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)

6. Health Care System Private: • Primary care: health center, midwive practices, nurse pratices (legally not recognized), doctor-solo practices, group practices • Supporting out-patient services: Clinical laboratories, dispensaries, drug stores, radiologies, etc. • Secondary: specialized practices/clinics (solo/group) • Tertiary: Private hospitals (about 700)

7. Health Financing • Financing to operate public facilities (public health centers and public hospitals) was mainly the responsibility of the Ministry of Health. Local governments supplements funding • Rigid bureacratic fund channelling resulted in poor perception of quality of services, inconsistent supplies of medicals, equipments, and drugs • 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. • Complaints of poor quality in public hospitals. • Efforts to mobilize fund via the US HMO models failed H Thabrany-- Indonesian Health System

8. Transtition Period. 1998-Now • Early 1990s. public hospitals experiented some autonomy on financial management. • Late 1990s. accountability of revenues in public facilities was problematic. The government took back financial autonomy. • Private hospitals and private clinics mushroomed due to poor public health facilities. • 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 H Thabrany-- Indonesian Health System

9. Decentralization started 2001 • 1998 financial crisis. started with exchange crisis when IDR plunged 400%. followed by massive reforms in politics. governances. legals. and all sectors • Health sector was decentralized given the authonomy of districts to manage. finance. and monitor health services. • The results stimulate growth in health financing. health providers. health education institutions. and health regulations • National data and information then became fragmented H Thabrany-- Indonesian Health System

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

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

12. Child Nutrition Status H Thabrany-- Indonesian Health System

13. Maternal Mortality H Thabrany-- Indonesian Health System

14. Epidemiologic Transition : 1980 -2001 H Thabrany-- Indonesian Health System

15. HEALTH SYSTEM UTILIZATION H Thabrany-- Indonesian Health System

16. Population Pyramide and Health Risks: 1970 - 2025 H Thabrany-- Indonesian Health System

17. HEALTH STATUS :Geographic disparity H Thabrany-- Indonesian Health System

18. HEALTH STATUS :Economic disparity H Thabrany-- Indonesian Health System

19. HEALTH SYSTEM UTILIZATION H Thabrany-- Indonesian Health System

20. Health Reform and Financing. The Future H Thabrany-- Indonesian Health System

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

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25. Trend of Per Capita Expenditure for Health from Public Sector. 2001-2008 H Thabrany-- Indonesian Health System

26. Government Spending of Health Budget by Level of Administration H Thabrany-- Indonesian Health System

27. Lack of Primary Care Allocation: MoH Budget for Health Care for the Poor (Jamkesmas) 2005-2008 H Thabrany-- Indonesian Health System

28. Outpatient Utilization (n=42.540) H Thabrany-- Indonesian Health System

29. The Road to Universal Coverage for Primary Care • Expanding coverage to universal maternity care Nationally. expansion of current Medicaid scheme using DRG payment. • Expanding coverage for maternity care • Local government initiatives to finance universal health coverage. • Free health care at primary care • Establishing comprehensive coverage via insurance mechanism • Still underway: National Health Insurance H Thabrany-- Indonesian Health System

30. Problem of Public Primary Care • Public primary care is the responsibility of local governments. with large variations of capacity of human resources and finance • Previous achievements of primary care had been deteriorated due to lack of commitment of local governments • Health system financing does not provide incentives to the development of public primary care H Thabrany-- Indonesian Health System

31. Problems of Private Primary Care • Lack of standards and financing mechanisms lead to more demand for specialized health care • Overproduction and maldistribution of general practitioners lead to huge disparities between large and small cities/districts • Lack of incentives to undertake promotion and prevention at primary care levels • MoH starts putting more attention to primary care doctors H Thabrany-- Indonesian Health System

32. Franchised Clinics—One of the Solutions H Thabrany-- Indonesian Health System

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