___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion.

___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.

Glion sur Montreaux, Switzerland.

SUB NATIONAL HEALTH SYSTEM PERFORMANCE

ASSESSMENT (Indonesia Experience)

National Institute of Health Research and Development

In Collaboration with

World Health OrganizationBPS Statistics Indonesia



DecentralizationDecentralization in 2001 redefined role of central in 2001 redefined role of central MoH and districts: created new challenges vis-à-vis MoH and districts: created new challenges vis-à-vis district-centre information flowsdistrict-centre information flows..

National health goalsNational health goals, similar to those identified by , similar to those identified by WHO HSPA.WHO HSPA.

Variety of Variety of reformsreforms in last 10 years: to improve staff in last 10 years: to improve staff distribution, insurance coverage, provider distribution, insurance coverage, provider performance (quality), etc.performance (quality), etc.

Interest in what existing data can say about district Interest in what existing data can say about district performance and what the implications would be for performance and what the implications would be for district benchmarkingdistrict benchmarking..

Why Assess District Health System Performance in Indonesia?



FUNCTIONS GOALS / OUTCOMES

WHO HSPA FrameworkGoals and functions of the health system

HEALTHHEALTH

Responsive-ness

Responsive-ness

Fair Financial

Contribution

Fair Financial

Contribution

Service Proviision

Service Proviision

Resources Generatio

n

Resources Generatio

n

Stewardship

(Oversight)

Stewardship

(Oversight)

Financing (Collecting, Pooling and Purchasing)

Financing (Collecting, Pooling and Purchasing)



WHO HSPA 2000 Framework Indonesia Application

Scope International/National District-level

Goals/Outcomes HALE Life expectancy Fairness in Financial Catastrophic expenditure

contribution Responsiveness Responsiveness

Risk Factors SmokingAccess to safe water

Intermediate Coverage indicators Coverage indicatorsOutputs Provider performance Utilization

Inputs Health expenditure Human resources Education Facilities

IncomeFemale education

Adaptation of WHO HSPA for Indonesia



Population based:Population based: CENSUS 2000.CENSUS 2000. Household surveys (Susenas and other Household surveys (Susenas and other

household surveys).household surveys).Health service based:Health service based: MoH inventories: human resources; facilities.MoH inventories: human resources; facilities. National health accounts.National health accounts. Public health expenditure review.Public health expenditure review.Studies:Studies: Indonesia Human Development Report 2001,04 Indonesia Human Development Report 2001,04

Health Information System: Indonesian Data Sources



Indonesia Sub-National HSPA ReportPart I: Intro/Background

III: Risk Factors and Health Services Provision

• Risk Factors• Coverage and health services utilization

IV: Health system resources• Human resources• Health facilities

V: Health system performance• Health system efficiency

VI: Conclusions

II: Health and Health System Goal• Health conditions• Financial protection• Responsiveness of the health system



Below National Estimate

Above National Estimate

National Estimate: 66.2

Range: 57.5 – 73.7

DISTRICT VARIATIONS IN LIFE EXPECTANCY AT BIRTH



There are significant differences in average life expectancy across provinces; 8 provinces exceed the Healthy Indonesia 2010 target of life expectancy of 67.9

DISTRICT VARIATION OF LIFE EXPECTANCY WITHIN PROVINCE



Percentage of Households with catastrophic health payments by province

0% 2% 4% 6% 8% 10%

Papua

M aluku Utara

Kalimantan Tengah

Banten

Sulawesi Tenggara

Bali

Riau

Kalimatan Timur

Sumatera Seltan

Kalimantan Selatanan

Kalimantan Barat

Sulawesi Selatan

M aluku

DKI J akarta

J ambi

Sumatera Utara

Bangka Belitung

Sulawesi Tengah

Nusa Tenggara Timur

Sumatera Barat

Sulawesi Utara

Nusa Tenggara Barat

Lampung

Bengkulu

DI Y ogyakarta

J awa Barat

J awa Timur

J awa Tengah

Gorontalo

National Average

Percentage of Households impoverished due to out-pocket payments by province

0% 2% 4% 6% 8% 10%

M aluku Utara

DKI J akarta

Bali

Kalimatan Timur

Bangka Belitung

Riau

Banten

Papua

Sulawesi Utara

Kalimantan Selatanan

Kalimantan Tengah

Sumatera Barat

Sumatera Seltan

Sulawesi Selatan

Sumatera Utara

J ambi

M aluku

Kalimantan Barat

Sulawesi Tenggara

J awa Barat

Sulawesi Tengah

Nusa Tenggara Barat

DI Y ogyakarta

J awa Timur

Bengkulu

Nusa Tenggara Timur

J awa Tengah

Lampung

Gorontalo

National Average

Catastrophic health payments and impoverishment



District Variationin Catastropic Health Payment within Province



Responsiveness

0

10

20

30

40

pro

mp

t a

tte

ntio

n

dig

nity

co

mm

un

ica

tion

au

ton

om

y

co

nfid

en

cia

lity

ch

oic

e

qu

alit

y o

f b

as

ic

am

me

niti

es

ac

ce

ss

to

su

pp

ort

% o

f u

se

rs r

ati

ng

do

ma

in a

s "

po

or"

ambulatory inpatient 1

60

12

16

3

25 2

Prompt Attention

Dignity

Communication

Autonomy

Conf identiality

Choice

Basic Amenities

Social Support

Health system responsiveness by domain

and type o care

Percentage of respondents rating a responsiveness

domain to be most important



Nu

sa

Te

ng

ga

ra T

imu

r

Su

law

esi T

en

gg

ara

Nu

sa

Te

ng

ga

ra B

ara

t

Ma

luku

Uta

ra

Ka

lim

an

tan

Ba

rat

Go

ron

talo

Ja

wa

Ba

rat

Su

law

esi T

en

ga

h

Su

law

esi S

ela

tan

Pa

pu

a

Ma

luku

Ba

nte

n

Ja

mb

i

Ka

lim

an

tan

Se

lata

n

La

mp

un

g

Ja

wa

Te

ng

ah

Ka

lim

an

tan

Te

ng

ah

Ba

ng

ka

Be

litu

ng

Ja

wa

Tim

ur

Be

ng

ku

lu

Su

ma

tera

Se

lta

n

Ria

u

Ka

lim

ata

n T

imu

r

Su

ma

tera

Ba

rat

DI Y

og

ya

ka

rta

Su

ma

tera

Uta

ra

Su

law

esi U

tara

Ba

li

DK

I Ja

ka

rta

0%

20%

40%

60%

80%

100%

% o

f b

irth

s a

tte

nd

ed

by

tra

ine

d p

ers

on

ne

l

kabupaten kota provincial avg. National avg.

DISTRICT VARIATION IN BIRTHS ATTENDED BY TRAINED PERSONEEL WITHIN PROVINCE



Human Resources and Coverage

Skilled Birth Attendance and MidwivesSource: MOH Inventory 2001, Susenas 2001

0

10

20

30

40

50

60

70

80

Less than 18 18 - 30 31 - 51 52+

Midwives per 100,000 population

Num

ber o

f Dis

tric

ts

Below 80% Coverage

Above 80% Coverage

Skilled Birth Attendance and Physicians, Nurses and

Midwives Source: MOH Inventory 2001, Susenas 2001

0

10

20

30

40

50

60

70

80

90

Less than 58 58 - 96 97 - 179 180+

Physicians, Nurses, and Midwives per 100,000

Num

ber o

f Dis

tric

ts

Below 80% Coverage

Above 80% Coverage

• A higher concentration of midwives increases the likelihood for a district to achieve greater than 80% skilled birth attendance (MDG target)

• However, the relationship is not very clear for the highest category of midwives – the number of districts achieving more than 80% coverage is less for the highest category (52+) than for the second highest (31–51)

• Though when we include physicians and nurses together with midwives the relationship between higher coverage and higher concentration of human resources is stronger



DISTRICT VARIATION IN UTILIZATION OF AMBULATORY CARE WITHIN PROVINCE



-4-2

02

4O

utp

ut in

de

x

-4 -2 0 2 4 6Input index

Indonesia district-level efficiency analysis

Wonogiri (Jawa Tengah)

Kulon Progo (DI Yogyakarta)

Soppeng (Sulawesi Selatan)

Jayawi Jaya (Papua)

Madiun (Jawa Timur)

Manokwari (Papua)

Blitar (Jawa Timur)

EFFICIENCY ANALYSIS



Key Messages HSPA framework can be applied at sub-HSPA framework can be applied at sub-

national & can be used for setting benchmarks.national & can be used for setting benchmarks. Benchmarks may include input, output, Benchmarks may include input, output,

outcome, non health-related aspects of health outcome, non health-related aspects of health system, quality of caresystem, quality of care

Input vs Output: Measure EfficiencyInput vs Output: Measure Efficiency Indicators selection and target settingIndicators selection and target setting Problems related to data availability and quality Problems related to data availability and quality

(HIS)(HIS)



Next steps

HIS assessment (HMN tool).HIS assessment (HMN tool). Advocacy: Common understanding on Advocacy: Common understanding on

principles of HIS for all parties principles of HIS for all parties concernedconcerned

Strengthen data sources both Strengthen data sources both population based and service basedpopulation based and service based

Population based:Population based: Surveys: strengthen the integrationSurveys: strengthen the integration Vital registration: Initiate IMRSSPVital registration: Initiate IMRSSP

NATIONAL HEALTH SURVEY (SURKESNAS)TOWARDS HEALTHY INDONESIA 2010

Other surveys

Other surveys

IDHSIDHS

NSESNSES

NHHS/BHR

NHHS/BHR

2001 2004 2007 2010

Baseline Monitoring EvaluationMonitoring

(Outcome& processindicators)

(Process indicators)

(Processindicators)

(Outcome& processindicators)

Facility/servicebased

Community based

RoundIntegratedApproach

Focus of surveyHFSHFS

SURKESNASSURKESNAS

Notes: NHHS/BHR: National Household Health Survey/Baseline Health Research; NSES (SUSENAS): National Social Economic Survey; IDHS (SDKI): Indonesia Demographic and Health Survey; HFS: Health Facilities Survey



IMRSSP: Flow of COD reporting (Generic)

DEATH EVENT

HOME Health Facility

RT/RWRT/RW

HEALTH CENTER

HEALTH CENTER

VILLAGEVILLAGE

SUB-DISTRICT

SUB-DISTRICT

POP ADMNPOP ADMN

DistrictHealth Office

DistrictHealth Office PROV

INCE

CERT, 2

CERT, 2

CERT, 1

CERT, 1

VA

DeathReport

Death Report

DOA

Death Report

COD Stat

COD Stat

Vital Stat

CODStat

COD Stat

CERT, 1

POLICEPOLICECENTRA

L

Death Report

Death Report

COD Notification System (Health Center DHO)



THANK YOU

___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion.

Documents

health system slide

health information system

national health goals

national health accounts

world health organization

health services utilization

glion sur montreaux

district performance