Consolidated Report Health Sector Review

HEALTH SECTOR REVIEW

CONSOLIDATED REPORT

OCTOBER 2014

Indonesian Health Sector Review 02/04/2015 Final report

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Contents

Foreword ................................................................................................................................ i

Acknowledgements ............................................................................................................ iii

Acronyms and translations ................................................................................................. v

Preface .................................................................................................................................. x

Executive summary .......................................................................................................... xiii

Investing in health ............................................................................................................ xiii

Public health challenges ................................................................................................... xiv

The health sector ............................................................................................................... xv

Health outcomes .............................................................................................................. xvi

Changing demand and the burden of disease ................................................................. xvi

Modelling changing demand .......................................................................................... xviii

Population and fertility trends ........................................................................................... xix

Nutrition ............................................................................................................................. xx

Non-communicable diseases .......................................................................................... xxii

The hospital sector ......................................................................................................... xxiii

The role of the private sector .......................................................................................... xxiii

Innovation ....................................................................................................................... xxiii

Better delivery of known interventions ............................................................................ xxiv

Implementation of JKN ................................................................................................... xxiv

Supply side readiness ..................................................................................................... xxv

Human resources for health ............................................................................................ xxv

Pharmaceuticals and medical technology ...................................................................... xxvi

Quality and safety of health care .................................................................................... xxvi

Monitoring performance and health information systems .............................................. xxvi

1 Risk matrix ....................................................................................................................... 1

1.1 Population, family planning and reproductive health ............................................... 1

1.2 Nutrition ................................................................................................................... 2

1.3 Maternal, neonatal, infant and child health .............................................................. 3

1.4 Communicable diseases ......................................................................................... 4

1.5 Non communicable diseases ................................................................................... 4

1.6 Health financing ....................................................................................................... 5


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1.7 Institutional strengthening ........................................................................................ 7

1.8 Supply side readiness ............................................................................................. 8

1.9 Human resources for health (HRH) ......................................................................... 9

1.10 Pharmaceutical and medical technology ............................................................... 11

1.11 Quality and safety of healthcare ............................................................................ 12

2 Achievements to date ................................................................................................... 14

2.1 Health outcomes .................................................................................................... 14

2.2 Nutritional status .................................................................................................... 15

2.3 Population growth and structure ............................................................................ 15

2.4 Health financing ..................................................................................................... 16

2.5 Institutional strengthening ...................................................................................... 17

2.6 Community empowerment and engagement ........................................................ 17

2.7 Human resources for health .................................................................................. 18

2.8 Health care delivery ............................................................................................... 20

2.9 Supply side readiness ........................................................................................... 21

2.10 Quality and safety of health care ........................................................................... 25

2.11 Pharmaceuticals, medical devices and technology ............................................... 26

2.11.1 Prescription and availability of pharmaceuticals ............................................. 26

2.11.2 Regulation of pharmaceuticals and medical devices ..................................... 27

2.11.3 Traditional medicines ..................................................................................... 28

2.11.4 Manufacturing of pharmaceuticals and medical devices ................................ 28

3 Remaining and emerging challenges .......................................................................... 29

3.1 Health outcomes and the burden of disease ......................................................... 29

3.1.1 Infant and child health .................................................................................... 29

3.1.2 Maternal mortality ........................................................................................... 31

3.1.3 Malnutrition ..................................................................................................... 32

3.1.4 Population and fertility .................................................................................... 34

3.1.5 Communicable diseases ................................................................................ 36

3.1.6 Non communicable diseases ......................................................................... 38

3.2 Changing demand for health services 2015-2019 ................................................. 40

3.2.1 Modelling changing demand .......................................................................... 41

3.2.2 Impact on the health sector budget ................................................................ 44

3.3 Commentary and challenges for 2015-2109 and beyond ..................................... 45


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3.3.1 Better delivery of known interventions ............................................................ 47

3.3.2 Implementation of JKN ................................................................................... 48

3.3.3 Integration of existing health insurance programs ......................................... 48

3.3.4 The informal sector ......................................................................................... 48

3.3.5 Strategic governance of BPJS ....................................................................... 49

4 Targets to be achieved by 2019 ................................................................................... 50

4.1 Headline population, nutrition and health outcomes ............................................. 50

4.1.1 Population dynamics ...................................................................................... 50

4.1.2 Reducing teenage fertility ............................................................................... 50

4.1.3 Nutrition .......................................................................................................... 51

4.2 Maternal and child health outcomes ...................................................................... 52

4.2.1 Reduction of MMR .......................................................................................... 52

4.2.2 Measurement of MMR .................................................................................... 52

4.2.3 Neonatal infant and child mortality ................................................................. 53

4.2.4 Non communicable diseases ......................................................................... 54

4.3 Public Health and clinical interventions ................................................................. 54

4.3.1 Reproductive health ....................................................................................... 54

4.3.2 Maternal and neonatal health ......................................................................... 55

4.3.3 Infant and child mortality ................................................................................ 55

4.3.4 Increased community participation ................................................................. 56

4.4 Health systems strengthening ............................................................................... 56

4.4.1 Supply side readiness .................................................................................... 56

4.4.2 Health financing .............................................................................................. 57

4.4.3 Human resources for health ........................................................................... 57

4.4.4 Institutional strengthening .............................................................................. 58

4.4.5 Quality and safety ........................................................................................... 58

4.4.6 Pharmaceuticals and medical technology ...................................................... 59

5 Policies and strategies ................................................................................................. 61

5.1 Population, family planning and reproductive health ............................................. 61

5.2 Nutrition ................................................................................................................. 62

5.3 Maternal, neonatal and child health ...................................................................... 63

5.4 Communicable diseases ....................................................................................... 64

5.5 Non communicable diseases ................................................................................. 64


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5.6 Health finance ........................................................................................................ 65




5.9.1 Production of HRH ......................................................................................... 72

5.9.2 Distribution of HRH ......................................................................................... 72

5.9.3 Equity and financial protection ....................................................................... 73

5.9.4 Quality and performance of HRH ................................................................... 73



5.11.1 Develop an integrated plan or framework for quality in healthcare ................ 76

5.11.2 Establish a national policy group .................................................................... 76

5.11.3 Establish a national policy group .................................................................... 77

5.11.4 Identify clear values and dimensions for quality in health services ................ 77

5.11.5 Set minimum service standards ..................................................................... 77

6 Health sector programs ................................................................................................ 79


6.2 Nutrition ................................................................................................................. 79



6.5 Non-communicable diseases ................................................................................ 81


6.7 Institutional strengthening and decentralisation .................................................... 83



6.9.1 Production of human resources for health ..................................................... 83

6.9.2 Distribution of the health workforce ................................................................ 84

6.9.3 Quality and performance of the health workforce .......................................... 84



7 Activities and indicators ............................................................................................... 86


7.2 Nutrition ................................................................................................................. 91


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7.5 Non-communicable diseases ................................................................................ 95



7.8 Supply side readiness ......................................................................................... 100

7.9 Human resources for health ................................................................................ 104

7.10 Pharmaceutical and medical technology ............................................................. 105

7.11 Quality and safety of healthcare .......................................................................... 106


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List of Tables

Table 1: Progress against the 2009-13 RPJMN targets and 2014 targets ............................. xi Table 2: Regional comparisons ............................................................................................ xiii Table 3: Total health expenditure for selected countries 2012 ............................................. xiv Table 4: Estimated change in health care costs for leading causes of morbidity, 2015 and 2019 ...................................................................................................................................... xix Table 5: Regional comparisons ............................................................................................. 15 Table 6: Outpatient and inpatient utilisation rates, 2004-2012 .............................................. 22 Table 7: Service-specific readiness assessment ................................................................... 24 Table 8: The estimated decline of infant and under-five deaths if neonatal deaths decreased by 50 per cent ........................................................................................................................ 29 Table 9: Top ten causes of disease burden in Indonesia, 1990-2010 ................................... 38 Table 10: Prevalence of active smokers aged 15 years and above by sex, Indonesia 1995-2013 ....................................................................................................................................... 40 Table 11: Estimated change in health care costs for leading causes of disease, 2015 and 2019 ....................................................................................................................................... 45 Table 12: Population dynamics target 2015-2019 ................................................................. 50 Table 13: Teenage fertility targets 2015-2019 ....................................................................... 50 Table 14: Nutrition targets for the Health Sector .................................................................... 51 Table 15: Targets for the overall contraceptive prevalence rate and the various methods being used 2015-2019 ........................................................................................................... 54 Table 16: Reducing unmet need and the increase needed in private sector use .................. 54 Table 17: Increasing the competence of bidan and contraceptive supply chain management (CSCM) .................................................................................................................................. 55 Table 18: 2019 targets for supply side readiness .................................................................. 56 Table 19: Key targets for UHC for HRH ................................................................................. 57 Table 20: Targets to drive the introduction of quality assurance in the health sector ............ 59 Table 21: Institutional arrangements under decentralisation ................................................. 69 Table 22: Policy 1: Lowering fertility to replacement level ..................................................... 86 Table 23: Policy 3: Support for later marriage (REMAJA) ..................................................... 86 Table 24: Policy 5: revitalisation of the family planning program ........................................... 87 Table 25: Nutrition activities and strategies ........................................................................... 91 Table 26: Maternal health indicators ...................................................................................... 94 Table 27: Neonatal health indicators ..................................................................................... 94 Table 28: Infant health indicators ........................................................................................... 94 Table 29: Children under-5 indicators .................................................................................... 95 Table 30: A selection of health financing recommendations ................................................. 97 Table 31: Selected institutional strengthening indicators ....................................................... 99 Table 32: Selected health financing indicators .................................................................... 100 Table 33: WHO Indicators for measuring general service readiness of health facilities ...... 101 Table 34: WHO Indicators for assessing service-specific readiness ................................... 102 Table 35: Human resources for health indicators ................................................................ 104 Table 36: Policy area 1: Pharmaceutical services ............................................................... 105 Table 37: Policy area 2: Control of Medicines ..................................................................... 105 Table 38: A selection of quality and safety of healthcare indicators .................................... 106


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List of Figures Figure 1: Burden of disease by cause in Indonesia, 1990-2010 ........................................... xvi Figure 2: Projected change of smoking rates among males in Indonesia 2015 and 2019 .. xvii Figure 3: Estimated health care costs for leading causes of morbidity, 2019 ...................... xviii Figure 4: Key population health outcomes in Indonesia, 1960-2011 ..................................... 14 Figure 5: Trends in Nominal Health Spending 1995-2011 ..................................................... 17 Figure 6: Increasing ratio of health workers to the population ............................................... 19 Figure 7: Increased supply of doctors comes from private sector school .............................. 19 Figure 8: The National Health System ................................................................................... 20 Figure 9: Number of hospitals and puskesmas, 2004-2013 .................................................. 21 Figure 10: Inpatient beds per capita, 2004-2013 ................................................................... 21 Figure 11: Hospital bed occupancy rates and average length of stay, 2004-2012 ................ 22 Figure 12: National average of availability of medicines and vaccines in public health facilities .................................................................................................................................. 26 Figure 13: Average percentage of generic prescribing in public health facilities ................... 27 Figure 14: Neonatal, infant and under-five mortality (per 1000 live births) by province ......... 30 Figure 15: Neonatal mortality (per 1,000 live births) by various characteristics .................... 31 Figure 16: Maternal mortality ratio trends in Indonesia, 1990-2015 ...................................... 32 Figure 17: Recent trends in underweight, stunting and wasting in children aged less than five years, 2007-2013 (Riskesdas) ............................................................................................... 33 Figure 18: Prevalence of stunting in children aged less than five years by province in 2007, 2010 and 2013 (Riskesdas) ................................................................................................... 33 Figure 19: Prevalence of stunting in children aged less than five years by wealth quintile in 2007, 2010 and 2013 (Riskesdas) ......................................................................................... 34 Figure 20: Indonesia: projected total population .................................................................... 35 Figure 21: Percentage of married women with unmet need for family planning .................... 36 Figure 22: Burden of disease by cause in Indonesia, 1990-2010 .......................................... 39 Figure 23: Predicted DALYs loss, 2010, 2015 and 2019 ....................................................... 39 Figure 24: Growth in the % the population aged 65+ in selected countries, 1950-2070 ....... 41 Figure 25: Prediction of DALYs lost in Indonesia, 2015 and 2019 ........................................ 41 Figure 26: Incidence of cerebrovascular disease (per 10,000 population), 2015 and 2019 .. 42 Figure 27: Incidence of diabetes mellitus (per 10,000 population), 2015 and 2019 .............. 42 Figure 28: Incidence of tuberculosis (per 10,000 population), 2015 and 2019 ...................... 42 Figure 29: Incidence of cancer (per 10,000 population), 2015 and 2019 .............................. 43 Figure 30: Predicted number of cases, 2015 and 2019 ......................................................... 43 Figure 31: Estimated health care costs for leading causes of disease, 2019 ........................ 44 Figure 32: Mapping the national health system ..................................................................... 76


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Foreword

Praise and gratitude to God the Almighty for blessing us in the completion of the Health Sector Review. The Health Sector Review serves as one of the inputs in for the technocratic draft of the 2015 – 2019 National Medium Term Development Plan (RPJMN).

The structure of the Health Sector Review includes current achievements, challenges faced, policy options, strategy and agreed selected indicators of the Indonesian health sector. Ten (10) areas were analyzed in the review, namely: 1) Disease Burden and Changing Demand for Health Services; 2) Fertility, Family Planning and Reproductive Health; 3) Maternal and Child Health; 4) Health Financing; 5) Human Resources for Health; 6) Pharmaceuticals and Medical Technology; 7) Institutional Analysis in the context of Decentralization; 8) Nutrition and Food Security; 9) Supply Side Readiness; 10) Quality and Safety of Health Care. Other areas, such as community empowerment, management, research and development were analysed using other mechanisms.

The development of the Health Sector Review involved related stakeholders, such as government counterparts, universities, research institutions, national and international experts, professional organisations, and the media.

We would like to express our appreciation and gratitude to: 1. Minister and Vice Minister of Ministry of National Development Planning/ National

Development Planning Agency (KemenPPN/Bappenas) for the guidance and advice in the development of Health Sector Review.

2. Ministry of Health, National Family Planning Coordinating Board (BKKBN), National Agency for Drug and Food Control (Badan POM), and Social Security Provider (BPJS) of Health, for their contribution of the provision of data and information and for their active role in the implementation of Health Sector Review.

3. International partners, namely the Department of Foreign Affairs and Trade (DFAT), WHO, UNICEF, World Bank, and WFP, for their contribution of the mobilisation of international experts and shared experiences on best practices in relevant topics.

4. Dr. Soewarta Kosen, Dr. Tati Suryati, Endang Indriasih, SKM, M.Si, Dr. Nugroho Abikusno, Thomas Wai-Chun Lung, Professor Philip Clarke, Professor Gavin W Jones, Professor Sri Moertiningsih Adioetomo, Professor Endang L. Achadi, Dr. Andreasta Meliala, Dr. Ian Anderson, Professor Budi Hidayat, Dr. John Langenbrunner, Dr. Debbie Muirhead, Dannie Nugroho, Dr. Suzanne Hill, Dr. Budiono Santoso, Professor Michael Jones, Dr. Made Suwandi, Dr. Budihardja Singgih, Professor. Laksono Trisnantoro, Dr. Sunarno Ranu Widjojo, Dr. Sunawang, Dr. Bjorn Ljungqvist, Sri Sukotjo, Dr. Harriet Torlesse, Aidan Cronin, Drajat Martianto, PhD, Elviyanti Martini, M.Sc, Maria Catharina, Mohamad Marji, Dr. Nils Grede, Ajay Tandon, Eko Setyo Pambudi, Dr. Darren Dorkin, dr. Puti Marzoeki, Dr. Charles Shaw, dr. Dewi Indriani, Dr. Kenneth Grant, Keih Christopherson Dunn and Morag Reid as national and international experts for their


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time, expertise, and dedication in completing the Health Sector Review in their respective topics.

5. Dr. Arum Atmawikarta, MPH as the Team Leader for guiding the processes of substance coordination and experts’ team colaboration from the beginning to the completion of the Health Sector Review under the coordination and direction of Dr. Hadiat, MA as the Director of Bappenas for Public Health and Nutrition, drg. Tini Suryanti, MPH as the Head of MoH Bureau of Planning and Budgeting, Pungkas Bahjuri Ali, S.TP, MS, Ph.D as the coordinator of HSR activities, and all staff of the Directorate of Public Health and Nutrition of Ministry of National Development Planning/ National Development Planning Agency (KemenPPN/Bappenas).

6. Mr. Ahmer Akhtar as the Manager of the Australia-Indonesia Partnership for Health Systems Strengthening (AIPHSS) Implementing Service Provider and Professor Ascobat Gani.

7. All parties which have contributed to the writing of this review document.

Hopefully this document can be useful for us and become a reference in the health sector in an attempt to improve health status of the people.

Dra. Nina Sardjunani, MA Deputy Minister of Bappenas on Human Resource Development and Cultural Affairs


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Acknowledgements

The Health Sector Review (HSR) has been supported by the Australian Indonesian Partnership for Health Systems Strengthening (AIPHSS). Funding was provided by the Australian Government Department for Foreign Affairs and Trade (DFAT). The Supply Side Readiness report was funded and prepared by the World Bank. The Nutrition and Food Security report was funded and prepared by UNICEF and the World Food Program (WFP). The Quality and Safety report was funded and prepared by the WHO.

The overall process to integrate the review recommendations into the 2015-2019 National Mid Term Development was led by Bappenas, Dra Nina Sardjunani M.A., Deputy of Human Resources and Cultural Affairs, supported by the director of the Health and Nutrition Department, Dr Hadiat M.A. and Ir Pungkas Bahjuri Ali Ph.D.

The Health Sector Review Consolidated Report is based on 10 individual reports conducted by expert teams. The Terms of Reference for these individual analyses were prepared by Ir Pungkas Bahjuri Ali PhD, supported by Professor Ascobat Gani, Program Technical Specialist for the AIPHSS program.

The implementation of the 10 reports and consolidated report was led by Dr Arum Atmawikarta supported by the team leader of the Implementing Service Provider for the AIPHSS program, Ahmer Akhtar. The Health Sector Review was supported by secretariat staff Ms. Chiquita Abidin and Ms. Fitri Inayati.

Lead Writer of the Consolidated Report

Dr Kenneth Grant, with support from Kieh Christopherson Dunn and Morag Reid in the Health Resource Facility for Australia’s aid program.

Expert Teams

Team 1: Burden of Disease and Changing Demand for Services

Dr. Soewarta Kosen , Dr.Tati Suryati, Endang L Indriasih, Dr. Nugroho Abikusno, Thomas Wai-Chun Lung, Professor Philip Clarke

Team 2: Fertility and Family Planning

Professor Gavin W Jones, Professor Sri Moertiningsih Adioetomo

Team 3: Reproductive, Maternal, Neo Natal and Child Health

Professor Endang Achadi, Professor Gavin Jones

Team 4: Human Resources for Health

Dr. Andreasta Meliala, Ian Anderson

Team 5: Pharmaceutical and Medical Technology

Dr. Suzanne Hill, Dr. Budiono Santoso

Team 6: Institutional Analysis and Decentralisation

Professor Michael Jones, Dr. Made Suwandi, Dr. Budihardja Singgih, Professor Laksono Trisnantoro


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Team 7: Nutrition and Food Security: UNICEF and WFP

Nutrition team: Sunarno Ranu Widjojo, Sunawang, Bjorn Ljungqvist, Sri Sukotjo, Harriet Torlesse, Aidan Cronin (WASH section)

Agriculture and Food Security: Drajat Martianto, Elviyanti Martini, Maria Catharina, Mohamad Marji, Nils Grede.

Team 8: Supply Side Readiness for Universal Health Coverage: World Bank Indonesia

Ajay Tandon, Eko Setyo Pambudi, Soewarta Kosen, Darren Dorkin and Puti Marzoeki

Team 9: Quality and Safety: World Health Organization

Dr. Charles Shaw, Dr Dewi Indriani

Team 10: Health Financing

Professor Budi Hidayat PhD, John Langenbrunner PhD, Debbie Muirhead, Dannie Nugroho

DFAT Health Team

Nicola Ross, Ria Arief, Kristen Stokes, John Leigh, Debbie Muirhead, Adrian Gilbert


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Acronyms and translations

1,000 HPK 1,000 Hari Pertama Kehidupan; Nutrition Improvement in the First 1,000 Days of Life Movement

AIDS Acquired Immunodeficiency Syndrome

APBN Anggaran Pendapatan Belanja Negara; National Budget

API Annual Parasite Incidence

APN Asuhan Persalinan Normal; Normal delivery care

ARI Acute Respiratory Infection

ASEAN Association of Southeast Asian Nations

Bappenas Badan Perencanaan Pembangunan Nasional; National Development Planning Agency

BCC Behaviour Change Communication

BFD Breast Feeding on Demand

Bidan Midwife

Bidan Delima Midwife accreditation program

BINFAR Director/Directorate General for Pharmaceutical Services and Medical Devices

BKKBN Badan Koordinasi Keluarga Berencana Nasional; National Population and Family Planning Board

BMI Body Mass Index

BMS Breast Milk Substitutes

BPJS Badan Penyelenggara Jaminan Sosial; Social Security Administrative Bodies

BPMD Badan Pemberdayaan Masyarakat Desa; Rural Community Development Agency

BPOM Badan Pengawas Obat dan Makanan; Food and Drug Monitoring Agency

BPPSDM Pusat Pengembangan Sumber Daya Manusia; Health Workforce Agency

BPRS Badan Pengawas Rumah Sakit; The Hospital Supervisory Board

BRICS Brazil, Russian, India, China, South Africa

BUKD The Directorate of Primary Health Care, Ministry of Health

Bupati Head of District Government

CBG Care-Based Groups

CBR Crude Birth Rate

CCF Country Coordination and Facilitation

CCT Conditional Cash Transfer


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CDC Communicable Diseases Control

CDR Case Detection Rate

CED Chronic Energy Deficiency

CI Confidence Interval

CPR Contraceptive Prevalence Rate

CRD Chronic Respiratory Disease

CSCM Contraceptive Supply Chain Management

CTU Contraceptive Technology Update

DAK Dana Alokasi Khusus; Special Allocation Fund

DALY Disability–Adjusted Life Year

DAU Dana Alokasi Umum; General Allocation Fund

DG Director General

DHO District Health Office

DinKes Dinas Kesehatan; Provincial/District Health Department

DRGs Diagnosis Related Groups

DTPK Daerah Terpencil Perbatasan dan Kepualauan; Program for disadvantaged areas, borders and remote areas

FFS Fee for service

FP Family Planning

GDP Gross Domestic Product

GMP Good Manufacturing Practices

GP General Practitioner

GoI Government of Indonesia

HIV Human Immunodeficiency Virus

HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome

HRH Human Resources for Health

HSR Health System Review

HTA Health Technology Assessment

IBI Ikatan Bidan Indonesia; Indonesian Midwives Association

ICPD International Conference on Population and Development

IDHS Indonesian Demographic and Health Survey

IDR Indonesian Rupiah

IEC Information, Education, and Communication

IFA Iron Folic Acid


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IFLS Indonesia Family Life Survey

IMCI Integrated Management of Childhood Illness

IMR Infant Mortality Rate

INA–CBGs Indonesian Case-Based Groups

ISQua International Society for Quality in Healthcare

IUD Intrauterine Device

IYCF Infant and Young Child Feeding

Jamkesda Jaminan Kesehatan Daerah; health insurance to cover poor missed by Jamkesmas

Jamkesmas Jaminan Kesehatan Masyarakat; pro-poor public insurance

JKN Jaminan Kesehatan Nasional; National Health Insurance

KARS Komisi Akreditasi Rumah Sakit; Hospital Accreditation Committee

Kepmenkes Keputusan Menteri Kesehatan; MoH Decree

KKI Indonesian Medical Council

KPAI Komisi Perlindungan Anak Indonesia; Indonesian Commission of Child Protection

KUA Kantor Urusan Agama; Office of Religious Affairs

LBW Low Birth Weight

MADE-FOR Maternal Deaths Follow on Review

MADE-IN Maternal Deaths from Informant

MDG Millennium Development Goal

MDR Multiple Drug Resistance

MIS Management and Information System

MKDKI Indonesian Medical Disciplinary Board

MMR Maternal Mortality Ratio

MMS Multiple Micronutrient Supplementation

MNCH Maternal, Newborn and Child Health

MNP Micronutrient Powders

MoE Ministry of Education

MoF Ministry of Finance

MoH Ministry of Health

MoHA Ministry of Home Affairs

MoSA Ministry of Social Affairs

MPW Ministry of Public Works


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MSS Minimum Service Standards

MTKI Majelis tenaga Kesehatan Indonesia; Indonesian Health Workforce Assembly

MUAC Mid-Upper Arm Circumference

NCD Non-Communicable Disease

NEC Necrotizing Enterocolitis

NHA National Health Accounts

NIHRD National Institute of Health Research and Development

NMR Neonatal Mortality Rate

NSPK Norma, Standar, Prosedur, dan Kriteria; Norms, Standards, Procedures, and Criteria

NTD Neglected Tropical Disease

OECD Organization of Economic Cooperation and Development

OOP Out of Pocket

OTSUS Otonomi Khusus Plus; Enhanced Autonomy for Papua Program

Permenkes Peraturan Menteri Kesehatan; Ministry of Health regulations

Perpres Peraturan Presiden; Presidential Regulation

PHC Primary Health Care

PHO Provincial Health Office

PLKB Family Planning Field Workers

PNC Pre-Natal Care

Polindes Pondok bersalin desa; village midwife

PONED Pelayanan Obstetri Neonatal Emergensi Dasar; Basic Emergency Obstetric Neonatal Care

PONEK Pelayanan Obstetric dan Neonatal Emergensi Komprehensif; Emergency Obstetric and Neonatal Care

Posyandu Integrated Health Services Posts

PP Peraturan Pemerintah; Government Regulation

PPJK Pusat Pembiyaan dan Jaminan Kesehatan; Centre for Health Financing and Social Health Insurance

PPKBD Pembantu Pembina KB Desa; village family planning assistant supervisor

PRD Pregnancy-related deaths

Puskesmas Pusat Kesehatan Masyarakat; Community Health Centre

PWS-KIA Pemantauan Wilayah Setempat Kesehatan Ibu dan Anak; local area maternal and child health surveillance

QIP Quality Innovation Performance


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RAN-PG National Plan of Action on Food and Nutrition

RDS Respiratory Distress Syndrome

RH Reproductive Health

Risfaskes Health Facility Survey

Riskesdas Basic Health Research Survey

RPJMN Rencana Pembangunan Jangka Menengah Nasional; National Medium Term Development Plan

SARS Severe Acute Respiratory Syndrome

SCM Supply Chain Management

SDSS Service Delivery and Supply-Side

SEANUTS the Southeast Asian Nutrition Survey

SGA Small for Gestational Age

SJSN Sistem Jaminan Sosial Nasional; National Social Security System

SKN Sistem Kesehatan Nasional; National Health System

SKPD Satuan Kerja Perangkat Daerah; regional working unit

SMAM Singulate Mean Age at Marriage

SOP Standard Operating Procedure

SPM Standar Pelayanan Minimal; Minimum Service Standard

Susenas Socioeconomics Survey

TB Tuberculosis

TFR Total Fertility Rate

TNP2K Tim Nasional Percepatan Penanggulangan Kemiskinan; Indonesian National Team for the Acceleration of Poverty Reduction

THE Total Health Expenditures

U-5 Under – Five

UHC Universal Health Coverage

UKBM Upaya Kesehatan Berbasis Masyarakat; Community-Based Health Efforts

UN United Nations

UNGASS United Nations Assembly Special Session on Drugs

USD United States Dollars

VAT Value Added Tax

WB World Bank

WHA World Health Assembly

WHO World Health Organization


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Preface

The Government of Indonesia (GoI), through the National Development Planning Agency (Bappenas) is currently preparing the 2015-2019 Medium Term Development Plan (RPJMN). This will draw on a situational analysis covering lessons learnt from and achievements of the previous 2009-2014 RPJMN, the projection of future challenges and potential problems, and the direction of the development agenda during the coming five years.

For the 2009-2014 RPJMN, a number of in-depth analyses on the health sector were conducted, supported by the World Bank (WB) and other development partners. While these still have certain level of validity, there have been substantial changes and developments in the health sector during the last five years that need to be taken into consideration.

There has been clear evidence of a rapid transition of the disease burden due to increasing non-communicable diseases (NCDs), superimposed on an unfinished agenda of communicable diseases control (CDC) and static mother and child health (MCH) outcomes. Inequity is a challenge with wide gaps in health status between social economic groups and between geographical areas.

Ten key performance indicators of poor health sector performance have been identified when compared with the targets for 2014 set in the previous RPJMN. Six of these have particularly poor results: (1) maternal mortality, (2) infant mortality, (3) total fertility rate (TFR), (4) access to clean water, (5) reduction of malaria cases and (6) decrease in infant stunting. The other four, which have also performed poorly, are (1) life expectancy, (2) delivery by trained health professional, (3) human immunodeficiency virus (HIV) prevalence and (4) the percentage of population covered by health insurance. The progress of these indicators is outlined in Table 1.

A new national health system (SKN), which promotes primary health care as the key building block of the Indonesia health care system, was introduced in 2012. In addition, Indonesia has committed to universal health coverage (UHC) by 2019 and has adopted a social health insurance system (JKN), based on the National Social Security System (SJSN) Law-40/2004, whose implementation started in January 2014.

Another important development is the on-going work led by Ministry of Home Affairs (MoHA) to revise Indonesia’s decentralisation laws and regulations. This work will formulate a new division of functions between the central, provincial and district governments. The current Minimum Service Standard (SPM – Kepmenkes-741/2007) will also be reformulated. Changes in functional divisions will affect the structure of health institutions, the standard staffing of the institutions as well as the financing of health programs, especially at the district level.


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Table 1: Progress against the 2009-13 RPJMN targets and 2014 targets

Indicator Achievement Target

in 2014 2009 2010 2011 2012 2013

Life Expectancy1

69.8 70.0 70.2 70.4 72.0

Maternal Mortality Ratio2 228 n/a n/a 359 118

Percentage of trained health workforce delivery 84.3 84.8 86.4 88.6 90

Infant Mortality Rate 34 34 34 32 24

Total Fertility Rate 2.6 2.4. n/a 2,6 2.1

Access to clean water 47.7 44.19 42.76 66.8 68

HIV Prevalence amongst 15-49 year olds 0.2

0.4

Annual Parasite Incidence (API) decline

1.85 1.96 1.75 1.69 1

Malnutrition prevalence (including mild malnutrition and severe malnutrition) of children under 5 (per cent)

18.4 17/9 19.6 <15

Stunting prevalence in children under 5 (per cent)

36.8 35.6 37.2 <32

Tuberculosis prevalence per 100,000 people 235 224

Decrease of Malaria cases (API) per 1,000 population 2 1

Complete basic immunisation of children 0-11 years (per cent)

80 90

% community with health insurance n/a 59.1 63.1 64.58 80.10

Health Sector Review The objective of the Health Sector Review is to provide an evidence-based evaluation and analysis to inform the formulation of the 2015-2019 RPJMN. It looks in particular at how the changing demand for health care services relate to current supply of health care services and changes that are likely to be needed in the health sector in future. The following areas were examined in the review (these reports are published as annexes to this consolidated report):

• changing demand for health services • fertility, family planning, and reproductive health • maternal and child health • human resources for health

1 Population Projections Indonesia 2010-2035 http://demografi.bps.go.id/proyeksi/index.php/proyeksi-penduduk2/parameter-

penduduk. 2 Source Indonesian Demographic and Health Survey. See section 3.1.2 for discussion on maternal mortality data.


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• health financing • institutional analysis in the context of decentralisation • pharmaceuticals, devices and technology assessment • quality and safety of health care • nutrition and food security • supply side readiness.

Each working group also considered the following key crosscutting issues:

• equity, poverty and the quality of healthcare services. • demographic change, epidemiological transition and other health determinants • private-public partnership in health development • community empowerment • introduction of 2012 National Health System • implementation of JKN 2014 • impact of regulatory reform on decentralisation.


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Executive summary

The Government of Indonesia (GoI) through the National Development Planning Agency (Bappenas) commissioned a review of the health sector to support the preparation of the 2015-2019 Medium Term Development Plan (RPJMN). This executive summary looks at the key issues and policy options for the health sector for 2015-19 and beyond.

In spite of its achievements to date, the health sector in Indonesia faces many key challenges. At the moment Indonesia is out performed by the health sectors in other countries in the region. For example, maternal mortality, which was 190 per 100,000 live births in Indonesia in 2012,3 compares unfavourably with the 50 per 100,000 that Thailand, Malaysia and Sri Lanka achieved in the 1980s, and which are now even lower.

Table 2: Regional comparisons

Life expectancy at birth (2012)

Under-five mortality rate (2012)

Infant mortality rate (2012)

Maternal mortality ratio (2013 interagency estimates)

Philippines 69 30 24 120 Indonesia 71 31 26 190 Malaysia 74 9 7 29 China 75 14 12 32 Thailand 75 13 11 26 Viet Nam 76 23 18 49 Source: WHO Global Health Observatory data repository

Unless these challenges are addressed, not only will individuals, families and communities not achieve the health status they deserve but Indonesia will not achieve its potential for economic growth. A properly functioning health sector is necessary for strong human capital development, increased productivity, a favourable dependency ratio and reduced inequalities. It has, for example, been estimated that:

• increasing life expectancy by one year can increase gross domestic product (GDP) by 4 per cent;4 and

• reductions in mortality account for about 11 per cent of recent economic growth in low-income and middle-income countries as measured in their national income accounts.5

Investing in health Indonesia does not invest enough in health. It ranks in the lowest 10 per cent of countries in terms of total health expenditure (THE) as a share of GDP.6 Unless it invests more it will not achieve the gains in productivity that a healthy population can deliver. Table 3 shows THE for selected regional and middle-income countries.

3 According to Joint UN-WB estimates – national estimates are higher. 4 The Lancet Commission on Investing in Health December 3, 2013. 5 Ibid. 6 Kutzin(2013 Health Financing MoH informal sector conference Yogjakarta.


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Table 3: Total health expenditure for selected countries 2012

Country Total health Expenditure (USD)

% of GDP % of THE which is public

Vietnam $ 102 4.6% 37.7% Indonesia $ 108 3.0% 39.6% Philippines $ 119 4.6% 37.7% Thailand $ 215 3.9% 42.6% China $ 322 5.4% 56% Malaysia $ 410 3.9% 55.5% South Africa $ 645 8.8% 47.9% Brazil $1056 9.3% 46.4% Source: World Bank 2014 world development indicators

The average THE for middle-income countries worldwide is USD262, for upper middle income countries it is USD446 and for Organization of Economic Cooperation and Development (OECD) countries USD4,635. Although THE in Indonesia increased in real terms between 2001 and 2011 this was due to increased private expenditure. Public spending on health declined in real terms and as a proportion of GDP. As Table 3 shows Indonesia compares badly with its regional peers and very badly compared with BRICS (Brazil, Russian, India, China, and South Africa) countries. There is heavy dependence on out of pocket expenditure and households are at real risk of going into debt as a result of the cost of catastrophic illness.

The commitment to UHC and the increase in demand for health care referred to below will put further pressure on the sector, and the GoI over the next five years needs to address how public health expenditure can be increased significantly. As well as giving health greater priority in the government budget at all levels, alternative sources of finance such as tobacco and fast food taxes need to be considered.

Public health challenges From the burden of disease analysis the public health challenges are obvious. Over the next five years and beyond the sector needs to focus on the following:

• addressing the inequality of health outcomes • reducing the maternal mortality rate • reducing the neonatal mortality rate • reducing the total fertility rate • reducing wasting and stunting • developing a public health program to reduce NCDs with a focus on reducing smoking,

obesity and salt intake • reducing the prevalence of tuberculosis (TB), malaria and HIV • eliminate the remaining neglected tropical diseases.

It will not be enough to set targets. This was done in the last RPJMN and key targets were not achieved. The clinical and public health interventions to address these areas are known. Policies to implement them are in place and where they are implemented they are successful. If the health outcomes achieved in the best performing geographical areas and socioeconomic groups were achieved nationally, Indonesia would be one of the best performing countries in the region.


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Achieving equity in health outcomes and ensuring best practice is delivered evenly across the country to all socioeconomic groups is the single most important step that the health sector can take. For multisectoral nutrition interventions Bappenas should take the lead in ensuring policies and strategies target the poor. Best practice guidelines for achieving geographic and socioeconomic equity need to be developed and a performance management framework needs to be designed in conjunction with the National Institute of Health Research and Development (NIHRD) to measure progress in this area. The TNP2K (Indonesian National Team for the Acceleration of Poverty Reduction) in the Vice President’s office (or its replacement by the incoming government) will play a key role in taking this work forward.

The other important step is to introduce a performance management system that will focus on delivery and ensure that annual targets for key health outcomes and interventions, both clinical and systemic, are set for the MoH, regions and districts. The MoH needs to work with the MoHA to ensure all provinces and districts have good annual health plans to deliver the targets, backed by a performance monitoring framework, which again the MoH can help the MoHA monitor. This should be linked to the annual health sector reviews that are produced by the districts and the centre each year. At the district and provincial levels these should be amended to show progress against key targets and to provide comparations in performance by district and provinces.

The health sector Indonesia has put in place the building blocks of a health sector that has the potential to deliver good health care to its population. These are underpinned by key policies that have been developed by the MoH over the last decade. A new national health system, SKN, was introduced in 2012, which promotes primary health care as the key building block of the Indonesian health care system. Responsibility for health service delivery is being decentralised to the provinces and districts. Indonesia has set a target of UHC for its population by 2019. The universal right to health care was included as an amendment to Indonesia’s constitution in 1999. This will be financed through a single-payer umbrella, which will merge all the existing contributory and non-contributory schemes and which will be managed by a single insurance administrator (BPJS-Social Security Administrative Bodies) which was set up in 2014. The government plans to incrementally extend coverage to the entire population by 2019.

Through BPOM, the National Agency for Food and Drug control, substantial progress has been made on regulating the quality and safety of medicines. There is a long history of good prescribing practices being encouraged in Indonesia. A national formulary was devised and endorsed in 2013 and will be the basis for medicines used by JKN (National Health Insurance). JKN will use a web-based list based on the national formulary that specifies products, by brand, and publishes the price so that it can be used for procurement. There is good availability of drugs and vaccines in most districts, however the supply side readiness survey found significant shortages of key drugs for maternal and child health.

The public health system is underpinned by a network of over 9,000 puskesmas (community health centres) and a hospital system of 548 district, 98 provincial and 33 central hospitals. Coverage is good with the majority of people able to reach a health centre in less than 15 minutes and a hospital between 30 minutes and an hour. These times are obviously longer


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in remote areas. There is a flourishing private sector, which now provides 60 per cent of outpatient visits and 43 per cent of hospital admissions.

Health outcomes Indonesia made steady and significant progress on several key population health outcomes from 1970 to 2003 but progress has stalled in the last ten years. Overall life expectancy has steadily increased from about 52 years in 1970 to 71 years in 2012. There was a significant reduction in the infant mortality rate (IMR) and the under-five mortality rate between 1991 and 2003. The IMR fell by 48.5 per cent from 68 per 1,000 live births in 1991 to 35 in 2003, while for under-five children there was a 52.5 per cent reduction from 97 per 1,000 live births in 1991 to 46 in 2003. However, the reduction in the last ten years has been minimal – the IMR and under-five mortality rate in 2012 were 32 and 40 respectively. It will therefore be difficult to reach the Millennium Development Goal (MDG) 2015 targets of 23 and 32 per 1,000 live births. There has also been no progress in reducing the high rates of underweight or stunting in children since 2007 and maternal mortality, which was already high, may have actually increased in the last five years.

The national averages for health indicators mask significant geographic and income-related inequalities within the country. Indonesia is a large, diverse, and geographically dispersed country. In poorer provinces such as Gorontalo and West Nusa Tenggara, the infant and child mortality rates are four to five times higher than those in richer provinces such as Bali and Yogyakarta. In addition, health indicators for the poor are far worse than those for the prosperous: child mortality rates among the poorest quintile in 2013 were three times the rate among the richest quintile.

Changing demand and the burden of disease The disease pattern is causing a double burden on the health sector. There is an unfinished agenda of communicable disease control for diseases such as TB, malaria and HIV, as well as NTDs such as leprosy, yaws, filariasis and new emerging diseases such as severe acute respiratory syndrome (SARS). At the same time, as evident in Figure 1, there is a major increase in NCDs such as cardiovascular disease, diabetes and dementia.

Figure 1: Burden of disease by cause in Indonesia, 1990-2010

Non-communicable

Communicable

Injuries

37%

56%

7%

1990

Non-communicable

Communicable

Injuries

49%43%

9%

2000

Non-communicable

Communicable

Injuries

58%33%

9%

2010

Source: IHME

Burden of disease by cause in Indonesia, 1990-2010


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This rise in NCDs is linked to a rise in obesity, a poor diet with low intake of fruit and vegetables and excess intake of salt, sugar and fat. In addition, due to very high smoking rates among men (64.9 per cent of those aged over 15 in 2013), the country faces a cancer epidemic over the next twenty years. Figure 2 shows projected smoking rates for 2015 and 2019 unless serious action is taken to reduce them. In addition to the burden of NCDs not only places a burden on the health sector, it also negatively impacts economic productivity.

Figure 2: Projected change of smoking rates among males in Indonesia 2015 and 2019

Demand for health care is expected to rise significantly in the next few years due to a combination of factors.

• An increasing population, with an annual growth rate of 5 million per year.

• An ageing population: The majority of the population growth is expected among those aged over 45 years. This age group is projected to increase by 24.6 per cent between 2013 and 2019, compared with a 3.2 per cent increase in those aged under 45 years. By 2025, the elderly population will almost double to 23 million.

• The changing burden of disease: Non-communicable chronic diseases are increasing and, unless detected early, are expensive to treat.

• New and expensive treatments becoming available, together with a growing middle class (100 million by 2015) who have higher expectation of high quality care, a greater awareness of new treatments and more aggressive health seeking behaviour.

• Universal coverage will see an increase in utilization of health services as the current inequity in access and utilisation is addressed. Previous experience supports this: under Jamkesmas (pro-poor public insurance) outpatient utilization rose by 106 per cent and inpatient by 50 per cent over five years, and the Jakarta Card Scheme saw outpatient utilization go up by over 500 per cent in one year alone.

51.18%

74.22% 72.29% 69.25% 63.70%

55.92% 48.92%

50.5%

73.2% 71.3%

67.4%

61.8%

53.9% 46.3%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

15-‐24 25-‐34 35-‐44 45-‐54 55-‐64 65-‐74 75+

2015 2019


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Modelling changing demand A study was carried out as part of this review to model the impact on demand for health care and the costs of the changing burden of disease, taking into account changes in the total population and its age structure. Costs are forecast to increase in all age groups with the majority of the increase in costs coming in the 55 -74 age group. Figure 3 sets out estimated costs for leading diseases in 2019, costs that are estimated to double between 2016 and 2019 (Table 4). However, the study almost certainly does not take fully into account the increased costs of improved quality of care and clinical interventions. This will likely lead to higher prescription and utilisation rates of more expensive diabetes drugs, statins and devices such as stents and the need for more expensive treatment such as renal dialysis. In addition, the introduction of UHC is almost certain to result in increased utilisation of health care services.

Figure 3: Estimated health care costs for leading causes of morbidity, 2019

90,939,225

139,722,002

152,639,272

201,903,755

235,589,235

150,165,135

579,809,572

1,431,162,936

77,139,222

173,131,982

420,507,244

376,493,640

366,728,040

503,423,236

885,406,172

2,136,056,578

168,078,447

312,853,984

573,146,516

578,397,395

602,317,275

653,588,371

1,465,215,744

3,567,219,514

0 1,000,000,000 2,000,000,000 3,000,000,000 4,000,000,000

Cancer

Chronic Obstruc?ve Pulmonary Disease

Cerebrovascular disease

Tuberculosis

Diabetes Mellitus

Road traffic accidents

Ischemic heart disease

Lower Respiratory Infec?ons

Es#mated Health Care Costs (IDR)

Total In pa?ent Out-‐pa?ent


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Table 4: Estimated change in health care costs for leading causes of morbidity, 2015 and 2019

Population and fertility trends Indonesia benefited greatly from the reduction in fertility rates that was achieved over the 1970s, 1980s and 1990s. This led to a near-cessation of growth in the school-age population, which in turn led to increasing educational enrolment rates, less growth in those using the health system, and slowing overall population growth. Changing age structures from a steady decline in fertility give a ‘demographic window of opportunity’ of an increase in the proportion of working age population in the total population. Such trends facilitate more rapid economic development.

However, over the past decade the total fertility rate (TFR) has stalled at 2.6 (0.5 higher than replacement level fertility). Fertility in 2012 was barely different from its level in 2002, in contrast to the rest of the region. This means that the total population is growing more rapidly than had been expected, the school-age population is growing and the challenges in providing for the health care needs of the population are increased.

2015 OP costs

2015 IP costs

2015 total costs

2019 OP costs

2019 IP costs

2019 total costs

Increase

Tuberculosis 113,260,965 186,243,211 299,504,176 201,903,755 376,493,640 578,397,395 93.12%

Lower respiratory infections

823,271,779 1,083,562,197 1,906,833,976 1,431,162,936 2,136,056,578 3,567,219,514 87.08%

Birth asphyxia and birth trauma

6,479,711 23,909,222 30,388,933 10,088,227 42,212,172 52,300,399 72.10%

Cancer 50,900,437 38,074,347 88,974,784 90,939,225 77,139,222 168,078,447 88.91%

Diabetes Mellitus 130,904,468 179,692,558 310,597,026 235,589,235 366,728,040 602,317,275 93.92%

Major depressives disorder

79,571,468 75,335,041 154,906,509 136,305,993 146,341,554 282,647,547 82.46%


335,554,376 451,863,245 787,417,621 579,809,572 885,406,172 1,465,215,744 86.08%

Cerebrovascular disease 80,161,050 194,741,064 274,902,114 152,639,272 420,507,244 573,146,516 108.49%

Chronic obstructive pulmonary disease

77,623,384 84,818,780 162,442,164 139,722,002 173,131,982 312,853,984 92.59%

Road traffic accidents 90,318,772 267,010,977 357,329,749 150,165,135 503,423,236 653,588,371 82.91%


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If fertility decline can be resumed quickly, the scenario for future total population and its age structure (reflected in dependency ratios) will be greatly affected. If Indonesia achieves replacement levels by the early 2020s its population will still increase by 86 million (36 per cent) by 2050. If it does not, the population could increase by an additional 49 million, a total increase of 135 million, by that time.

There are considerable regional variations in fertility. Ten provinces have a TFR of 3.0 or over. However all but one are the less populated provinces so their overall contribution to population growth is not substantial.

There needs to be a concerted effort to increase family planning services and the contraceptive prevalence rate (CPR), and induce a shift from short term methods such as the pill to long acting methods such as intrauterine devices (IUDs), implants and sterilisation. Incentives need to be addressed, since there is a financial incentive for the private sector (where 72 per cent of women access family planning services) to provide short-term methods. It is therefore important that the public services led by BKKBN (National Population and Family Planning Board) are maintained, as they deliver longer-term methods. This will require greater clarity for responsibility for planning, resource allocation, and supply chain management and of the role of BKKBN following decentralisation.

There are many inequities in access, use and quality of family planning and reproductive health services - between provinces, between districts within provinces, and among poor and marginalized groups within the general population. The private sector is unlikely to address equity because it is not easy and because reaching the difficult-to-reach groups is costly. The GoI must take the lead on this issue and, through BKKBN, set priorities and develop interventions based on the identification of priority areas and groups, needs assessments and strategic factors. Each disadvantage group faces different issues and so will require different approaches, activities and resources.

The new JKN will cover some aspects of family planning, but some key issues will still need to be addressed: there need to be incentives to increase uptake, which may require inbuilt safeguards or incentives as the planned capitation system may work against increased uptake; services BKKBN currently provides to the poor need to be protected; and there has to be clarification as to how the bidans (midwives) will be paid under the benefit system.

Nutrition The prevalence of malnutrition in women and children remains stubbornly high and the 2014 RPJMN targets will not be met. In 2013, 37.2 per cent of children aged less than five years were stunted, 19.6 per cent were underweight, 12.1 per cent were wasted and 11.9 per cent were overweight.7 There has been no progress in reducing child underweight or stunting in the last six years. This is a serious concern as these undernourished children are more likely to suffer serious illness, and less able to learn at school, earn income as adults and contribute to the economy. Stunting lowers lifetime earnings by up to 20 per cent,8 perpetuates the cycle of poverty from one generation to the next, and impedes economic growth by costing at least 2-3 per cent of GDP.9 In addition, adults who were undernourished at birth or during the first two years of life are more likely to become overweight and obese in

7 RISKESDAS 2013. 8 Grantham-McGregor S et al. (2007). Developmental potential in the first 5 years for children in developing countries. Lancet

369, 60–70. 9 Horton S (1999). Opportunities for investments in nutrition in low-income Asia. Asian Development Review 171, 246-273.


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adulthood and to suffer from NCDs such as high blood pressure, diabetes, and heart disease.10,11

Low birth weight (LBW) (<2.5 kg) remains high. There was a slight decrease between 2010 (11.1 per cent) and 2013 (10.2 per cent).12 A recent publication in the Lancet estimated that 1,042,300 infants (23.8 per cent) were born small for gestational age (SGA) in Indonesia in 2010.13 Infants with LBW, and in particular those who are SGA, are at increased risk of dying. The slow progress in reducing LBW may partly explain the lack of progress in reducing neonatal and infant mortality.

Anaemia remains a public health problem in children and women, with estimates of 28.1 per cent in children aged 12-59 months and 53.7 per cent in children aged 6-23 months in 2013.14,15 Anaemia was also reported in 37.1 per cent of pregnant women, a rate that has not substantially reduced from 40 per cent in 2001.16 The high prevalence of anaemia may be partly responsible for the lack of progress in reducing neonatal deaths – a study has suggested that 20 per cent of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy.17 Severe anaemia in pregnancy is also a risk factor for maternal deaths.

The number of adults who are overweight is rising at an alarming rate and affects more women than men. The percentage of overweight women (Body Mass Index (BMI) ≥25 kg/m2) more than doubled from 14.8 to 32.9 per cent between 2007 and 2013,18,19 and exceeded 40 per cent in five provinces. In adult men, the prevalence of overweight increased from 13.9 to 19.7 per cent between 2007 and 2013. Overweight/obesity is found in all wealth quintiles in both children and adults, and is no longer an issue for the upper wealth quintiles alone. This has led to the substantial increase in the prevalence of NCDs associated with obesity. In the last three years the prevalence of diabetes has doubled to 2 per cent, hypertension increased by 25 per cent to 9.5 per cent and stroke by 50 per cent to 1.2 per cent.

The interventions to tackle both under nutrition and over nutrition are known and are set out in the report. This knowledge has been translated into policies and action plans, including a National Plan of Action on Food and Nutrition (RAN-PG, 2011-15) and the National Movement to Accelerate the Reduction in Under Nutrition in Indonesia during the First 1,000 Days of Life (1,000 HPK). However this is not being translated into action on the ground. The coverage of eight out of the ten nutrition specific interventions recommended by the Lancet is none, very low or unknown.

10 Thomas, D & Strauss J (1997). Health and wages: evidence on men and women in urban Brazil. Journal of Econometrics 77,

159-85. 11 Hunt, JM (2005). The potential impact of reducing global malnutrition on poverty reduction and economic development. Asia

Pacific Journal of Clinical Nutrition 14, 10-38. 12 RISKESDAS 2013. 13 Lee et al (2013). National and regional estimates of term and preterm babies born small for gestational age in 138 low-

income and middle-income countries in 2010. Lancet Global Health 1, e26–36. 14 RISKESDAS 2013. 15 Sandjaja et al (2013). Food consumption and nutritional and biochemical status of 0.5-12 year old Indoneisan children: the

SEANUTS study. British Journal of Nutrition 110, S11-S20. 16 RISKESDAS 2001. 17 Titaley et al. (2009). Iron and folic acid supplements and reduced early neonatal deaths in Indonesia. Bulletin of the World

Health Organization 87, 1–23. 18 BMI and waist circumference data for 2007 and 2010 included children and adults aged at least 15 years; BMI data for 2013

included adults aged at least 18 years. 19 RISKESDAS 2007 & RISKESDAS 2013.


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Addressing under and over nutrition requires multisectoral interventions. This means that there is no single or ministry responsible for service delivery and meeting targets. The stewardship and allocation of resources is divided between Bappenas and various line ministries. Clear estimates of the costs, secured funding and funding gaps to scale up nutrition services are not available, and there are currently no financial mechanisms to secure nutrition funding in any of the sectors.

Bappenas is responsible for cross-ministry coordination of planning and budgeting. It should, in addition to setting appropriate targets in the RPJMN, make sure all ministries have appropriate action plans and that these are translated into provincial and district plans. They should also produce a national nutrition budget showing spending by ministry against need. Monitoring of the implementation of the nutrition policies and action plans is coordinated by Coordinating Ministry of Social Affairs (Menkokesra), who will need to develop an appropriate evaluation framework for the five years of RPJMN.

It might also be appropriate to appoint a nutrition expert with national stature based in either Bappenas or Menkokesra or indeed the President’s office to provide national leadership on nutrition.

Non-communicable diseases Further work on national strategies and policies on the prevention and early treatment of NCDs is needed. Unless the incidence and prevalence of NCDs is reduced significantly, Indonsia will face uncontrollable costs pushing up health expenditure with little or no health gain, while compromising all other health programs. There is considerable international evidence as to what interventions work and these needs to be targeted both at the population level and at the individual level. There needs to be investment in health promotion and disease prevention with a particular focus on obesity and salt reduction, an increase in physical activity and reduction in smoking. This should be led by the MoH, with provincial and district action plans and a ring-fenced budget at all three levels of government to support this.

Polices to address nutrition and tobacco will be contentious with both the food and the tobacco industries and they should be involved in policy development. However, international experience suggests that whilst working with the food industry can bring benefits, working with the tobacco industry is unlikely to be successful.

Tobacco control is a particularly strategic public health intervention for reducing premature death and disability especially amongst the poor in Indonesia. Raising the (real) price of tobacco is particularly important as a means of preventing premature death and disability, whilst simultaneously raising revenue for the government. Tobacco control is politically sensitive but remains one of the most strategic, affordable, and cost-effective public health interventions open to governments across the globe.20

The cost of road traffic accidents are predicted to be the third highest among the leading causes of morbidity by 2019 (Table 4) unless action is taken to reduce them. This should be a priority for cross-government intervention.

The MOH and BPJS need to work together to build incentives into the capitation formula that promote healthy lifestyles and to ensure the formula delivers effective personal public health

20 Beaglehole et al. (2011) Priority actions for the non-communicable disease crisis Lancet 377(9775): 1438-47


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programs, such as the full continuum of maternity care, family planning and the prevention, early detection and effective community treatment for NCDs, particularly diabetes and hypertension.

Further work needs to be done to refine the modelling to cost the impact of the change in the burden of disease, factoring in costs of clinical interventions, especially more expensive ones such as stents and renal dialysis. Cost benefit analyses should be done on investments to prevent NCDs and a separate study should be carried out on the economic impact of smoking and the return on investments in programs to reduce smoking rates.

The hospital sector While the focus has to be on public health and primary health care, it is important to also address the hospital sector to ensure that it is working efficiently and effectively and that overall costs are contained. Bed occupancy rates at 66 per cent are low compared with the OECD average of 78 per cent, suggesting that there is capacity to deal with increased demand. Internationally, clinical practice has changed significantly in the last two decades with a major shift to ambulatory care and the use of new technology. This change has implications for the shape and size of the hospital sector and can drive and shape expenditure to the detriment of the primary care budget. There is currently no data to show what changes in clinical practices are taking place in Indonesia. The role of BPJS in controlling secondary care behaviour and expenditure on this will be crucial, but the MoH has to be involved in planning the shape of the supply side and agreeing the benefit package. BPJS should work with the MoH and NIHRD to agree how best to use the data emerging from the reimbursement mechanisms to improve knowledge of what is going on in both the public and private hospital sector.

The role of the private sector Indonesia has a vibrant private sector in both primary and secondary care. While little data is available, it is estimated to be the major provider of secondary care in urban areas. This data gap needs be addressed and clear policies developed around the future of private health care and how public-private partnerships will work. Private hospitals will be included in JKN and discussions are taking place on levels of reimbursement. It will be important to address two key issues: firstly, determining how to address the discrepancy with public hospitals who receive both insurance payments and supply side funding in the reimbursement schedules. Without addressing this, private hospitals may not participate. Secondly, ensuring that private hospitals do not take advantage of the system by manipulating the diagnosis related groups (DRGs) based reimbursement system to over-claim.

Innovation There needs to be a focus on innovation and the introduction and the use of new technologies such as m-health and telemedicine. The way in which health care is being delivered in both hospital and primary care settings is changing rapidly, driven by smart phone technology, and it is important that Indonesia is aware of international best practice in this area and contributes to it. There should be a lead in the MoH for this.


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Better delivery of known interventions The focus for the next five years has to be on delivery of known effective evidence based interventions. This means addressing the systemic issues identified in the reports. These systemic issues include:

• roles and responsibilities for delivery in a decentralised system • performance management in a decentralised system • the role of the private sector and public–private partnerships • meeting the changing and increased demand for health care – public health, finance

and human resources, • implementation of JKN • supply side readiness including pharmaceuticals and medical technology • improving the quality of care.

Two key drivers that have to be addressed are decentralisation and the implementation of JKN. Two themes appear frequently in the institutional analysis. The first is how the MoH exercises a leadership role in the context of a decentralised constitutional structure, and how bilateral relationships can be managed in a transparent way (for example with Ministry of Education and Culture (MoEC), BPJS, Ministry of Public Works (MoPW) etc.). The second is how governance is conveyed through a hierarchical structure from the centre to village level, while respecting the legitimacy of Provincial and District Parliaments.

Implementation of JKN Adequate financing for UHC in Indonesia is estimated by the World Bank to be somewhere between USD13 and USD16 billion (IDR126.8 trillion to IDR156.1 trillion). BPJS will pool contributions from three categories of people: (i) the poor and near-poor whose fixed premium contributions will be paid for entirely by the central government; (ii) those employed in the formal sector, both public and private, whose salary-based contributions will be paid for by employers and employees; and (iii) those who are non-poor and work in the informal sector who will be expected to pay a fixed premium contribution upon enrolment in the program. The central government outlays to finance the premiums of 86.4 million poor and near-poor in 2014 are expected to be IDR19.9 trillion USD2.04 billion, approximately 0.2 per cent of GDP), up from IDR6 trillion or USD615 million allocated for financing Jamkesmas in 2011 (approximately 0.1 per cent of GDP).

It will be important that the MoH develops a close relationship with JKN, building on the work started by PPJK (the Centre for Health Financing and Social Health Insurance), and is able to both influence its policies to deliver health gains and monitor their implementation to ensure early detection of adverse impact on health outcomes. It will be particularly important that it monitors the introduction of capitation in selected locations to ensure that key programs such as family planning, maternal health and nutrition are not affected and that moral hazard such as under prescribing do not take place.

Health insurance coverage is still partial and will need to be expanded to other groups in the country gradually, with a roadmap objective of reaching 100 per cent coverage by 2019. The Indonesian economy and workforce is dominated by the informal sector. Sixty eight million people (about 62 per cent of all workers) work in the informal sector. A recent Bappenas study reported that about 32.5 million informal workers will not be covered by any health


xxv

insurance schemes in 2014 (not including family members).21 There are two issues related to insurance coverage for the informal workers that need to be addressed. First what happens if they do not or cannot pay their premiums? Second, how can contributions be collected, since this can be challenging and costly, in such a way that the costs do not exceed the income generated through premiums?

There are several governance issues for BPJS that remain to be addressed, including:

• the mechanisms for representing interests • the forms and scope of governmental supervision (level of autonomy) • information reporting requirements • the fact that the fund is not subject to competition • the types of provider payment arrangements in place • the capacity for effective service purchasing, contract management and monitoring • ensuring the purchasing mechanism delivers health gains and improves quality and

does not just reimburse clinical activities.

Supply side readiness Service delivery and supply-side (SDSS) readiness have seen significant improvements over the past decade. The number of hospitals has almost doubled, from 1,246 in 2004 to an estimated 2,228 in 2013, with more than half of all hospitals now being private. The number of puskesmas has also increased over the same period: from 7,550 in 2004 to 9,654 in 2013, with almost a third having inpatient beds.

The 2011 Risfaskes health facility census showed that between 80-90 per cent of all puskesmas had good service readiness in terms of infrastructure, drugs and equipment. Service-specific availability has also improved. Almost all puskesmas, 65 per cent of private clinics, and about 60 per cent of posyandu (integrated health services posts) provide antenatal care services and 62 per cent of all puskesmas provided delivery assistance. About 74 per cent of puskesmas reported providing family planning services, 86 per cent provided immunisation, and 66 per cent provide child preventive and curative care services. For NCDs, about 76 per cent of puskesmas provided care for diabetes, 73 per cent for chronic respiratory diseases (CRDs), and about 81 per cent for cardiovascular conditions.

These figures however mask significant regional disparities in many aspects of SDSS readiness, with deficiencies particularly acute in areas with a high burden of disease, eastern provinces and rural and poor areas. Examples include the inability of more than 75 per cent of puskesmas in eight provinces to undertake blood glucose or urine tests; shortages of TB drugs, particularly in areas with a high prevalence of TB; poor service readiness for routine childhood immunisation in certain provinces and in the private sector; and variations in malaria diagnostic capability. The challenge for the next few years is to get this up to 100 per cent and tying accreditation of puskesmas to receiving the capitation payment should facilitate and accelerate this.

Human resources for health Indonesia has achieved a noticeable increase in the ratio of health workers to the overall population, rapidly increasing the number of health workers and surpassing the minimum

21 Bappenas, 2013.


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number recommended by the World Health Organization (WHO). Much of the increase has come from the private sector, particularly through investment in medical schools. Of the 72 medical schools about 60 per cent are private.

The three priorities for human resources for health (HRH) are: production – ensuring there are sufficient numbers to meet the demands of UHC; distribution – ensuring their availability in remote and rural areas; and improving the quality and performance of health workers by ensuring schools meet government standards and regular competency training.

The second priority – ensuring availability in remote and rural areas – is crucial to achieving key health outcomes and needs to be the main focus. Identifying and putting in place incentives is the key. While salary enhancement is important, other factors such as access to post graduate training and formal rotations can play a part.

Pharmaceuticals and medical technology A lot has been achieved in this area and the work on quality assurance, the use of generics and supply chain management needs to continue. A new area is technology assessment where the MoH has set up a committee to evaluate new technology. This needs to be linked to the development of clinical protocols, best practice guidelines and BPJS reimbursement mechanisms. There are a number of issues around the introduction of JKN that still need to be addressed. They include: clarification of the approach used to specify the medicines, devices and technologies covered under the benefits package; funding and payment mechanism for medicines/technologies used in primary care; and the control and enforcement of the supply chain.

Quality and safety of health care The focus in the past has been on increasing access. There now needs to a focus on quality. Many of the building blocks to deliver this such as accreditation, credentialing and regulations are in place but they need to be brought together under one national strategy, and they need to be enforced. The work on quality assurance needs to link to the work on developing clinical protocols to benchmark best practice. The introduction of JKN offers a real opportunity to move this area forward with reimbursement being linked to accreditation of facilities and individuals. The MoH and BPJS need to work together on this.

Monitoring performance and health information systems Indonesia relies on two key household surveys- Riskesdas (Basic Health Research Survey) and the Demographic and House hold Survey (DHS) to collect data about the health of its population and the effectiveness of the health sector such as maternal mortality and immunisation rates. This is insufficient for effective planning, monitoring and evaluation. Two factors offer the opportunity over the next five years to remedy this. First is the introduction of JKN, which will require hospitals to supply accurate information on inpatient activity for reimbursement purposes. In the primary care sector, capitation based reimbursement will require accurate population data including the registration of new births. If performance based reimbursement is built into the capitation mechanism then data on immunisation rates, key disease prevalence, obstetric complications and mortality etc. can be readily captured. The second factor is the rapidly increasing use of smart phone technology for data capture in health systems, bypassing the need for computer-based systems.


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The MoH should work with BPJS to develop a vision of what health information systems would look like by 2019 based on these two factors, which would meet the needs of an effective reimbursement system and allow effective planning, monitoring and performance management. They then should draw up a detailed plan for a robust monitoring and evaluation system and implement it.


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1 Risk matrix

1.1 Population, family planning and reproductive health

Area/Issue Potential Problems

Potential Impact Potential Solutions

Institutional arrangements

Lack of political and financial commitment, weak management and implementation of family planning policy and services at all levels.

Health Outcome: Increase in unintended pregnancies and in maternal mortality due to unsafe abortions; increase in morbidity due to too many births and short space between births. Economic: Higher fertility will slow down economic development.

(1) Ministry of Home Affairs (MoHA) and Ministry of Health (MoH) implement Law 52 of 2009 to establish PPKBD with the authority to fund and implement FP program at district levels. (2) Create high level advocacy team to influence executives and legislatives at district level on FP program. (3) Implement a mass campaign about the benefits of the FP program. (4) Increase coordination of SKPD-KB with DinKes and Bupati.

Implications of social national health insurance (JKN) on FP

(1) Lack of clarity re: funding and reimbursement for FP under JKN. (2) BPJS stipulation re providers with coverage of 3,000 prevents the reimbursement of other providers, mostly midwives. (3) Funding FP through JKN will encourage use of short-term methods, high discontinuation of use.

Health Outcome: Poor sustainability and declining in FP services leads to increase in unwanted pregnancies, unsafe abortion and higher maternal morbidity and mortality. Financing: Providers demotivated to contract with JKN system leads to decrease in FP. Equity: Regulation under JKN on the basis of area coverage is difficult to implement in low density population. The macro effect of unmet need is increasing fertility and poverty.

(1) Review BPJS regulation re: payment / exemption for FP, items covered, size of population for contractor. (2) Make IUDs, implants and injectables more accessible and affordable.


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FP/ reproductive health (RH) services for unmarried people

(1) Declining age at first marriage. (2) RH services not available for unmarried youth, while demand for services grows.

Health Outcomes: Early childbearing increases the risk of maternal morbidity and mortality. Increase in unintended pregnancy and unsafe abortion among youth, with no RH services.

(1) Review law that only married couples can access FP services. Government should encourage legislatives at all levels and community leaders not to criminalise unmarried people and youth. (2) Government to collaborate with NGOs and private sector to provide RH services and IEC for youth and unmarried people. Strengthen BKKBN role to educate youth on avoiding risky behaviour and preparing to be responsible parents.

Supply side readiness (availability of midwives and contraceptive)

(1) Serious shortage and mal-distribution of certified midwives with competence in contraceptive technology. (2) Failure in contraceptive supply chain management.

Health Outcomes: threatens the sustainability of quality FP services impacting on maternal health outcomes, and increasing TFR, affecting poverty and development.

(1) BKKBN to recruit more bidans (midwives); advocate district governments to recruit more midwives. (2) MoH increase number and improve quality of midwives. (3) MoH and BKKBN review rules and regulations hampering the training organisations. (4) strengthen collaboration with private sector, especially professional organisations such as IBI. (5) provide financial support for IBI to conduct bidan training, monitoring and evaluation. (6) use DAK to improve quality of supply chain management of contraceptives.

1.2 Nutrition



Promotive and preventive nutrition interventions missing from benefits package under JKN

Low prioritisation of cost effective nutrition packages, so low coverage. Essential nutrition interventions at risk of becoming further marginalised if JKN does not cover the full set of nutrition interventions needed to protect against malnutrition.

Health and nutrition outcome: effects of stunting in early life include reduced survival, growth, and educational achievement, increased likelihood of obesity, diabetes and heart disease. Financial: Financial burden of malnutrition, with lower earnings and cycle of poverty perpetuated, impeding economic growth. Equity: Malnutrition disproportionately affects the poor and marginalised, who will be least able to afford nutrition services if they are not fully covered under JKN. Political: Not including nutrition interventions in JKN will result in

MoH, BPJS and MoHA should take action to include essential nutrition interventions in the benefits package for JKN. Joint decree of MoH and MoHA is needed to support this.


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inadequate essential nutrition services and the central and local governments’ commitments to scale-up nutrition services under 1,000 HPK Movement will be at risk.

Full set of essential nutrition interventions not included in the minimum service standards (SPM)

One exclusion is micronutrient powders to prevent micronutrient deficiencies in young children. The links and coordination between local government and JKN/BPJS in implementing SPM are not clear.

Political: If the SPM does not comprehensively regulate the essential nutrition services needed to improve the nutrition status of children during the first 1,000 days of life, there will be no assurance that the central government's policy on nutrition improvement (1,000 HPK Movement) will be implemented in all districts.

MoH and MoHA should ensure that all nutrition services needed to improve the nutritional status during the first 1,000 days of life are included in SPM, and that planning, funding and implementation of SPM is clearly defined and coordinated with implementation of JKN/BPJS.

1.3 Maternal, neonatal, infant and child health



Indonesia has no method for MMR measurement

No information available on the cause of maternal and neonatal deaths by region.

Health Outcomes. The absence of information leads to inappropriate programs and strategies locally.

Determine a method for MMR measurement, for national and district levels, which will enable programs to be monitored and for focused improvements to be made.

MMR remains high

Lack of 24/7 access to high quality obstetric and neonatal care and links between community level care (Midwife and PONED), effective referral and PONEK services.

Health Outcomes: Increase in maternal and child deaths. Women with complications who need 24/7 emergency care in hospital in may not reach an equipped hospital in time or may not receive adequate care in hospital.

To halve MMR by 2025, 80 per cent of obstetric complications need to be managed in hospital. This requires:

(1) 90 per cent of bidan have basic competency. (2) 80 per cent of deliveries take place in health centres. (3) Each target district provides PONED services 24/7 covering at least 80 per cent of the population. (4) At least 60 per cent of complicated cases referred are managed in hospitals. (5) Focus on areas with the highest neonatal deaths and


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outreach areas.

The MDG targets for IMR and under-five mortality rate are unlikely to be met because the neonatal mortality rate remains high

Neonatal deaths are linked to poor quality of delivery care and post-partum care during the first 24 hours; LBW and poor infant, child and maternal nutritional status are all strongly related to infant and child morbidity and mortality.

Health Outcomes: The neonatal mortality rate, as well as the infant mortality rate and under-five mortality rate, remain high.

Neonatal mortality can be reduced by half if: (1) 80% per cent of obstetric and neonatal complications are managed in hospital. (2) The prevalence of LBW is reduced to less than 10 per cent. (3) The percentage of women of reproductive age with BMI < 18.5 is decreased by 20 per cent. (4) The consumption of iron folate tablets during pregnancy is increased to at least 60 per cent. (5) Focus on the areas with the highest burden of neonatal deaths and outreach areas.

1.4 Communicable diseases



Communicable Diseases

Continued high burden of communicable diseases.

Health Outcomes: Increasing morbidity and premature death. Equity: greater impact on poor and rural communities.

Intensification and integration of communicable disease control programs.

1.5 Non communicable diseases



NCDs Growing crisis of NCDs.

Health Outcomes: Impact on individual and population health. Economic: Lower productivity, higher costs of services and curative care, leading to potential for catastrophic expenses. Equity: Effect on the poor leading to greater inequalities. Increase poverty from long-term illnesses. Political: Risk of cost and fiscal unsustainability for JKN.

Implement behaviour change programs focusing on prevention, health promotion and nutritional education. Inter-sectoral coordination for reducing tobacco, food industry. Early detection of NCDs. Control of major risk factors for all population.

Road traffic accident injuries

Significant increase in road traffic accidents.

Health Outcomes: Increased deaths and disabilities. Economic: Rising costs related to disability, catastrophic expenses, inability to work. Social: Higher demand for social welfare and services for disabled.

Cross-sectoral preventive programs by the health sector, National Police, Ministry of Public Works, Ministry of Transportation.


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Access to health services

Serious under-utilisation of primary health care services.

Health Outcomes: Increasing morbidity and mortality due to late detection of chronic disease. Economic: Decreasing productivity of workforce. Health services: Higher level referral leading to increasing burden on hospitals and increasing costs of health care and threatens fiscal sustainability of JKN. Decreasing preventive care.

Increase knowledge for seeking health care. Urgently improve the availability of quality primary health care. Increase coverage of JKN to overcome barriers to accessing primary health care for the poor.

1.6 Health financing



Financing for prevention and public health programs

Insufficient funding levels for prevention and public health programs while Indonesia faces new public health challenges.

Political: threats to healthcare systems in terms of both cost and capacity (the ability to improve health outcome) in the future. Economic: healthcare costs keep rising due to focus on curative care only.

(1) MoF needs to allocate appropriate funding levels for prevention, various public health programs and/or activities. (2) MoH needs to move from a high proportion of funding levels from personal health (UKP) to prevention and public health (UKM) programs.

Insuring all Indonesian in the JKN scheme

Sustainability of paying premium amongst informal workers is low; higher lapse and evasion rate of the informal workers in the JKN scheme.

Political: Indonesia unable to achieve the goal of UHC by January 2019. Financial: Higher administrative costs to manage informal workers (e.g., premium collections for informal sector may higher than the premium rate itself).

(1) MoF extends contribution assistance and pay premiums for the informal sector. (2) MoH, MoF and Bappenas need to have a pilot to find a strategic solution for extending coverage to the informal workers.

JKN benefits package

JKN provides comprehensive benefits packages without clear definitions on the procedure, treatments, drugs, and

Technical: Given providers payment (Capitation and CBGs), there will be financial incentives for providers to give too little necessary care, too few medicines, or care of substandard quality; there will be potential disputes between BPJS and providers.

(1) MoH needs to develop SOP for each disease category; develop clinical guidelines to direct providers’ practices. (2) MoH needs to institutionalise health technology assessment (HTA) (e.g., do cost-


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medical devices. Failure to settle the standard operating procedure (SOP) (treatment, drugs, and medical devices) for each benefits basket, and failure to regulate the coordination of benefits (COB).

Financial: Private insurers creams skim, taking easy patients to their contract hospitals and destabilising CBG tariffs to public hospitals. Over time private insurers will turn away sick patients from private supplemental insurance. Equity: unequal benefits package due to concessions to civil servants lead to cost impacts on BPJS that will hurt the poor.

effectiveness analysis and include equity considerations as part of benefit package definition logic). (3) Both BPJS and Clinical Advisory Board do a regular monitor and/or spot-check. (4) BPJS use provider-network only; pay claims or have access to all claims data to monitor; create a firewall between claims under BPJS and private supplemental insurance claims systems (5) GoI do not give in to civil servants’ political demands.

Out-of pocket payments

Failure to regulate healthcare payments made by the insured when they utilise healthcare services.

Financial: degree of financial risk protection drops; incident of catastrophic payment cannot be stopped leading to reduction of functions of insurance to prevent poverty. Political: risk of perception of meaningless to have insurance if the payment made by the insured is quite significant. Equity: Unmet need for healthcare services cannot be eliminated, especially for the poor and vulnerable.

(1) Vice President and MoH need regulation to prevent providers from asking for payment from the insured. (2) BPJS oversight/monitor of JKN implementation (e.g., routine utilisation review management program).

Provider payment reforms and cost containment issues

Unintended consequences of provider payment reforms (e.g., capitation and INA-CBGs) on both JKN finances and quality of services.

Technical: Unadjusted capitation promotes enrolment of healthier relative to sicker people and promotes the financial solvency of providers and their ability to manage risks. Financial: Fiscal risk to JKN revenues due to (a) inappropriate CBGs coding systems (e.g., CBGs coding flaw, CBGs grouper do not adequately represent Indonesian diseases); and (b) CBGs for outpatient care leading to higher readmission rate.

(1) Capitation must be adjusted by risks factors (for initial steps it can be based on age and gender compositions). (2) MoH and BPJS need to standardise coding system, develop accreditation systems for coding, routine audits of coding of claims. They also need to develop analytic team in house and with universities to modify it with claims data coming into BPJS.


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(3) MoH needs to abolish CBGs for outpatients and opt to cap FFS or combine FFS with pay-for-performance.

1.7 Institutional strengthening



Unclear distribution of functions on health matters from central to sub national government followed by unclear MSS (SPM) and NSPK.

The unclear boundary between central and local responsibilities creates overlap in implementation and financing of health among MoH, PHO and DHO. MoH/central level provides funds for the provision of some main health duties and functions of the district level government, which means that district governments do not take responsibility and accountability for these.

Unclear distribution of functions will lead to: Political: Reluctance and negligence of local governments to be responsible for health. (1) Unclear MSS/NSPK, blurs the

financial responsibility for MSS and excuses the local government from financing and planning for health services. This also increases the burden on the central level.

(2) Some district levels ignore responsibility of some of the health workforce needed to implement the MSS.

(3) Roles and responsibilities for monitoring and evaluation between central and local governments are blurred.

(4) Reduces accountability of local government and diverts political pressure to the centre.

(5) Regional inequity is increasing due to the wealthier local governments diverting responsibilities to the centre, leading to unequal economic development and inequities in health outcomes.

(6) Reduces the accountability of local politicians to their local constituents.

(1) Revision of Law 32 /2004 by incorporating a clear distribution of health function in the law, which will create a clearer division of responsibilities among tiers of governments. (This revision is in process by MoHA and must be finalized and approved by parliament). (2) The Permenkes 741/2008 on MSS has been updated and revised based on the Life Cycle approach according to MoH guidance. And should be approved by the Minister of Health as a next step. (3) The NSPK should be updated, remove the obsolete sections.


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Weak coordination between key institutions

Weak coordination between tiers of government and between MoH, BPJS, and other related ministries and agencies.

Technical: Improvements in health sector performance will not be achieved without strong and close coordination between ministries and institutions. Weakness in relationships and coordination creates missed opportunities to implement cross-sector/cross-cutting plans, supervision and facilitation, and wasting of resources. Health Outcomes: Reduces the synergy and opportunities to strengthen systems based on primary health care leads to failure of health service delivery. Political: Weak coordination between MoH and MoHA will hamper the implementation and guidance and supervision (Binwas) of health matters of local governments.

The coordination of MoH with other ministries/agencies needs a clear legal umbrella, to promote compliance of local government. (1) MoH to undertake a mapping of cross-cutting issues which need a joint ministerial decree/ Presidential Decree or Agreement among partners/agencies, to improve health planning and implementation. (2) Create the Joint Decree (Joint Ministerial Decree/Presidential Decree, Agreement) among MoH, MoHA, BPJS or other related ministries/agencies for special cross sectoral purpose. (3) In order to monitor the target of RPJMN, a high level policy dialogue among ministries is needed, coordinated by Coordinating Minister of Social Welfare.

1.8 Supply side readiness



Supply side readiness

Insufficient funding for public facilities.

Political: government at all levels will be held accountable for impacts of inefficient financing to ensure supply-side readiness; Social: JKN beneficiaries and users may become dissatisfied with services; equity, deficiencies are greater in rural areas, and for the urban poor. Technical: effectiveness and efficiency of health services are reduced due to improper diagnosis and treatment.

(1) Clarify, specify and socialise the supply-side implications of the JKN benefits package. (2) Use demand-side financing to improve supply-side readiness by linking provider payment to facility readiness in service provision (accreditation /credentialing systems). (3) Introduce carrot and stick approaches to incentivise local governments to spend more on health to meet national standards of service provision.


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Economic: poorer health outcomes, higher out-of-pocket spending, and lower economic growth due to reduced human capital development.

(4) Improve the effectiveness of the use of central level funds (e.g. DAK) to improve supply side readiness of public facilities.


Insufficient accountability.

Political: unclear accountability mechanisms create confusion, lack of oversight, and shifting of responsibility. Social: as knowledge about JKN benefits package improves, beneficiaries and users may become dissatisfied with public health services. Economic: Some studies show increased and improved governance and accountability supports economic growth.

(1) Align minimum service standards to better reflect service delivery needs to meet UHC. (2) Introduce regulation to prevent the capture of health revenues by local government. (3) Strengthen existing accreditation system, transparency and autonomy of health facilities. (4) With more autonomy at the facility level, ensure that facilities are incentivized to improve supply side readiness. (5) Introduce social accountability, encouraging citizens’ voice and action to improve government accountability.


Weak monitoring and evaluation.

Inaccurate policies and planning for investment to ensure supply side readiness in meeting UHC.

(1) Establish an independent monitoring and evaluation system for supply-side readiness. (2) Institutionalise the recording and collection of relevant facility-level data to track progress.

1.9 Human resources for health (HRH)

Area/Issue Potential Problems Potential Impact Potential Solutions

HRH production

No master plan to plan and produce the required numbers, and skills, of HRH.

Wasted economic and human resources if increased HRH are not of high quality and well aligned to the changing burden of disease. Political: UHC target for 2019 will fail without sufficient numbers and quality of HRH.

MoH BPPSDM should take the lead in HRH strategic planning. CCF should be revitalised to improve coordination among stakeholders to formulate the development of a master plan.

HRH distribution

Mal-distribution of HRH. Equity: Poor and rural regions without health workers, with the budget being absorbed in areas with adequate HRH – mainly urban and wealthy regions.

BPPSDM has endorsed stakeholders to develop a special policy for DTPK. Finalise the regulations and polices prior to enactment of these primary regulations.

Quality and Quality of medical Health Outcomes: (1) MoEC, MoH, and


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Area/Issue Potential Problems Potential Impact Potential Solutions

productivity training is not fit for changing demand for health care. Many schools are not accredited. Curriculum is not well aligned to changing burden of disease. Lack of HRH planning undermines technical and economic efficiency and productivity. Shortage of leadership and strategic management training for top level staff, and a shortage of planners and economists to shape policy based on evidence.

Unaccredited schools can produce poor quality graduates. Technical: Absence of good data on HRH productivity means poor HR allocation. The standard should be defined and tested for particular type of HRH. Standard competency of HRH links directly to quality of services. Political: JKN requires accreditation for institutions to be their partners. If the HRH is not accredited, the institutions cannot be a partner of BPJS.

professional associations should develop strategy to improve standards and quality of medical education (2) Develop a special program for team based deployment to under-served areas, providing a critical mass of services to support retention. (3) Implement capacity development for senior managers through executive development and leadership courses to help improve HRH productivity and efficiency.

Definition of primary health doctors

No strategy for the definition and production of primary health care doctors.

Technical: Results in increase in referral to higher level facilities and costs.

MoH, MoEC, & IDI/IMA should formulate the definitions, production, career management, and job description of primary health doctors.

HRH for public health services

HRH is focused on curative services, although preventive public health services are needed to meet the health challenges of under-nutrition, high prevalence of tobacco consumption, and the rapid rise of NCDs.

Health Outcomes: Increased burden from preventable diseases. Economic: Higher financial and economic cost to government and households because HRH are not sufficiently focused on primary and secondary prevention.

Empowerment of PH-HRH should be led by professional associations and supported by MoH. Greater focus in the curriculum, and in testing of competency, on primary and secondary prevention of NCDs.


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1.10 Pharmaceutical and medical technology



Management of the benefits package under JKN - selection of pharmaceuticals and technologies

Failing to have a proper process for selecting medicines and technologies for funding (i.e. without using clinical evidence and a transparent process).

Health outcome: the wrong products are selected and health outcomes do not improve; Financial: expensive products that are no better than cheaper ones are selected and the costs of the insurance become unaffordable; Equity: some patients can afford better products than others and patients who need technologies cannot obtain them. Political: risk of the perception of corruption if there is no transparency in product selection.

(1) Review the current National Formulary using rigorous HTA as a basis for insurance reimbursement within JKN. (2) Devise a functioning system of HTA within the MoH. (3) Use utilisation review management (BPJS), monitoring of prescribing practices and promote appropriate use of medicines by prescribers and consumers.

Price controls on pharmaceuticals and technologies

Selectively controlling prices of only generic products. Failure to adopt a comprehensive price control policy for the pharmaceuticals and technology sector.

Equity: poor patients get worse products, or none. Financial: incentives for doctors to prescribe more expensive and uncontrolled drugs; disincentives throughout the supply chain to provide quality products. Technical: excessive price controls on some generic medicines leading to poor quality products, disappearance of products and use of more expensive drugs.

(1) Introduce a comprehensive pricing policy for all products, that does not only target a few generics. (2) gradually introduce controls on the pricing components within the supply chain, such as mark-ups and taxes. (3) Promote generic prescribing among prescribers and consumers. (4) Undertake monitoring of price, availability and quality of medicines in the market.


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Supply chain management

Failure to set national standards to ensure proper management of the supply chain for medicines and technologies.

Technical: medicines and technologies are not available to those who need them, resulting in poor health outcomes. Political: lack of access to medicines and technologies will jeopardise support for JKN and reducing the chance of reaching MDG targets. Economic and equity: patients will have to pay out of pocket for higher priced alternatives. Financial: cost of replacement products as emergency supplies are likely to increase.

(1) Set national standards for strengthening supply chain management system of medicines and technologies at district and health centre levels, including standards for IT. (2) Set national standards to improve the competence of staff running medicines supply at district and health centres.

1.11 Quality and safety of healthcare



Systems level quality

Quality systems unidentified and fragmented.

Financial: Fragmented systems are prone to conflict and duplication and result in inefficiency in resource utilisation. Many relevant organisations already exist but their responsibility and connection is not clearly defined. Equity: The current quality improvement initiative is limited to the institutional level (more on big hospitals, none in puskesmas), which leads to disparities of quality of services.

MoH to define a clear vision; establish formal communication and collaboration; establish task force to catalogue existing policies, structures, methods and resources; map responsibilities for quality and standards within MoH; establish a national resource centre. National stakeholder group to define national strategy for quality and safety: organisation, methods, resources.


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Clinical governance

Weak clinical governance systems.

Health outcome: Lead to bad clinical practice and poor quality of care, which influences patient outcomes and impacts population health. Financial: poor clinical practice can cause overuse, misuse or underuse of expensive medical technology and waste resources. Moreover, nosocomial infection, complications and medical incidents create additional burden to patients and costs to the health system.

If a national resource centre is established, it should provide technical advice, practical tools and performance data for clinicians, managers, regulators and finance. Develop peer review as a vehicle for in-service training, CPD, CME, and determine responsibility for this (IMA? NHTAC? MoH?). Promote professional ethics, self-regulation and accountability (IMA/IMC/ other professional bodies).

Information system for quality improvement

Information systems are unreliable, fragmented or absent.

Technical: Information systems are central to quality improvement: if reliable data is not available, insurers, managers and clinicians cannot measure and compare performance reliably within and between institutions. Financial: failure to capture co-morbidity and complications underestimates case based reimbursement, fails to explain extended length of stay, and additional costs to the hospital and BPJS.

MoH and BPJS to define national information strategy: standardise data definitions, collection, aggregation, sharing and protection. MoH, BPJS and institutions to promote feedback, information exchange, transparency and learning.

Incentives for improvement

Inconsistent incentives for improvement.

Financial: Without links between payments and quality assessment of the health facility and clinical performance, there is no incentive for compliance with approved clinical practice guideline, either for individuals or for institution. BPJS should explicitly agree how payments will be related to quality assessment of organisation (health facility) and clinical performance.

BPJS and MoH link reimbursement and differential tariffs to organisational performance, service delivery and compliance with clinical guidelines; MoH and MoE develop knowledge, attitudes and skills regarding quality in workforce.


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2 Achievements to date

2.1 Health outcomes Indonesia has made steady and significant progress on several key population health outcomes over the past few decades. Life expectancy has steadily increased to 70 years in 2011; up from about 52 years in 1970 (see Figure 4). The under-five mortality rate has declined steadily from 164 per 1,000 live births in 1970 to 85 in 1990 and 31 in 2012 (see Figure 4). At current trends, Indonesia is projected to meet the child-health related MDG which calls for a two-thirds reduction in under-five mortality between 1990 and 2015. According to Joint United Nations-World Bank (UN-WB) data, Indonesia’s IMR decreased from 61.7 deaths per 1,000 live births in in 1990 to 25.8 in 2012, a decline by an annual average of 3.9 per cent over the period 1990-2012.22 Based on this trend, Indonesia will not meet the MDG target for a two-thirds reduction in IMR between 1990 and 2015 without accelerations in improvements in its IMR.

Figure 4: Key population health outcomes in Indonesia, 1960-2011

Within these overall figures, there are considerable regional differences and differences between socioeconomic groups in health outcomes. These will be discussed in detail in section 3.1 on health outcomes and the burden of disease.

The 1997 economic crisis and the decentralisation of government administration in 2001 do not appear to have had a discernible impact on trends in average life expectancy, infant mortality, and under-five mortality in Indonesia. Based on global comparisons, Indonesia’s IMR in 2013 was lower than the average for its income level and its life expectancy was about average for its income level. However from a regional perspective, Indonesia lags behind its peers in most health attainment indicators. Its life expectancy, under-five mortality, and infant mortality rates are worse in comparison with selected peer countries in the region such as China, Malaysia, Thailand, and Vietnam.

22 UN Statistics Division. 2014. http://mdgs.un.org/unsd/mdg/Default.aspx.

Under-five mortality

Infant mortality

Life expectancy

5055

6065

70Li

fe e

xpec

tanc

y

2550

100

150

200

Und

er-fi

ve/in

fant

mor

talit

y ra

te

1970 1980 1990 2000 2010Year

Source: WDINote: y-scale logged

Key population health outcomes, 1970-2011


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Table 5: Regional comparisons

Life expectancy at birth (2012)

Under-five mortality rate (2012)

Infant mortality rate (2012)

Maternal mortality (2013)

Philippines 69 30 24 120 Indonesia 71 31 26 190 Malaysia 74 9 7 29

China 75 14 12 32 Thailand 75 13 11 26 Vietnam 76 23 18 49

Source: WHO Global Health Observatory data repository; Interagency estimates for maternal mortality

2.2 Nutritional status Indonesia continues to have a high prevalence of undernutrition in children under the age of five and is not on track to meet the MDG goal of halving the prevalence of underweight children. Despite a decrease in the prevalence of underweight children from 31 per cent in 1989 to 17.9 per cent in 2010, prevalence rose to 19.6 per cent in 201323, and the prevalence of stunting also increased from 35.6 per cent in 2010 to 37.2 per cent in 2013. These prevalence rates are high by regional and global standards. The prevalence of wasting declined marginally from 13.3 per cent in 2010 to 12.1 per cent in 2013, and it remains a serious public health problem. Indonesia is experiencing a double burden of malnutrition, with rapidly increasing overnutrition in the adult population. It has, however, made progress in improving certain nutrition indicators, with the proportion of people who suffer from hunger projected to halve between 1990 and 2015. The proportion of the population below the minimum level of dietary energy consumption decreased from 22.2 per cent in 1992 to 9.1 per cent in 2012, placing Indonesia in the category of having a low level of undernourishment.

2.3 Population growth and structure Indonesia benefited greatly from the reduction in fertility rates that was achieved over the 1970s, 1980s and 1990s. This led to a near-cessation of growth of the school-age population – increasing educational enrolment rates, slowing the increase in the burden of numbers on the health care system, and slowing overall population growth. Changing age structures from these steady declines in fertility give a ‘demographic window of opportunity’ of an increase in the proportion of working age population in the total population. Such trends facilitate more rapid economic development.

However, the TFR has stalled over the past decade at 2.6 children per woman (0.5 children per woman higher than replacement level fertility). In contrast to the rest of the South East Asia region, fertility in 2012 was barely different from its level in 2002. This means that total population is growing more rapidly than had been expected, the school-age population is increasing and the challenges in providing for the health care needs of the population are increased.

The exact trend of fertility since 2000 is a matter of considerable controversy. The reference to a stalling of TFR at about 2.6 compares the estimated figure from the 2002 Indonesian

23 1989 data determined using WHO Growth Standards. Available at http://www.who.int/nutrition/nlis/en/.


16

Demographic and Health Survey (IDHS) with the estimated figure for the 2012 IDHS. However, careful analysis of what happened since the 1990s suggests that TFR may have actually reached a low of about 2.2 in 2002 and risen to about 2.5 in 2011,24-though the data are not robust enough to confirm this. What is clear, however, is that the fertility decline experienced during the 1990s has not continued in the present century.

2.4 Health financing Indonesia has made substantial progress in increasing the accessibility and affordability of health services in terms of formal insurance coverage. The proportion of people covered by its pro-poor public insurance program Jamkesmas (and its predecessor program, Askeskin) increased from 8 per cent in 2001 to nearly one-third by 2011 (although substantial proportions of the poor and near poor remain uninsured). Jampersal, initiated in 2011, was another government program designed to increase accessibility and affordability to health services for the disadvantaged. This program has provided free birth and delivery services at Class D government hospitals to all pregnant women, regardless of income.

At the district level there are currently several sources of funds. The DAU (General Allocation Fund) which nationally accounts for 56 per cent of health sector funding; PAD (District Funds) makes up 8.8 per cent of the total; the share of key taxes comprises 22.8 per cent and DAK is the remaining 3.2 per cent. In addition, funds are starting to flow from BPJS (Social Security Administrative Bodies).

The Government of Indonesia (GoI) has continued its push to close remaining health insurance gaps by instituting UHC beginning January 1, 2014, which integrates five central insurance schemes and folds in a limited number of local schemes. All Indonesians will be eligible for coverage under this single payer health insurance system. Important policy decisions (for example the level of premium subsidies for the poor and near poor and benefits packages for subsidised subscribers) were finalised in 2013, though other issues (mechanisms to locate and enrol informal sector workers) remain to be worked out. The proportion of the population with some form of health insurance has increased from under 25 per cent in 2001 to about 65 per cent in 2014.

A number of initiatives have also been put in place to address geographic inequities, such as the OTSUS (special autonomy) law in 2001 that gave Papua and West Papua a greater level of autonomy and funding for health care.25

Indonesia has made inconsistent progress on macroeconomic measures of health financing. In real terms, total per capita health spending increased 133 per cent between 2001 and 2011. In 2011 total health expenditure per capita was $101, of which $38 was public spending. However, health spending as a proportion of gross domestic product (GDP) increased less markedly from 2 per cent in 2005 to 2.9 per cent in 2011. The country remains a global “outlier” in terms of low commitments for funding for health as a share of GDP. Globally it is among the lowest 10 per cent of countries.26

The health sector has benefited from an increased level of political commitment, evidenced by the modest growth in the proportion of total government spending allocated to health (4.6

24 Hull, forthcoming. 25 an amalgam of two Bahasa words Otonomy and Khusus. 26 Kutzin, J. (2013). Health Financing, Universal Health Coverage, and the Informal Sector, presentation in Yogjakarta, The

MoH Informal Sector Conference, October.


17

per cent in 2001; 5.3 per cent in 2011), and the tripling of the per capita payment for the poor under the JKN (National Health Insurance) single payer model for 2014.

Figure 5: Trends in Nominal Health Spending 1995-2011

Source: World Bank, Fiscal Health Data Base, 2014 The JKN system as of January 1, 2014, has already made good progress in strategic purchasing arrangements. It has, for example, streamlined different benefit packages across insurance schemes and introduced a standardised benefits package to improve equity and access to the covered population. It has improved contracting and has introduced capitation payment models for primary care and hospitals to encourage efficiency and quality.

2.5 Institutional strengthening The JKN will become the major player in the reimbursement of providers for delivering personal health care services; while the Ministry of Health (MoH) plans to lead a strengthening of public/population health care. The MoH has been reorganised to reflect this and there will be a new Directorate General (DG) (Public Health). The redistribution of health functions between tiers of government has been agreed and the MoH has developed NSPK (Norms, Standards, Procedures, and Criteria) as guidance for provinces, districts and cities in the execution of their delegated health functions. Permenkes 741/2008 on MSS has been issued referring to 18 standards that local government should implement. However much work remains to be done on both their definition and implementation.

The government has developed a guide to the implementation of UHC. This is known as the Road Map toward National Health Insurance—Universal Coverage 2012-2019 (Peta Jalan Jaminan Kesehatan Nasional 2012-2019) and has clear targets and milestones. The way the MoH and BPJS work together to achieve this will be crucial.

2.6 Community empowerment and engagement Desa Siaga (Alert Village) was launched in 2005 and supports community participation and empowerment in the villages (Desa/Kelurahan), along with preparedness of the community

0

30

60

90

120

150

180

210

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Health expen

diture (trillio

n rupiah

)

Total expenditure on health General government expenditure on health

Private expenditure on health Out of pocket expenditure


18

to maintain their health independently. The Alert Village Board of Managers, which includes village health volunteers, is backed up by health professionals (midwives/nurses) from puskesmas (community health centres). Alert Villages are supported by the formal health care system in the form of village health post (poskesdes), which is managed by health workers (normally a midwife, assisted by at least two health workers) and supervised by the Alert Village board and the puskesmas.

The Alert Village Board and village health volunteers (kaders) are trained to carry out surveillance on community-based health problems, which will be used to solve those problems and to formulate action plans.

Primary health care is delivered in the villages mainly through puskesling (mobile health centres) and various types of UKBM (community based health efforts) such as the poskesdes (village health posts), and posyandu (integrated health service posts). These efforts at the village level are coordinated and organized through the Alert Village.

Poskesdes are intended to develop and provide basic health services for rural communities and can be regarded as the interface between the input of the community and government support. Services in poskesdes may include preventive and curative care delivered by health workers (especially midwives) with the involvement of volunteers.

The public health activities conducted within poskesdes post include at least:

• simple epidemiological surveillance (especially infectious diseases), identification of risk factors (including nutritional status) as well as antenatal health

• curative activities, especially the management of infectious diseases, as well as reducing risk factors (including nutritional status)

• preparedness and emergency response for health disaster

• basic medical services

• other activities such as health promotion, nutrition awareness, an increase in positive health behaviour, environmental health

• poskesdes infrastructure must include buildings, equipment, and medical equipment.

Evidence of commitment to community empowerment is shown by the support for UKBM. However improving community access to health care and improving its quality through social mobilisation and community empowerment remains a challenge.

2.7 Human resources for health

Indonesia has achieved a noticeable increase in the ratio of health workers to the overall population. The World Health Organization (WHO) suggests that a minimum of 2.3 doctors, nurses and midwives per 1,000 population is needed to deliver essential maternal newborn and child health services in developing countries. As shown in Figure 6 below, Indonesia has been able to rapidly increase the overall number of health workers as a ratio of the population in terms of a national average, and has surpassed the minimum number recommended by WHO.


19

Figure 6: Increasing ratio of health workers to the population

Source: BPPSDM 2014

Much of the increase has come from the private sector, particularly through investment in medical schools (see Figure 7 below for doctors), saving public funds. The number of medical schools has increased by 80 per cent from 40 schools in 2003 to 72 schools in 2013. Of those 72, about 60 per cent are private medical schools. The number of midwifery and nursing schools has also increased. Around 60 per cent of graduating physicians in Indonesia are female, compared with 20 per cent in India.

Figure 7: Increased supply of doctors comes from private sector school

Public school

Private school

295

1164

2700

45224083

54585838

6296

7014

9004

6306

5082

020

0040

0060

0080

0010

000

# G

radu

ate

stud

ents

020

4060

8010

0

% S

hare

d so

urce

of g

radu

ated

doc

tors

(pub

lic/p

rivat

e sc

hool

)

2000 2002 2004 2006 2008 2010Year

Source : Higher Education - HPEQ, 2013

Number and source of graduated doctors2000-2011


20

There is not a large outward migration of health workers. BPPSDM (Indonesian Health Workforce Agency) data for 2012 shows that only 14 doctors, 16 midwives, and 1,356 nurses migrated overseas in 2011. Additionally, in contrast to primary and high school teachers, there is not a particularly large cohort of health workers on the verge of retirement. This suggests that the quantity of human resources for health should not be a significant limitation to health service delivery in Indonesia.

2.8 Health care delivery Indonesia has put in place the building blocks of a health sector that has the potential to deliver good health care to its population. These are underpinned by key policies which have been developed by the MoH over the last decade. A new national health system (SKN) was introduced in 2012, with seven main focus areas: (1) governance, (2) health work force, (3) pharmaceuticals and medical equipment, (4) health research and development, (5) community participation, (6) health financing and (7) health service delivery. Responsibility for delivery is being decentralised to the provinces and districts.

Figure 8: The National Health System

Source: Presidential Decree No.72, 2012

The public health system is underpinned by a network of over 9,000 puskesmas, each serving catchment areas of 25,000-30,000 individuals and a hospital system of 548 district, 98 provincial and 33 central hospitals. Coverage is good, with a median distance to a health facility of five kilometres,27 and the majority of people able to reach a health centre in less than 15 minutes and a hospital in between 30 minutes and an hour. These times are obviously longer in remote areas. There is a flourishing private sector, which now provides 60 per cent of outpatient visits and 43 per cent of hospital admissions. The public primary care system also includes 23,000 auxiliary puskesmas (pustu) for outreach activities in remote regions, village-level delivery posts (often the home of the polindes or village midwife), and poskesdes. In addition, community-level participation is active in maternal and child health promotion activities at around 270,000 integrated posyandu.

27 WHO recommends that time to nearest facility be no more than 1 hour, based on the most common mode of transportation

used.

Regulation, Management,, Heath Information System

Human Resources for Health

Pharmacy, medical equipment, food safety

Health Financing

Research and Development

Health programs/ services

Community empowerment

The highest attainable

health status of the population


21

2.9 Supply side readiness Service delivery and supply-side readiness have seen significant improvements over the past decade. The number of hospitals has almost doubled, from 1,246 in 2004 to an estimated 2,228 in 2013, with more than half of all hospitals now being private. The number of puskesmas has also increased over the same period: from 7,550 in 2004 to 9,654 in 2013, with almost a third having inpatient beds (see Figure 9). As a result, the number of inpatient beds per capita has increased between 2004 and 2013 from 7.0 to 12.6 per 10,000 population, with a significant increase occurring after 2011 in both public and private hospitals (Figure 10).28

Figure 9: Number of hospitals and puskesmas, 2004-2013

Figure 10: Inpatient beds per capita, 2004-2013

28 This number does not include beds in private clinics.

All

Private

025

050

075

010

0012

5015

0017

5020

0022

50

Num

ber o

f hos

pita

ls

2004 2006 2009 2011 2013Year

Hospitals

All

With beds

020

0040

0060

0080

0010

000

Num

ber o

f pus

kesm

as

2004 2006 2009 2011 2013Year

Puskesmas

Source: MOH

Number of health facilities, 2004-2013

All

Public

Private

Puskesmas02.

55

7.5

1012

.515

per 1

0,00

0 po

pula

tion

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013Year

Source: MOH

Inpatient beds per capita, 2004-2013


22

Outpatient and inpatient utilisation rates have risen steadily, especially among the two lowest wealth quintiles which have now reached parity with national rates. Outpatient utilisation rates in 2012 were 2.9 per cent (with about two-thirds of utilisation occurring at private facilities). Inpatient utilisation rates in Indonesia have almost doubled over the period 2004-2012 to 1.9 per cent (see Table 6). Nationally, the number of caesarean sections – another indicator capturing improved access to high-end maternal health services - has tripled from 4 per 100 deliveries in 2002 to 12 per 100 deliveries in 2012.29 However there is considerable variation both geographically and between wealth quintiles. Bed occupancy rates are still relatively low in Indonesia: averaging about 65 per cent in 2012. The average length of stay has been trending upwards (see Figure 11).

Table 6: Outpatient and inpatient utilisation rates, 2004-2012

2004 2005 2006 2007 2009 2010 2011 2012

Outpatient utilisation (all)

National 10.1% 9.2% 9.6% 13.6% 15.1% 13.6% 13.4% 12.9%

Bottom 40% 9.0% 7.9% 8.5% 12.3% 13.5% 12.4% 12.2% 12.9%

Outpatient utilisation (private)

National 5.7% 5.3% 5.1% 8.1% 9.2% 8.1% 8.2% 8.1%

Bottom 40% 4.3% 3.9% 3.8% 6.4% 7.0% 6.4% 6.5% 7.8%

Inpatient utilisation (all)

National 1.0% 1.2% 1.2% 2.0% 2.4% 2.5% 2.1% 1.9%

Bottom 40% 0.6% 0.7% 0.7% 1.3% 1.5% 1.6% 1.4% 1.9%

Inpatient utilisation (private)

National 0.4% 0.5% 0.5% 0.8% 1.0% 1.1% 0.9% 0.8%

Bottom 40% 0.2% 0.2% 0.2% 0.4% 0.5% 0.5% 0.5% 0.8%

Figure 11: Hospital bed occupancy rates and average length of stay, 2004-2012

29 WHO recommends caesarean sections be between 10-15% of all deliveries: below 10% generally shows underuse, and

above 15% generally shows overuse; Gibbons, L, J. Belizán, J. Lauer, A. Betrán, M. Merialdi, and F. Althabe. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report 2010. Background Paper No. 30. WHO. (2010b).

Length of stay

Bed occupancy

01

23

45

67

8

Ave

rage

leng

th o

f sta

y (d

ays)

2040

6080

100

Bed

occ

upan

cy ra

te (%

)

2004 2005 2006 2007 2008 2009 2010 2011 2012year

Source : MOH

Hospital bed occupancy and length of stay, 2004-2012


23

General service-readiness of health facilities has also shown improvement. In the 2007 Indonesian Family Life Survey (IFLS), almost 90 per cent of respondents indicated that health services were “adequate” or “somewhat adequate” in their village/town (less than 10 per cent responded “not adequate” or “far from adequate”).30 Over 70 per cent of the same key informant respondents said that the state of health services was “better” or “much better” compared with 2000 (about 10 per cent said health services were “worse” or “much worse” compared with 2000) in their village/town.31 In the same IFLS 2007 facility survey, 51 per cent of puskesmas heads responded that the availability of drugs had improved since 2000, and 54 per cent noted improvements in the availability of medical supplies over the same period.32

Data from the 2011 Risfaskes facility census show achievements across several fronts with regard to puskesmas’ general service readiness. For basic amenities, 98 per cent of all puskesmas had access to electricity; all puskesmas in the country had rooms with auditory and visual privacy for patient consultations; 84 per cent had telephones; and 82 per cent had access to emergency referral transportation. For basic equipment, most puskesmas across the country reported having a spotlight source, blood pressure apparatus, stethoscopes, thermometers, and adult scales. From a standard precaution for infection prevention perspective, most reported having gloves, single-use standard disposable/auto-disposable syringes, storage for sharps waste, and disinfectant. In terms of diagnostic capacity, 89 per cent had microscopes, and 81 per cent reported being able to conduct haemoglobin tests. With regard to essential medicines, over 80 per cent of all puskesmas reported having captopril, paracetamol, oral rehydration solution, and amoxicillin tablets/syrup.

Service-specific availability has also improved. Almost all puskesmas, 65 per cent of private clinics, and about 60 per cent of posyandu provide antenatal care services. Whereas IFLS 2007 indicated that only about a third of puskesmas in the 13 provinces included in the sample provided delivery assistance services, Risfaskes data indicated that 62 per cent of all puskesmas did so in 2011. About 74 per cent of puskesmas reported providing family planning, 83 per cent provided antenatal care services, 86 per cent provided immunisation, and 66 per cent provide child preventive and curative care services. For NCDs, about 76 per cent of puskesmas provided coverage for diabetes, 73 per cent for chronic respiratory diseases (CRDs), and about 81 per cent for cardiovascular conditions.

There remain however significant deficiencies in service delivery and supply side readiness, which will risk the achievement of UHC. There are numerous regional disparities in many aspects of service delivery and supply-side (SDSS) readiness, with deficiencies particularly acute in areas with a high burden of disease, Eastern provinces and rural and poor areas.

• NCD-related supply side problems – 54 per cent of puskesmas reported the ability to test for blood glucose and 47 per cent the ability to test urine. In Gorontalo, Papua, West Papua, Southeast Sulawesi, Maluku, North Sulawesi, East Nusa Tenggara, and West Papua, less than 25 per cent of all puskesmas reported the capacity to conduct either blood glucose or urine tests.

30 Key informants were: school principals/senior teachers; health professionals; youth activists; religious leaders; local political

party activists; and local business leaders. 31 In IFLS EAST 2012, 80 per cent of key informants thought that health services were “adequate” or “somewhat adequate”;

and 70 per cent thought that health services had improved since 2007. 32 The corresponding responses in IFLS 2012 EAST were 32 per cent and 29 per cent, respectively.


24

• Antenatal care – in some provinces including North Sulawesi, Maluku, and Papua, less than 60 per cent of puskesmas could undertake haemoglobin testing, compared with over 90 per cent of puskesmas in the Java-Bali.

• Maternal care – poor availability of equipment for basic obstetric care, such as transport, manual vacuum extractors and Dopplers, in provinces with some of the highest MMRs, such as Papua, West Papua, and North Maluku.

• Child health – low availability of training on integrated management of childhood illness (IMCI) (43 per cent of puskesmas) and growth monitoring (57 per cent).

• Immunisation – less than 80 per cent of puskesmas in Papua, West Papua and Maluku reported availability of the measles, DPT, polio and BCG vaccines. In the private sector only 25 per cent of private facilities (and 10 per cent of private facilities in Eastern provinces) reported availability of these vaccines.

• Communicable diseases control (CDC) – malaria blood tests were available in only 71 per cent of puskesmas in the ten provinces with the highest prevalence of malaria, and antimalarial drugs available in only 62 per cent.

Table 7 below summarises results from an assessment of service-specific readiness of selected health services for which data were available.

Table 7: Service-specific readiness assessment

Health services Service-specific readiness

Puskesmas Private clinics

Public hospitals

Private hospitals

Family planning & maternal health Family planning services Fair Poor * * Antenatal care services Good Poor Good Fair Basic obstetric care Fair Poor Good Good Comprehensive obstetric care ** ** Good Good Child & adolescent health Routine child immunisation Good Poor * * Preventive and curative care Fair Poor Good Fair Adolescent health * * * * Communicable diseases Malaria Fair * Fair Fair TB Fair Poor Poor Poor Non-communicable diseases Diabetes Fair Fair Good Fair Cardiovascular diseases Good * Good Good Chronic respiratory diseases Fair * Good Good Basic surgery & blood transfusion Basic surgery Poor ** Good Good Blood transfusion ** ** Poor Poor Additional hospital-level indicators Comprehensive surgery ** ** Fair Good Laboratory capacity in addition to primary lab tests ** ** Good Fair

High-level diagnostic equipment ** ** Good Good


25

Health services Service-specific readiness

Puskesmas Private clinics

Public hospitals

Private hospitals

Primary data source for assessment

Risfaskes IFLS; IFLS East

Risfaskes Risfaskes

Note: *=not enough/no data; **=not applicable.

2.10 Quality and safety of health care While there is not a national strategy on quality and safety of health care but is implicit in a wide range of legislation and directives as well as some relevant regional policies. There has been a focus on accreditation of health care providers. The national accreditation agency for hospitals, KARS, was set up within the MoH in 1995 and BPRS (the Hospital Supervisory Board), was established in 2012. The Hospital Law of 2009 made accreditation compulsory for all hospitals every three years. In 2010 a ministerial decree reinforced this by making accreditation a condition of hospital licensing. Despite this, there are still many hospitals that are licensed to operate without being accredited.

Puskesmas accreditation is being developed by the Commission on Accreditation and its provincial representatives. BUKD (The Directorate of Primary Health Care), through a group of national consultants, commissioned the development of accreditation standards and instruments and released a draft in October 2012. The standards were derived from Quality Innovation Performance (QIP) in Australia and first tested in Central Java (resulting in nine amended versions) before extending to three provinces. Currently there is no legal basis to support this process.

Provincial health authorities also operate inspectorates, and District Health Offices issue professional licenses and are responsible for licensing the facilities they own and operate, as well as private providers in their districts.

Professional regulation of doctors was formalised in 2004 with the establishment of the KKI (Indonesian Medical Council) and MKDKI (Indonesian Medical Disciplinary Board). KKI is governed by a board of 17 members, three of whom represent the lay public. The Council is certified under ISO 9001. The medical committee in each hospital is responsible for annual credentialing of all medical staff. The MTKI (Indonesian Health Workforce Assembly) was introduced in 2011 for 23 types of health workers excluding doctors and pharmacists.

Some medical laboratories are accredited under HMD No. 298/2008 - Accreditation Guideline for Health Care Laboratory) or certified under ISO 15189. Many hospital emergency departments (and some puskesmas) have been certified under ISO 9004 (a generic standard for quality management systems). Other national entities related to quality include the healthcare branch of the National Agency on Consumer Protection, the National Blood Committee, and the Indonesian Medical Association, which is designated by the MoH as a partner in the formulation of national clinical guidelines.

The rights of patients in terms of eligibility for health coverage are defined by health insurers, especially BPJS. Rights to informed consent are regulated but there is no national charter to describe, in simple language, the rights of patients to choice, privacy or information. An exception is the ‘Patient Charter for TB Care’ issued by the patients’ association PAMAL in 2009.


26

Some patient satisfaction surveys are conducted by individual providers particularly in the private sector. Individual institutional complaint and compliment mechanisms do exist, particularly in private providers, and some districts maintain registers of complaints about public services.

2.11 Pharmaceuticals, medical devices and technology

2.11.1 Prescription and availability of pharmaceuticals There is a long history of good prescribing practices being encouraged in Indonesia and practices are being reviewed with the introduction of JKN. Through JKN, a national formulary was devised and endorsed in 2013 with a ministerial decree. The formulary contains a comprehensive list of medicines that should be made available in health facilities, and is the basis for medicines use by JKN. It lists products by generic name, strength and formulation but does not specify price or brand. JKN uses the e-catalogue of medicines and technologies (see http://inaproc.lkpp.go.id/v3/public/ekatalog/ekatalog.htm). This is a web-based list that specifies product, by brand, and publishes the price so that it can be used for procurement. The e-catalogue is based on the National Formulary but suppliers can elect to bid to have their products included (or not); therefore not all products in the National Formulary are included in the e-catalogue. It is not yet clear how devices/technologies are selected for inclusion although the bidding process still applies.

There is good availability of drugs and vaccines throughout most health facilities. Based on the annual report of the MoH, DG of Pharmacy 2012, the availability of medicines and vaccines was 92.5 per cent, compared with the target of 90 per cent for 2012, and it should reach 100 per cent in 2014 (see Figure 12).

Figure 12: National average of availability of medicines and vaccines in public health facilities

There are however challenges, and for UHC to be effective, there needs to be a major improvement in all aspects of the supply chain, from selection and governance, through to rational use. The striking disparities between provinces also need to be addressed. In three provinces (Maluku, Gorontalo and Riau Islands) the average availability is well below 80 per cent - reported as between 65 to 73 per cent. In contrast, in six provinces (East Kalimantan,


27

West Sumatra, North Maluku, Yogyakarta, East Jawa and West Kalimantan) the average availability is far higher than 100 per cent, ranging from 105 to 129 per cent.

An ongoing campaign promoting the prescription and use of generic medicines has also resulted in a steady increase in generic prescribing in public health facilities (see Figure 13).33

Since 2012, procurement has been done through an electronic logistics system (e-logistics, which incorporates the e-catalogue). Provincial health offices and district health offices procure medicines and commodities for public facilities. These are stored at the districts’ warehouse(s) – there may be more than one - and distributed to public health facilities. Hospitals can directly purchase medicines using the e-logistics system.

Figure 13: Average percentage of generic prescribing in public health facilities

2.11.2 Regulation of pharmaceuticals and medical devices Medicines in Indonesia are regulated by BPOM (National Agency for Drugs and Food Control), an independent body reporting to the President and in coordination with the MoH. All medicinal products marketed and used in Indonesia must be registered and licensed by the BPOM. Equivalence testing for registration of generics is mandatory but it is unclear how this is being implemented. The scope of regulation includes domestically produced products, imported products, products for export, and products under patent.

There are approximately 17,000 registered medical products in Indonesia. The registration is valid for five years. Medical devices must meet national standards set by the MoH. Most of the medical devices used in Indonesia are imported; only 15 per cent are produced domestically. In 2012, 64.7 per cent of the 34 production facilities inspected met the standard of good production practices.

The performance of BPOM has improved substantially over the last 5 years. ‘Whistle blowing’ in relation to medicines regulatory affairs involving BPOM is actively encouraged. The focus on promoting good governance and transparency has had a very positive impact. In 2013, BPOM was assessed by the Indonesia Commission Against Corruption, and given

33 Laporan Akuntabilitas Kinerja Direktorat Jendral Bina Kefarmasian dan Alat Kesehatan Taahun 2012, Kementrian Kesehatan

Republik Indonesia 2013. Ministry of Health, Directorate General of Pharmaceutical Services, Accountability Report 2012. http://binfar.kemkes.go.id/buku-kinerja-program-kefarmasian-dan-alat-kesehatan/, accessed April 10 2014.


28

the highest rating of government agencies in good governance. Lessons learnt by the BPOM to achieve this rating should be shared and replicated in other agencies involved in the pharmaceutical sector.

2.11.3 Traditional medicines There is a National Policy on Traditional Medicines, and under BPOM, a special directorate is designated for pre and post market control of traditional medicines to ensure the safety and quality of traditional medicines products. Traditional medicines need to be licensed prior to marketing. Guidelines on Good Manufacturing Practice for Traditional Medicines have been devised for the manufacturers. However in spite of several decades of development only six products have completed clinical trials.

2.11.4 Manufacturing of pharmaceuticals and medical devices Indonesia has developed a substantial and diverse manufacturing base for pharmaceuticals that is capable of supplying a large number of different drugs and is moving towards Good Manufacturing Practices (GMP) certification. The industry has had the advantage of trade protections from major foreign competitors. There are in total 225 pharmaceutical manufacturers in Indonesia, not all of which are certified for good manufacturing practices. The certification process needs to be continued until all manufactures are GMP certified.


29

3 Remaining and emerging challenges

This chapter is in three parts. The first sets out the health status and the disease burden of the population, the second looks at the impact of future changes in the disease burden and other factors on demand for health services in the future, and the last sets discusses future challenges for the sector including what changes need to be made to meet them.

One particular challenge is to improve the collection of routine data on morbidity and mortality. Much of the data reported here comes either from the basic household health research survey – Riskesdas – which is conducted on a sample of households nationally every three years and the IDHS which is conducted every five years. Accurate routine morbidity and mortality data at either community or health facility level is not available.

3.1 Health outcomes and the burden of disease

3.1.1 Infant and child health In 2012, Indonesia had an IMR of 32 per 1,000 live births and an under-five mortality rate of 40 per 1,000 live births. The targets for 2015 were 23 per 1,000 live births for IMR and 32 per 1,000 live births for the under-five mortality rate. Following substantial progress in the 1990s, the reduction in these figures in the last ten years has been minimal, manily due to the stagnation in the reduction of neonatal deaths. Neonatal deaths will need to be reduced in order to resume the decline in infant and under-five deaths, so this area will need particular focus and effort over the next five years. Table 8 illustrates the estimated decline in infant and under-five deaths if the neonatal mortality rate (NMR) were reduced by 50 per cent.

Table 8: The estimated decline of infant and under-five deaths if neonatal deaths decreased by 50 per cent

Current rates Rates if NMR were reduced by 50%

Deaths/ 1,000 live births (IDHS 2012)

Number of deaths (Census 2010)

Estimated deaths/ 1,000 live births

Estimated number of deaths

Estimated % decline of deaths rates

Neonatal deaths 19 92,110 9.5 46,055 50%

Infant deaths 32 155,132 23 109,077 30% Under 5 deaths 40 193,915 31 147,860 24%

There is considerable interprovincial variation, with noticeable reductions in neonatal, infant and under-five mortality in some provinces but not in others. In 2012, neonatal death rates ranged from 12 per 1,000 live births in East Kalimantan to 37 in North Maluku province. The variation is not only between islands, but also within islands. In Java, for example, the neonatal mortality rate ranges from 14 per 1,000 live births in East Java to 23 in Banten province. Provincial disparities in infant mortality are also obvious, ranging from 21 per 1,000 live births in East Kalimantan to 74 in West Papua. In nine provinces - Gorontalo, Papua, West Papua, North Maluku, Southeast Sulawesi, Central Kalimantan, DI Yogyakarta, Central Java, and DI Aceh provinces - there have been significant increases in both the neonatal and infant mortality rate between 2007 and 2012. The provincial disparities in the under-five


30

child mortality rate are also very wide, ranging from 28 per 1,000 live births in Riau islands and 115 per 1,000 live births in Papua province.

Figure 14: Neonatal, infant and under-five mortality (per 1000 live births) by province

Source: IDHS 2007 and 2012

0 50 100 150 200 250

Sumatera DI Aceh 2007 DI Aceh 2012

North Sumatera 2007 North Sumatera 2012 West Sumatera 2007 West Sumatera 2012

Riau 2007 Riau 2012

Jambi 2007 Jambi 2012

South Sumatera 2007 South Sumatera 2012

Bengkulu 2007 Bengkulu 2012 Lampung 2007 Lampung 2012

Bangka Belitung 2007 Bangka Belitung 2012

Riau islands 2007 Riau islands 2012

Jawa DKI Jakarta 2007 DKI Jakarta 2012 West Jawa 2007 West Jawa 2012

Central Jawa 2007 Central Jawa 2012 DI Yogyakarta 2007 DI Yogyakarta 2012

East Jawa 2007 East Jawa 2012 Banten 2007 Banten 2012

Bali 2007 Bali 2012

West Nusa Tenggara 2007 West Nusa Tenggara 2012 East Nusa Tenggara 2007 East Nusa Tenggara 2012

Kalimantan West Kalimantan 2007 West Kalimantan 2012

Central Kalimantan 2007 Central Kalimantan 2012 South Kalimantan 2007 South Kalimantan 2012 East Kalimantan 2007 East Kalimantan 2012

Sulawesi North Sulawesi 2007 North Sulawesi 2012

Central Sulawesi 2007 Central Sulawesi 2012 South Sulawesi 2007 South Sulawesi 2012

Southeast Sulawesi 2007 Southeast Sulawesi 2012

Gorontalo 2007 Gorontalo 2012

West Sulawesi 2007 West Sulawesi 2012

Maluku 2007 Maluku 2012

North Maluku 2007 North Maluku 2012 West Papua 2007 West Papua 2012

Papua 2007 Papua 2012

Neonatal Mortality 2007 Infant Mortality 2007 Under Five Mortality 2007 Neonatal Mortality 2012 Infant Mortality 2012 Under Five Mortality 2012

Sulawesi

Kalimantan

Malaku and Papua

Sumatera

Bali and Nusa

Jawa


31

LBW continues to contribute to child mortality. Neonatal deaths are more than eight times higher among LBW babies than among larger babies, while infant mortality is 4.5 times higher for LBW babies. Continued efforts to reduce the number of LBW babies is therefore a significant component of reducing neonatal deaths.

Beyond provincial differences, disparities are also obvious by wealth quintiles, mother’s education level and residence. For all three child mortality measures, the rates are higher among the poor, the least educated and in rural areas. The disparity is the highest for under-five mortality. A similar pattern is observed for disparities in LBW. A breakdown for neonatal mortality is provided in Figure 15.

Figure 15: Neonatal mortality (per 1,000 live births) by various characteristics

Source: IDHS 2012

The main causes of death among neonatal, infant and under-five children are dominated by preventable diseases, primarily infection.

The main causes of deaths of neonates aged 0-6 days are breathing difficulties/asphyxia, prematurity, infection and hypothermia. Infection and hypothermia are related significantly to LBW. The percentage of LBW babies decreased minimally from 11.1 per cent in 2010 to 10.2 per cent in 2013.

The main causes of death among neonates aged 7-28 days are sepsis, congenital malformation, pneumonia, respiratory distress syndrome (RDS) and prematurity.

The three main causes of death of infants are diarrhoea, pneumonia, and meningitis.

The main causes of deaths of children aged 1-5 years are diarrhoea, pneumonia, necrotizing enterocolitis (NEC), meningitis, dengue and measles.

3.1.2 Maternal mortality There have been significant challenges in measuring maternal deaths in Indonesia due to an absence of data. Data have been collected through the IDHS since 1991, but these figures only represent the national aggregate level (with no sub-national information), and the number of deaths collected is very small, leading to a wide confidence interval, making


32

correct interpretation difficult. The UN and World Bank produced separate joint estimates, which are quite different from the national estimates.

Using data from IDHS, the point prevalence of MMR has increased from 228 per 100,000 live births in 2007 (confidence interval: 132-323) to 359 per 100,000 live births in 2012 (confidence interval: 239-478). The data suggests a startling rise in the point prevalence, though, given the width of the confidence intervals, it is not certain that there actually was a significant rise. In contrast, joint WB-UN data gives different data with a MMR of 220 per 100,000 live births in 2010 and 190 per 100,000 live births in 2013. These trends are illustrated in Figure 16 below. With both sets of data, it is clear that the MMR in Indonesia has not decreased as expected, and remains far above the MDGs target of 102 per 100,000 live births.

Figure 16: Maternal mortality ratio trends in Indonesia, 1990-2015

3.1.3 Malnutrition Another key challenge facing the country is that of chronic child malnutrition. Indonesia is not on track to attain the nutrition-related MDG target of reducing the prevalence of underweight among children under five, and reducing the prevalence of other malnutrition-related indicators such as early childhood stunting remains a challenge.34 The RPJMN target for 2014 for child underweight will not be met. In 2013 19.6 per cent of children under five were underweight. Stunting remains a problem with 37.2 per cent of Indonesian children, more than one out of every three children under five, shorter than the standard height for their age in 2013.35 Growth faltering is established in the first months following delivery and plateaus by two years of age.

34 Riset Kesehatan Dasar (Riskesdas) 2010 estimates gizi buruk (4.9%); gizi kurang (13.0%). 35 Background Study on Nutrition, June 2014.

IHME

DHS

2010 Census

MDG target

Joint WB-UN

100

300

500

700

900

Mat

erna

l dea

ths

per 1

00,0

00 li

ve b

irths

1990 1995 2000 2005 2010 2015Year

Sources: Joint WB-UN estimates; Indonesia censusDHS; Institute of Health Metrics and Evaluation (IHME)Note: Shaded area represents joint WB-UN estimation uncertainty

Maternal mortality ratio in Indonesia, 1990-2015


33

Young child wasting rates remain high, with 18 provinces reporting prevalence over 15 per cent, which WHO considers an emergency situation requiring supplementary feeding programs (see Figure 17).36

Figure 17: Recent trends in underweight, stunting and wasting in children aged less than five years, 2007-2013 (Riskesdas)

There is also wide variation in the prevalence of stunting within Indonesia. According to Riskesdas 2010 data, 16 out of 33 provinces in Indonesia had a stunting rate among children 0-5 years old that exceeded the national average (Figure 18). This problem is also significant in rural areas where it is estimated that 42 per cent of households had stunted children, a level comparable to those observed in poorer sub-Saharan African countries.37

Continued problems with poor sanitation, open defecation, and inadequate access to clean water contribute to the problems associated with early childhood stunting in Indonesia.

Figure 18: Prevalence of stunting in children aged less than five years by province in 2007, 2010 and 2013 (Riskesdas)

36 Shrimpton, R. and C. Rokx. The Double Burden of Malnutrition. World Bank. Report 76192-ID. 2013. 37 IFLS 2007. IFLS data is likely to underestimate the problem, especially in rural areas, as it did not include the poorest

provinces of the country.


34

There is also significant variation in the prevalence of stunting by wealth quintile (see Figure 19).

Figure 19: Prevalence of stunting in children aged less than five years by wealth quintile in 2007, 2010 and 2013 (Riskesdas)

As mentioned above LBW (<2.5 kg) is an issue.38 A recent publication in the Lancet estimated that 1,042,300 infants, 23.8 per cent, were born small for gestational age in Indonesia in 2010.39

Lastly anaemia remains a public health problem in children and women with rates of 28.1 per cent in children aged 12-59 months and 53.7 per cent in children aged 6-23 months in 2013.40,41 Anaemia was also reported in 37.1 per cent of pregnant women, with similar prevalence in urban areas (36.4 per cent) and rural areas (37.8 per cent).42 This rate has not substantially reduced from the 40 per cent rate in 2001.43 This high prevalence of anaemia may be partly responsible for the lack of progress in reducing neonatal deaths; a study has suggested that 20 per cent of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy.44 Severe anaemia in pregnancy is also a risk factor for maternal deaths.

3.1.4 Population and fertility Reductions in the TFR have stalled over the past decade at 2.6 (half a child per woman higher than replacement level fertility). There are considerable regional variations in fertility, with ten provinces having a TFR of 3.0 or higher, but since all but one are the less populated provinces their overall contribution to population growth is not substantial. At the national level, fertility in 2012 was barely different from its level in 2002, in contrast to Indonesia’s neighbours, where fertility rates have continued to fall. This means that total population is

38 RISKESDAS 2013. 39 Lee et al (2013). National and regional estimates of term and preterm babies born small for gestational age in 138 low-

income and middle-income countries in 2010. Lancet Global Health 1, e26–36. 40 RISKESDAS 2013. 41 Sandjaja et al (2013). Food consumption and nutritional and biochemical status of 0.5-12 year old Indoneisan children: the

SEANUTS study. British Journal of Nutrition 110, S11-S20. 42 RISKESDAS 2013. 43 RISKESDAS 2001. 44 Titaley et al. (2009). Iron and folic acid supplements and reduced early neonatal deaths in Indonesia. Bulletin of the World

Health Organization 87, 1–23.


35

growing more rapidly than had been expected, the school-age population is increasing and greater strains will be placed on the provision of health care.

The stalling of the TFR influences population projections. Whether fertility decline can be resumed quickly or not influences future total population and its age structure projections. Figures 20 and 21 compare trends in the official population projections released in January 2014 with those derived from the latest UN projections from 2012. The UN projections show the alternative paths of total population and of dependency rates depending on whether fertility increases slightly from its present levels (the assumption in the high projection), declines to replacement level by the early 2020s (the medium projection) or declines rapidly to levels well below replacement level (the low projection). The official Indonesian projection is close to the UN medium projection. Comparing the high and medium projections, the trajectory of fertility could make a difference of about 49 million in the total population by 2050.

Figure 20: Indonesia: projected total population

Early marriage and teenage fertility is a key reason for the high TFR. By age 16 almost 5 per cent of girls have started childbearing, reflecting marriages below the legal minimum age of 16. At age 19, almost 25 per cent of young Indonesian women have begun childbearing. Childbearing at ages 15-19 is heavily concentrated among the poorest young women; the percentages fall from 16.7 per cent in the lowest wealth quintile to 2.6 per cent in the highest45. Early childbearing exacerbates the other disadvantages faced by the poor.

Family planning Insufficient access to family planning services is one of the reasons for the stalling of TFR. Unmet need for contraception in Indonesia has been declining over time46 and it is not particularly high (11.4 per cent47) compared with many other countries,48 but it is high enough to be considered a real reproductive health issue. There are many inequities in use, access and quality of family planning and reproductive health services - between provinces, between districts within provinces, and between the general population and the poor and

45 IDHS 2012, page 61 Table 5.12. 46 IDHS 2012, page 96. 47 IDHS 2012 page 95, Table 7.20. 48 Jones, 2012.

100

150

200

250

300

350

400

1980

1985

1990

1995

2000

2005

2010

2015

2020

2025

2030

2035

2040

2045

2050

Thou

sand

s

Historical

Official Indonesian Projec?on

United Na#ons Popula#on Projec#on: High Variant

Total Popula#on ('000) -‐ Indonesia


36

marginalised groups. This is reflected in the TFR in each province, which varies from 3.7 in Papua Barat to 2.1 in DI Yogyakarta.

Figure 21: Percentage of married women with unmet need for family planning

Source: IDHS 2012

There has been a major shift from the public sector to the private sector for provision of family planning services. The latter has a perverse incentive to provide short-term methods which again impacts the TFR. However as Figure 21 above shows there is a significant unmet need for long term methods once families are complete.

Abortion rate The abortion rate in Indonesia is unclear, since data are very unreliable and estimates can only be based on assumptions with a wide range of uncertainty. Since the estimate of 2 million abortions in 2000 made by Utomo et al,49 no credible estimates have been made. The available studies suggest that the women who obtain abortions in clinics or hospitals tend to be married and educated. But in rural areas, traditional birth attendants are estimated to perform more than four fifths of abortions. ‘Altogether, nearly half of all women seeking abortion in Indonesia turn to traditional birth attendants, traditional healers or masseurs to terminate their pregnancy. (Women who induce their own abortions are not included in these estimates).’50

3.1.5 Communicable diseases There is an unfinished agenda of communicable diseases control in Indonesia. Diseases such as TB, human immunodeficiency virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS), diarrhoea, malaria and pneumonia remain an issue, although they account for a diminishing portion of the disease burden – the portion has dropped from 56 per cent in 1990 to 33 per cent in 2010.

• Malaria: In 2013 the incidence was 1.9 per 1,000 population and prevalence was 6.0 per 1,000 population. The lowest prevalence was in Riau (0.2 per 1,000) and the

49 Utomo et al, 2001. 50 Sedge and Ball, 2008.

6.3

0.9 0.4

15.3

0

2

4

6

8

10

12

14

16

18

15-‐19 20-‐24 25-‐29 30-‐34 35-‐39 40-‐44 45-‐49

Percen

tage

For Spacing

For Limi#ng


37

highest prevalence in Papua (27.0 per 1,000 population). The Annual Parasite Incidence (API) has decreased to 1.69 in 2012, from 1.96 in 2010, 3.62 in 2000 and 4.68 in 1990. A further drop is required to meet the RPJMN API target of 1.00 by 2014.

• TB: The number of TB cases in Indonesia is still high. It is ranked a high burden country both for TB and for multiple drug resistance TB by WHO. The prevalence of TB of all ages in 2012 is reported by WHO as being 297/100,000 (confidence interval: 144-506) and by the MoH as 400/100,000 nationally (0.4 per cent). The province with the lowest prevalence is Bali (0.1 per cent); the highest prevalence is in West Java (0.7 per cent). The proportion of population covered by the national TB program was on average 56.2 per cent in 2013. Coverage was lowest in Riau (30.0 per cent) and highest in West Java (65.0 per cent).51

• Hepatitis B: The prevalence of Hepatitis B (all ages, diagnosed by health workers in the last 12 months) increased from 0.6 per cent in 2007 to 1.2 per cent in 2013. The province with the lowest prevalence was East Kalimantan (0.3 per cent) and the highest prevalence was East Nusa Tenggara (4.4 per cent).

• HIV: Indonesia is one of nine countries where the estimated incidence rate of HIV infection among adults (15-49 years) increased over 25 per cent between 2001 and 2011.52 In 2013 The MoH reported a total of 127,416 HIV positive individuals with 52,348 cases of AIDS.53 There is considerable interprovincial variation with DKI Jakarta having the most individuals HIV positive (28,790) and West Sulawesi the least (31). The majority of transmission is heterosexual. Underreporting and detection are recognised as issues.

In addition, a number of neglected tropical diseases (NTDs) are still prevalent.

• Rabies. The number of cases of bites by a rabies-infected animal increased from 21,245 in 2008 to 84,750 in 2012. Post exposure treatment also increased: from 14,683 cases in 2008 to 74,331 cases in 2012.

• Leprosy. Trends have shown little change in the period 2007-2012. Prevalence remained almost the same, while there was a slight decline in incidence. In five provinces (Jakarta, West Java, Central Java, Yogyakarta, and East Java) the total number of cases in 2007 was 566, which declined until 2009 (with 335 cases), but increased again through 2011 when the number of cases reached 855.54

• Filariasis. The number of filariasis cases in 2012 was 11,903, a slight decline from 2011 (12,066 cases), but an increase in cases compared to 2008 (11,699 cases).

• Leptospirosis. The number of cases increased from 115 in 2005 to a peak of 857 in 2011, and decreased in 2012 to 239 cases. The case fatality rate of 13.91 in 2005 decreased to 5.16 in 2008, but was high again in 2012 at 12.3.

• Anthrax. The number of cases has been fluctuating: 17 in 2008, 41 in 2011, and 22 in 2012. However since 2011 all patients diagnosed/reported with anthrax have been treated.

51 Balitbangkes, Riskesdas 2013. 52 UNAIDS. Global Report. 2012. 53 Directorate General CDC & EH. 54 Ditjen PP&PL,MoH RI, 2013.


38

• Yaws. There are a high number of cases in East Nusa Tenggara, Papua and Southeast Sulawesi.

Although the numbers of NTDs are small they cause serious problems for the individuals affected and they are preventable. Other countries in the region have managed to eradicate these diseases and Indonesia should draw up a program to do likewise.

3.1.6 Non communicable diseases Indonesia is undergoing a rapid epidemiological transition and NCDs now make up the dominant share of the overall disease burden in the country. While in 1990 only about 37 per cent of morbidity and mortality in the country was due to NCDs, by 2010 this had risen to 58 per cent (see Figure 22).55 The prevalence of diabetes doubled between 2007 and 2013 to just over 2 per cent. This increase in NCDs is expected to continue as the share of the population aged over 65 years will begin to rise rapidly after 2015, and ageing will bring an even higher growth in NCDs.

Disability-adjusted life years (DALYs), which quantify the life years lost due to morbidity and premature mortality are a useful measure of the burden of disease. Table 9 below shows the top ten causes of the disease burden by DALY for 2010 and Figure 23 shows predicted DALYs loss from 2010 and 2019. Stroke was responsible for the largest share of the overall disease burden in Indonesia in 2010, causing 8 per cent of all DALYs.56 Stroke was also the leading cause of premature mortality in 2012. Ischemic heart disease, unipolar depressive disorders, and diabetes are other prominent NCDs in the top ten causes of the disease burden, with most of these conditions having doubled their share of the disease burden in Indonesia over the period 1990-2010. However this data comes from a community household survey based on experience in the previous year so has certain limitations.

Table 9: Top ten causes of disease burden in Indonesia, 1990-2010

Rank in 2010

Top ten diseases/conditions in 2010

DALYs lost share 1990 2000 2010

1 Stroke 4.3% 6.3% 8.0% 2 TB 7.5% 7.6% 7.6% 3 Road injury 3.3% 4.6% 4.7% 4 Low back and neck pain 2.8% 3.8% 4.5% 5 Diarrheal diseases 6.9% 5.6% 4.0% 6 Ischemic heart disease 1.9% 2.8% 3.8% 7 Unipolar depressive disorders 2.6% 3.4% 3.8% 8 Diabetes 1.7% 2.6% 3.5% 9 Lower respiratory infections 13.7% 5.9% 3.0%

10 Neonatal encephalopathy 2.5% 3.3% 2.9% DALYs per 100,000 44,144 35,074 32,053

Life expectancy in years 62 66 69 Source: Institute of Health Metrics and Evaluation (2013)

55 Institute of Health Metrics and Evaluation (2013). 56 DALYs refer to aggregated healthy years of time lost at the population level as a result of disease-related morbidity and

premature mortality.


39

Figure 22: Burden of disease by cause in Indonesia, 1990-2010

The rise in NCDs in Indonesia is a result of several socio-demographic and lifestyle factors. Ageing is one contributory factor, although the prevalence of NCDs among younger age groups in Indonesia is also increasing. Physical inactivity, excess salt, sugar and fat in the diet, tobacco use, and harmful alcohol consumption are key risk factors for NCDs. They translate into obesity, hypertension, and diabetes which again are risk factors for NCDs. The share of dietary risks and high blood pressure as contributors to DALYs lost has more than doubled over the period 1990-2010.

Figure 23: Predicted DALYs loss, 2010, 2015 and 2019

Source: Health Sector Review to support RPJM: ‘Changing Demand for Health and Health Services’ 2014

Obesity Obesity is fast becoming a major problem and is contributing to the NCD burden. The prevalence of obesity among Indonesian adult males increased from 13.9 per cent in 2007 to 19.7 per cent in 2013, and in women it increased from 13.9 per cent in 2007 to 32.9 per cent in 2013. There is considerable interprovincial variation with the lowest prevalence in

Non-communicable

Communicable

Injuries

37%

56%

7%

1990

Non-communicable

Communicable

Injuries

49%43%

9%

2000

Non-communicable

Communicable

Injuries

58%33%

9%

2010

Source: IHME

Burden of disease by cause in Indonesia, 1990-2010


40

women in East Nusa Tenggara Province (6.2 per cent) and the highest in North Sulawesi Province (24.0 per cent).

Tobacco Tobacco smoking is a major health issue with some of the highest male smoker rates in the world. The tobacco industry is now targeting females so their rates are likely to increase as well (see Table 10 for smoking prevalence). Smoking rates are higher among the poor, so there is a disproportionate effect on their health. Unless action is taken to reduce tobacco-smoking rates, Indonesia will face a major epidemic of cancer over the next twenty years, plus a further increase in cardiovascular disease and diabetes.

By smoking tobacco, the risk for men of developing lung cancer is increased 25 times, diabetes is increased by 30-40 per cent and heart disease and stroke increases by a factor of two to four times. Smoking also exacerbates and can be a cause of TB. As well as direct increased costs to the health sector there are considerable indirect costs to the economy through absenteeism and premature death.

Table 10: Prevalence of active smokers aged 15 years and above by sex, Indonesia 1995-2013

Year Male Female Total Population Source of data

1995 53.9 1.7 27.2 Susenas 2001 62.9 1.4 31.8 Susenas 2004 63.0 5.0 35.0 Susenas

2007 65.3 5.6 33.4 Baseline Health

Research

2010 65.9 4.2 34.7 Baseline Health Research

2011 67.0 2.7 34.8 Global Adult Tobacco

Survey

2013 64.9 2.1 36.2 Baseline Health Research

3.2 Changing demand for health services 2015-2019 There will be an increased demand for health services in the future. This can be partially explained by the growth of the total population in Indonesia, which is expected to grow by 7.8 per cent from 2013 to 2019. However the change in the population structure of Indonesia will have most impact on the demand for health services. The majority of the population growth over that period will be in the over 45 age group (24.6 per cent), whilst the population under 45 years is only expected to grow at 3.2 per cent. Figure 24 shows the predicted growth in the population aged 65 and over for Indonesia and other countries in the region. This transition to an increasingly ageing population will also see a continued shift in burden of disease to chronic NCDs, such as diabetes, stroke and cancer. Ongoing treatment costs associated with these diseases (anti-hypertensive drugs, cancer treatment, statins, etc.) along with significant hospitalisation costs will produce a significant cost burden along with associated productivity losses and premature death. Unless the remaining legacy of communicable diseases is addressed the country will face a double burden of disease, with TB in particular a problem.


41

Figure 24: Growth in the % the population aged 65+ in selected countries, 1950-2070

3.2.1 Modelling changing demand A study was carried out as part of this review to model the impact on health care demand and costs of the changing burden of disease, taking into account changes in the total population and its age structure. It looked at the health expenditure for the ten leading causes of the burden of disease as measured by DALYs.

The report also modelled the impact of key prevention interventions such as exercise, reduction in tobacco consumption, and a better diet.

There are reservations about the data as Riskedas relies on survey questions in the previous 12 months and relied on people having accurate knowledge of their disease. This means that the results may, if anything, underestimate the problems.

The modelling suggests as expected a continued rise in the burden of disease caused by NCDs, and rise in the prevalence of stroke, diabetes and tuberculosis in all age groups over 45 (see Figures 25 to 30).

Figure 25: Prediction of DALYs lost in Indonesia, 2015 and 2019

Communicable Diseases, 30.3%

Non Communicable Diseases, 57.1%

Injuries, 12.6%

2015

Communicable Diseases, 28.3%

Non Communicable Diseases, 59.3%

Injuries, 12.3%

2019


42

Figure 26: Incidence of cerebrovascular disease (per 10,000 population), 2015 and 2019

Figure 27: Incidence of diabetes mellitus (per 10,000 population), 2015 and 2019

Figure 28: Incidence of tuberculosis (per 10,000 population), 2015 and 2019

2.00

2.06

1.95

2.00

2.06

1.95

1.85

1.90

1.95

2.00

2.05

2.10

Total Males Females

Incidence of Cerebrovascular Disease

2015 2019

72.41 71.39

73.43

78.23 76.70

79.79

66.00 68.00 70.00 72.00 74.00 76.00 78.00 80.00 82.00

Total Males Females

Incidence of Diabetes Mellitus

2015 2019

62.6

66.9

58.3

67.0 67.1 67.0

52.0 54.0 56.0 58.0 60.0 62.0 64.0 66.0 68.0

Total Males Females

Incidence of Tuberculosis

2015 2019


43

In the modelling, there was a decreasing trend in the prevalence of cancer and heart failure with very low rates. This seems unlikely and needs to be revisited. There is a slight decrease predicted in the prevalence of hypertension but rates still remain very high. Regardless of changing prevalence, because of the changing population, the overall number of cases will continue to increase.

Figure 29: Incidence of cancer (per 10,000 population), 2015 and 2019

Figure 30: Predicted number of cases, 2015 and 2019

15.65

8.12

23.26

16.86

9.02

24.77

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Total Males Females

Incidence of Cancer

2015 2019

489.65

714.56

1,116.54

1,329.37

1,600.43

1,849.74

3,876.02

9,286.28

551.14

810.31

1,169.51

1,594.74

1,797.39

2,097.26

4,219.39

10,170.17

0.00 2,000.00 4,000.00 6,000.00 8,000.00 10,000.00 12,000.00

Cancer




Tuberculosis

Diabetes Mellitus

Ischaemic heart disease

1. Lower Respiratory Infec?ons

Predicted Number of Cases (thousands)

2019 2015


44

3.2.2 Impact on the health sector budget Figure 31 sets out the estimated costs of eight leading causes of morbidity in 2019, while Table 11 shows the projected increases in costs for the ten leading causes of morbidity between 2015 and 2019. This modelling demonstrated that unless significant action is taken there will continue to be significant cost increases for the health sector over the next five years, with a doubling of the costs associated with the leading causes of disease between 2015 and 2019.

Figure 31: Estimated health care costs for leading causes of disease, 2019

90,939,225

139,722,002

152,639,272

201,903,755

235,589,235

150,165,135

579,809,572

1,431,162,936

77,139,222

173,131,982

420,507,244

376,493,640

366,728,040

503,423,236

885,406,172

2,136,056,578

168,078,447

312,853,984

573,146,516

578,397,395

602,317,275

653,588,371

1,465,215,744

3,567,219,514

0 500,000,000 1,000,000,000 1,500,000,000 2,000,000,000 2,500,000,000 3,000,000,000 3,500,000,000 4,000,000,000

Cancer



Tuberculosis

Diabetes Mellitus



Lower Respiratory Infec?ons

Es#mated Health Care Costs (IDR)

Total In pa?ent Out-‐pa?ent


45

Table 11: Estimated change in health care costs for leading causes of disease, 2015 and 2019

3.3 Commentary and challenges for 2015-2109 and beyond

This section builds on the analysis of the health outcomes and burden of diseases set out above and sets the scene for the remaining chapters. It identifies in particular some of the key systematic issues that will need to be addressed. From the burden of disease analysis the public health challenges are obvious. Over the next five years and beyond the sector needs to focus on the following:

• addressing the inequality of health outcomes • reducing the maternal mortality rate • reducing the neonatal mortality rate • reducing the total fertility rate • reducing wasting and stunting • a population based public health program to reduce NCDs with a focus on reductions in

smoking, obesity and salt intake

2015 outpatient (OP) costs

2015 inpatient (IP) costs

2015 total costs

2019 OP costs

2019 IP costs

2019 total costs

Increase

Tuberculosis 113,260,965 186,243,211 299,504,176 201,903,755 376,493,640 578,397,395 93.12%

Lower respiratory infections

823,271,779 1,083,562,197 1,906,833,976 1,431,162,936 2,136,056,578 3,567,219,514 87.08%

Birth asphyxia and birth trauma

6,479,711 23,909,222 30,388,933 10,088,227 42,212,172 52,300,399 72.10%

Cancer 50,900,437 38,074,347 88,974,784 90,939,225 77,139,222 168,078,447 88.91%

Diabetes Mellitus 130,904,468 179,692,558 310,597,026 235,589,235 366,728,040 602,317,275 93.92%

Major depressives disorder

79,571,468 75,335,041 154,906,509 136,305,993 146,341,554 282,647,547 82.46%


335,554,376 451,863,245 787,417,621 579,809,572 885,406,172 1,465,215,744 86.08%

Cerebrovascular disease 80,161,050 194,741,064 274,902,114 152,639,272 420,507,244 573,146,516 108.49%

Chronic obstructive pulmonary disease

77,623,384 84,818,780 162,442,164 139,722,002 173,131,982 312,853,984 92.59%

Road traffic accidents 90,318,772 267,010,977 357,329,749 150,165,135 503,423,236 653,588,371 82.91%


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• a personal primary care based program for adults aimed at supporting behaviour change for risk factors for NCDs; screening for early detection of hypertension and diabetes with good control of those found positive

• reducing the prevalence of TB, malaria and HIV • eliminating the remaining neglected tropical diseases.

It will not be enough to set targets. This was done in the last RPJMN and key targets were not achieved. The clinical and public health interventions to address neonatal, child and maternal health reduce wasting and stunting, reduce the TFR and control or eliminate communicable diseases are known. Policies to implement them are in place and where they are implemented they are successful. If the health outcomes achieved in the best performing geographical areas and socio economic groups were achieved nationally, Indonesia would be one of the best performing countries in the region.

Further work needs to be done in devising strategies and policies for NCDs but there is considerable evidence as to what works and what does not. There will need to be a focus on both secondary prevention – controlling NCDs once they are detected to reduce disease progression - and primary prevention, both at the population level and at the individual level.

There needs to be investment in health promotion and disease prevention with a particular focus on obesity and salt reduction, increase in physical activity and reduction in smoking. This will involve agreeing on national policies and strategies and should be led by the MoH with provincial and district action plans. There needs to be a ring-fenced budget at all three levels of government to support this. In addition, work needs to take place jointly between the MoH and BPJS to build incentives into the capitation formula to promote healthy lifestyles and to screen for and effectively treat diabetes and hypertension.

Further refinement is needed on costing the impact of the change in burden of disease, factoring in costs of clinical interventions, especially more expensive ones such as stents and renal dialysis. Cost benefit analyses should be done on the value for money of investments in the prevention of NCDs. Additionally, a separate study on the economic impact of smoking and the return on programs to reduce smoking rates should be carried out.

There needs to be a more holistic approach with a focus on the social determinants of health and intersectoral working. Better nutrition and better reproductive health can reduce maternal and neonatal mortality as well as contribute to the reduction in NCDs in later life. The difficulty of working intersectorally should be recognised and for nutrition in particular, where investments offer such strong benefits, there needs to be clear lines of accountability. Cross-ministry coordination for the process of planning and budgeting should be managed by Bappenas. The monitoring of the implementation of the policy option is to be coordinated by Coordinating Ministry of Social Affairs (Menkokesra). The current arrangements for accountability are insufficient - someone needs to be in charge and be held accountable. Consideration should be given to creating such a post in the president’s office.

Within the health sector, while the focus has to be on public health and primary health care, it is important to also address the hospital sector to ensure it is working efficiently and effectively and that overall costs are contained. Clinical practice has changed significantly in the last two decades with a major shift to ambulatory care and the use of new technology. This has implications for the shape and size of the hospital sector and can drive to the detriment of the primary care budget. NCDs can be very expensive to treat if not managed at


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an early stage in primary care. There needs to be a national debate as to what treatments – for example renal dialysis for renal failure associated with diabetes, stents for myocardial infarction– will be made available, what budget will be allocated, and what should be spent on primary and secondary prevention.

Linked to that is the role of the private sector in health. Indonesia has a vibrant private sector in both primary and secondary care, but little data on it is available. This needs to be addressed and clear policies developed around its future role and how private public partnerships will work.

There also needs to be a focus on innovation and the use and introduction of new technologies such as m-health and telemedicine. The way in which health care is being delivered in both the hospital and primary care settings is changing rapidly, driven by smart phone technology, and it is important that Indonesia is aware of international best practice in this area and contributes to it.

3.3.1 Better delivery of known interventions The focus has to be on delivery, which will include addressing the systemic issues identified in the reports. These systemic issues include:

• roles and responsibility for delivery in a decentralised system • performance management in a decentralised system • the role of the private sector and public–private partnerships • meeting the changing and increased demand for health care – public health, finance

and human resources • implementation of JKN • supply side readiness including pharmaceuticals and devices • improving the quality of care.

Two key drivers that have to be addressed are decentralisation and the implementation of JKN. Two themes appear frequently in the institutional analysis carried out for the review. The first is how the MoH exercises a leadership role in the context of a decentralised constitutional structure, and how bilateral relationships can be managed in a transparent way (with MoEC, BPJS, Ministry of Public Works (MoPW) etc.). Second is how governance is conveyed down through a hierarchical structure from the centre to Village-level, whilst respecting the legitimacy of Provincial and District Parliaments.

It will not be enough for Bappenas to set targets at the regional level for health outcomes or for the MoH to monitor MSS. The MoH needs to work with the Ministry of Home Affairs (MoHA) to ensure all provinces and districts have good annual health plans to deliver the targets backed by a performance monitoring framework which the MoH can help the MoHA monitor.

It will be important that the MoH develops a close relationship with JKN and is able to both influence its policies to deliver health gain and to monitor their implementation to ensure early detection of adverse impact on health outcomes.

The MoH, provinces and districts all need a separate budget for population based disease prevention and health promotion activities. It is equally important that they work with BPJS to ensure that the capitation funding mechanism for primary care is designed and monitored to ensure it delivers effective personal public health programs, such as the full continuum of


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maternity care, family planning and the prevention, early detection and effective community treatment for NCDs.

These are covered further under subsequent chapters on targets, policies and strategies but some key issues for BPJS are of such importance they are addressed further here.

3.3.2 Implementation of JKN

Adequate financing for UHC in Indonesia is estimated by the World Bank to be somewhere between USD13 and USD16 billion IDR126.8 trillion to IDR156.1 trillion). The unified social insurance program will pool contributions from three broad categories of people: (i) the poor and near-poor whose fixed premium contributions will be paid for entirely by the central government; (ii) those employed in the formal sector, both public and private, whose salary-based contributions will be paid for by employers and employees; and (iii) those who are non-poor and work in the informal sector who will be expected to pay a fixed premium contribution upon enrolment in the program. The central government outlays to finance the premiums of 86.4 million poor and near-poor in 2014 are expected to be IDR19.9 trillion or USD2.04 billion (approximately 0.2 per cent of GDP), up from IDR6 trillion or USD615 million allocated for financing Jamkesmas in 2011 (approximately 0.1 per cent of GDP).

In addition to demand-side financing from the central government, additional supply-side financing from the central, provincial, and district governments will be needed to meet rising utilisation rates as coverage expands.

3.3.3 Integration of existing health insurance programs Health insurance coverage is still partial and will need to be expanded to other groups in the country gradually, with a roadmap objective of reaching 100 per cent coverage by 2019. This includes:

• integration of hundreds of separate Jamkesda (health insurance to cover poor people missed by Jamkesmas)

• integration of employer-provided healthcare services to its employees (self-insured) • coverage of the informal sector.

One of the critical links for achieving UHC by 2019 is the involvement and coordination of local government units to:

• link the existing Jamkesda to the national health insurance scheme • finance costs not paid by central government • facilitate the participation of uncovered population • ensure availability of functional health facilities at the district level.

3.3.4 The informal sector The Indonesian economy and workforce is dominated by the informal sector. Analysis of the 2012 Sakernas (Nationl Labour Force Survey) found that approximately 120 million people are of working age, of whom about 95 per cent (114 million) hold working status. Among those who work, about 68 million (or about 62 per cent of all workers) work in the informal sector. Further analysis indicates that amongst the informal workers: (i) 20 million (28.3 per cent) were unpaid family workers; (ii) 35.6 million (about 31.5 per cent) work less than 35 hours per week or are almost jobless, (iii) 55.5 million (49.2 per cent) have achieved


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education levels below a primary school education, and (iv) the average annual income was only IDR 1.5 million. A recent Bappenas study57 reported that about 32.5 million informal workers will not be covered by any health insurance schemes in 2014 (not including family members).

There are two issues related to insurance coverage for the informal workers that need to be addressed. Firstly, it is unclear what happens if they do not or cannot pay their premiums. Secondly, collecting contributions from informal workers can be both challenging and costly, and the costs could be more than the income generated through premiums.

3.3.5 Strategic governance of BPJS The BPJS governance issues are important for the overall performance of the BPJS. There are a number of remaining areas that need to be addressed.

• The mechanisms for representing interests. There may be a need for BPJS to have its own Board with stakeholders from various groups such as President’s Office, Parliament, ministries, local governments, providers, and consumers.

• The forms and scope of governmental supervision (level of autonomy). The BPJS reports to the President and has some level of ministerial autonomy. The question is whether this provides sufficient oversight and accountability and ensures full coordination with the MoH.

• Information reporting requirements. This should include annual audits of finances by an independent accounting firm, with results disseminated publicly.

• Issues related to the fact that the fund is not subject to competition. By law, all funds integrate with the BPJS. Single payer models have different issues relative to multiple payer models. Without competition how will the GoI know it is getting value for money?

• The types of provider payment arrangements in place. With BPJS, new payment systems are sophisticated and “best practice” by international standards, but design details suggests models are rudimentary at this stage, are not precise, and need further analytic development and refinement to be fair and provide clear market signals.

• The capacity for effective service purchasing, contract management and monitoring. There are several areas where more development and capacity is needed, including:

o actuarial forecasting - there is currently none in the BPJS and this capacity is essential for forecasting and managing both revenues and costs;

o information systems, including a data dictionary, unique identifiers for patients and providers - not yet in place in January 2014; and

o quality assurance systems for monitoring quality and perverse incentives under the new payment models.

• Implementation of strategic purchasing reforms. It is important that the purchasing mechanism delivers health gains and improves quality and does not just reimburse clinical activities. The BPJS, the MoH and the MoF will need to work together to ensure the objectives of the payment reforms actually and fully occur.

57 Bappenas, 2013


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4 Targets to be achieved by 2019

This chapter sets out key targets for the health sector over the period between 2015 and 2019. They are a mixture of targets for health outcomes and clinical and public health interventions to help reach them. Some are for consideration for the RPJMN, others for inclusion in the health strategy and national, provincial and district health plans

4.1 Headline population, nutrition and health outcomes

4.1.1 Population dynamics The main target is to reduce the TFR to 2.3 by 2019. This will reduce population growth from 1.3 per cent in 2015 to 1.1 per cent in 2019.

Table 12: Population dynamics target 2015-2019

Area of HSR Indicators 2015 2016 2017 2018 2019

Fertility, FP and RH

TFR (# of children per woman) 2.4 2.4 2.3 2.3 2.3

Crude Birth Rate (birth per 1,000 population) 19.2 18.8 18.5 18.2 17.8

Case Detection Rate (death per 1,000 population) 6.4 6.4 6.4 6.5 6.5

Rate of growth (annual %) 1.3 1.2 1.2 1.2 1.1

# births (x1,000) 4,985 4,869 4,840 4,810 4,780

# deaths (x1,000) 1,622 1,653 1,684 1,717 1,753

Population increase (x 1,000) 3,362 3,216 3,156 3,093 3,027

Source: Official population projection, 2010-2035

4.1.2 Reducing teenage fertility There needs to be a particular effort to reduce teenage fertility with a focus both on spacing and unmet need. This needs to be linked with efforts to raise the age at marriage.

Table 13: Teenage fertility targets 2015-2019

Area of HSR Indicator 2015 2016 2017 2018 2019 Notes

Fertility, FP and RH

Teenage fertility, 15-19 43 41 39 37 35/1000 Age specific fertility rate

Age at first marriage 22.2 22.3 22.4 22.7 23 years SMAM based on SP2010

% teenage unmet need for spacing 14.4 13.4 12 10 8 Age 15-24

years % teenage unmet need for limiting 1 0.5 0.3 0.1 0.1 Age 15-24

years


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4.1.3 Nutrition The full set of indicators endorsed by WHO member states to monitor progress towards improving maternal and child nutrition should be considered. These indicators include stunting, wasting, child overweight, low birth weight, anaemia in women of reproductive age and exclusive breastfeeding (Table 14). Child underweight and anaemia in pregnant women have been added because, although not included in WHO’s list of indicators, they are important and measured in health facilities. In addition, there is one year remaining to report on the achievement of the 2015 underweight target for MDG 1.

In addition targets now need to be set to reduce overnutrition. The targets included in Table 14 are modest, do not set targets for salt reduction and and would only stall an increase in obesity. Once programs to target risk factors for NCDs are developed, more ambitious targets should be considered.

Child stunting should be included in the list of Main National Development Targets. Child height at two years is the best predictor of future human capital,58, and child stunting is expected to replace underweight in the list of indicators to measure the progress of the Post-2015 Development Agenda.59

Table 14: Nutrition targets for the Health Sector

Indicator Baseline (2013)

Target (2019) High

investment Medium

investment *Child stunting in under-fives: Prevalence of stunting in children aged 0-59 months

37.2% <30% <32%

*Child stunting in under-twos: Prevalence of stunting in children aged 0-23 months 33% <26% <28%

*Child wasting in under-fives: Prevalence of stunting in children aged 0-59 months

12.1% <9% <10%

Child underweight in under-fives: Prevalence of underweight in children aged 0-59 months

19.6% <15% <17%

*Child overweight in under-fives: Prevalence of overweight in children aged 0-59 months

11.9% <10% <12%

*Low birth weight: Percentage of live-births with a birth weight less than 2.5 kg

10.2% <8% <9%

*Anaemia in women of reproductive age: Percentage of women of reproductive age with a haemoglobin concentration below

21% <16% <18%

*Exclusive breastfeeding: Percentage of infants aged less than six months who are exclusively breastfed

41.5% >80% >60%

58 Victora CS et al. (2008). Maternal and child undernutrition: consequences of adult health and human capital. Lancet

371(9609):340-57. doi: 10.1016/S0140-6736(07)61692-4. 59 UN (2013). A new global partnership: eradicate poverty and transform economies through sustainable development. The

report of the High-Level Panel of eminent persons on the Post-2015 Development Agenda. United Nations, New York.


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Indicator Baseline (2013)

Target (2019) High

investment Medium

investment Anaemia in children aged 12-23 months: Percentage of children aged 12-23months with a haemoglobin concentration below 11 g/dL

47.5% <35% <40%

Anaemia in pregnant women: Percentage of pregnant women with a haemoglobin concentration below 11 g/dL

37.1% <28% <32%

Over nutrition in women: Percentage of non-pregnant women >18 years with BMI ≥ 25 kg/m2

32.9% 30% 32%

Over nutrition in men: Percentage of men >18 years with BMI ≥ 25 kg/m2

19.7% 17% 19%

*Indicators endorsed by WHO member states to monitor progress towards improving maternal and child nutrition (World Health Assembly Resolution 65/6).

Two targets for each nutrition indicator are provided, one target that assumes high investment in reducing nutrition and one that assumes medium investment. The high investment targets assume that investment in nutrition is sufficient to achieve full coverage of nutrition-specific interventions needed to reduce under nutrition, as well as scale-up of nutrition-sensitive interventions. For WHO indicators, the high investment targets for stunting, wasting, low birth weight and anaemia in women of reproductive age were determined by calculating the progress needed by 2019 in order be on track to achieve the WHO targets by 2025. The high investment targets for exclusive breastfeeding and child overweight are more ambitious than the World Health Assembly targets, which are considered too unambitious. The medium investment targets assume a lower level of investment in nutrition.

4.2 Maternal and child health outcomes

4.2.1 Reduction of MMR This has to be the key health target. The proposed target is to reduce MMR by about one-half (to become 130 or 95 per 100.000 live births) by 2019, depending on which current estimate of MMR is accepted. Using data from the 2007 and 2012 IDHS, the point prevalence of MMR has increased from 228 in 2007 (confidence interval (CI) 132-323) to 359 in 2012 (CI 239-478). However the latest UN/WHO interagency rates for 2012 give a rate of 190.

4.2.2 Measurement of MMR The lack of MMR measurement for Indonesia has led to uncertainty about the trends of MMR. There are two methods available which are used elsewhere and which can potentially provide information on maternal deaths: the MCH local area monitoring system (PWS-KIA), and the Maternal Deaths from Informant / Maternal Deaths Follow on Review (MADE-IN/MADE-FOR).


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The PWS-KIA60 has been implemented for some time, however it has not been able to provide appropriate information on maternal deaths due to lack of compliance by the community providers (bidan and their link partners such as traditional birth attendants and kader) to identify, record and report the results on a routine basis. If this is done properly, it has the potential to provide data on maternal deaths with modification of the recording and reporting form.

MADE-IN/MADE-FOR is a promising reliable and efficient method to capture maternal deaths, using two existing informants in the community; the head of neighbourhood units (Ketua RT) and the kader.61 The likely pregnancy related deaths (PRD) identified from MADE-IN are validated through visits to the homes of women, to confirm the PRD status and add information on the cause of death. This method proved able to identify many more deaths than PWS-KIA in Banten province and routine information in Pakistan.62 This method can be used at district level and can be done periodically e.g. every 2-3 years allowing geographical monitoring and evaluation as this method also provides the cause of death.

4.2.3 Neonatal infant and child mortality The target is to reduce neonatal mortality by 50 per cent from 19/1000 live births to 9.5/1000 by 2019. The evidence is that both IMR and under-5 (U-5) mortality cannot be decreased significantly unless there is a significant reduction in neonatal mortality. As was noted in chapter 3, it is estimated that a 50 per cent reduction of neonatal mortality will reduce IMR by 30 per cent from 32 to 23, and reduce U-5 mortality by 24 per cent from 40 to 31 per 1,000 live births. However reducing neonatal deaths is challenging and requires a high commitment to be effective.

In addition to the reduction in infant and child death rates due to the reduction in neonatal mortality, a further reduction should be targeted as result of intervention in the under one and under five age groups. Targets in reducing infant mortality and child deaths need to be set.

Communicable diseases For children the incidence of the main infections that cause infant and under-five deaths should be reduced, through immunisation and through infection management. Special effort should be given to areas with very high infection prevalence and low immunisation rates. The recommended national targets for 2019 are:

• increase the complete immunisation rate to 90 per cent • increase the measles vaccination rate at 1 year of age to 90 per cent • reduce the prevalence of diarrhoea by 30 per cent • reduce the prevalence of Acute Respiratory Infection (ARI), including pneumonia by 30

per cent • reduce the prevalence of Measles by 30 per cent.

60 Kementerian Kesehatan RI, Direktorat Jenderal Bina Kesehatan Masyarakat, Direktorat Bina Kesehatan Ibu, 2010. Pedoman

Pemantauan Wilayah Setempat (PWS-KIA). http://www.gizikia.depkes.go.id/wp-content/uploads/downloads/2013/08/Pedoman-PWS-KIA.pdf .

61 Qomarijah et al. An option for measuring maternal mortality in developing countries: a survey using community informants. BMC Pregnancy and Childbirth 2010, 10:74. http://www.biomedcentral.com/1471-2393/10/74.

62 Verbal information from Dr. Qomarijah who conducted the study in Pakistan with the team leader from University of Aberdeen. Published document will be soon available.


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No adult targets were set in the review although trends for TB were estimated as part of the changing demand work, showing an increase in all age groups. In the first year of the next RPJMN, further work needs to be done to set targets for communicable diseases. At the very least TB and HIV should not increase in prevalence and NTDs should become a rarity.

4.2.4 Non communicable diseases

Again no targets were set either for modifying risk factors or disease prevalence. This needs to be done in year one as part of the overall design of a program to control and reduce NCD prevalence. The following diseases result in a significant proportion of DALYs lost and so should be prioritised – diabetes; cardiovascular disease, including stroke, ischemic heart disease and hypertension; cancer and road injuries.

4.3 Public Health and clinical interventions This section sets out targets for some key interventions that will be needed to achieve the headline targets set out above.

4.3.1 Reproductive health Table 15: Targets for the overall contraceptive prevalence rate and the various methods being used 2015-2019

Area of HSR Indicator 2015 2016 2017 2018 2019

Fertility, FP, RH

Contraceptive prevalence rate (CPR) all methods (% of married women of reproductive age)

60.5 60.8 61.1 61.5 61.8

Method

Injectables (% of all users) 44.8 44.3 41.8 40 38.8

Pill (% of all users) 25 24 23.5 22.5 22.2

Condom (% of all users) 2.8 3 3.4 3.4 3.8

IUD (% of all users) 11.3 11.8 12.8 13.8 14.1

Implant (% of all users) 11.3 11.8 12.8 13.8 14.1 Female Sterilization (% of all users) 3.8 4 4.6 5.3 5.8

Male Sterilization (% of all users) 1 1.1 1.1 1.2 1.2 Source: estimated by SMA and GWJ based on the policy to make balance method mix while at the same time strengthening the role of private sector and increasing male participation.

Table 16: Reducing unmet need and the increase needed in private sector use


Fertility, FP, RH

Unmet need (% (new formula)) 10.2 9.8 9.4 8.9 8.5 Short term method (% of users) 71.3 68.7 65.9 64.8 62.8

Long acting (% of users) 28.7 31.3 34.1 35.2 37.2 Use of private sector (% source of supply) 72.7 72.8 72.9 73 75


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Table 17: Increasing the competence of bidan and contraceptive supply chain management (CSCM)


Fertility, FP, RH

Increase in # Bidan Delima (Midwife accreditation program) (to anticipate increase in long-term method)

12,500 14,000 16,000 18,000 20,000

Increase in CSCM (% of storage management meeting gold standard)

20% 40% 60% 80% 100%

4.3.2 Maternal and neonatal health To achieve the target reduction in MMR and NMR, there are a number of targets around the continuum of obstetric care that need to be met. The focus should be on high-risk districts with high populations and a high MMR.

• 80 per cent of obstetric complications are managed in hospitals. • 90 per cent of bidan are trained in APN (normal delivery care). • 80 per cent of deliveries take place in a health facility (not including polindes). • Each target district provides PONED (basic emergency obstetric neonatal care)

services (including human resources, equipment and pharmaceuticals) that function 24/7 to at least 80 per cent of the population.

• 70 per cent reduction in the prevalence of anaemia in pregnant women. • 50 per cent increase in the percentage of pregnant women who consume iron folic acid

(IFA) or MMN.

4.3.3 Infant and child mortality In addition to the targets for neonatal mortality and for immunisation, targets are needed to reduce infant and under-five undernutrition.

Improving infant and young child feeding (IYCF) practices is equally important in reducing child deaths. Achieving coverage of 99 per cent of exclusive breastfeeding up to 6 months and continued breastfeeding up to 12 months would lead to a 13 per cent reduction of child deaths, while coverage of 99 per cent of appropriate complementary feeding would prevent 6 per cent of child deaths.63

The recommended national targets are: • Increase the percentage of early initiation of breastfeeding within one hour by 50 per

cent • Increase exclusive breast feeding on demand (BFD) from 0-6 months to 60 per cent • Increase BFD until 1 year to 80 per cent • Increase BFD until 2 year to 70 per cent

63 Gareth Jones, Richard W Steketee, Robert E Black, Zulfiqar A Bhutta, Saul S Morris, and the Bellagio Child Survival Study

Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65-71.


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• Increase the coverage of micronutrient sprinkles among children 6-59 months to 90 per cent from 80.1 per cent

• Improve the Minimum Diet Frequency from 66 to 80 per cent • Improve the Minimum Diet Variation from 58 to 80 per cent • Improve the Minimum Acceptable Diet from 37 to 60 per cent • Increase the percentage of children 6-59 months receiving vitamin A supplementation to

80 per cent from 60.5 per cent.

4.3.4 Increased community participation The role of community is imperative in improving health and nutritional status. In Indonesia, one key strategy to increase community participation is strengthening the posyandu system. This has the potential to improve maternal and child nutritional status and health through various activities, including monitoring of child’s nutritional status, screening for maternal nutritional status, distribution of vitamin A, iron and folate supplementation, and behaviour change communication (BCC) for improved complementary feeding, washing and hygiene practices.64

The recommended target is 80 per cent attendance at posyandu for all pregnant women and those with children under five.

4.4 Health systems strengthening

4.4.1 Supply side readiness

Several key targets for Indonesia’s RPJMN 2015-2019 are proposed. The indicators are largely based on those recommended by WHO, and proposed targets are based on the necessary improvements on baseline values to deliver UHC by 2019 (see Table 18).

Table 18: 2019 targets for supply side readiness

Indicator Baseline 2019 target

Central registry and service-readiness assessment of private clinics and hospitals

* 100%

Inpatient bed density per 10,000 population 12.6 25 Inpatient admissions per 10,000 population 1.9% 5.0% Average bed occupancy rate 65% 80% Percentage of district/city public hospitals delivering PONEK services 25% 100% General service readiness of puskesmas 65 71% 100% Service-specific readiness of puskesmas for basic obstetric services 62% 100% Service-specific readiness of puskesmas for NCDs 79% 100% Service-specific readiness of public hospitals for PONEK services 86% 100%

64 Zulfiqar A. Bhutta, et al. What Works? Intervention that affect maternal and child undernutrition and survival. The Lancet,

published online January 17, 2008 DOI: 10.1016/S0140-6736(07)61693-6. 65 Availability of basic amenities, basic equipment, standard precautions for infection prevention, diagnostic capacity, and

essential medicines.


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4.4.2 Health financing The headline target is for 100 per cent coverage of the Indonesian population by JKN by 2019. At this stage of the development of JKN considerable work needs to be done between BPJS, the MoH and the MoF to put intermediate targets both on the road map for JKN and on the overall fiscal envelope for health financing. In the first year of the next RPJMN they should work together to agree a set of interim targets and a performance monitoring framework, which would include some of the following indicators:

• overall patterns of expenditures become more equitable and pro-poor • health expenditure and its distribution • increased financial protection • increased coverage, pooling of funds, and management strengthening of BPJS • strategic purchasing • public management of funds.

4.4.3 Human resources for health The GoI has prioritised six key indicators for HRH to support UHC listed in Table 19 below. In principle, UHC requires 100 per cent coverage of these indicators by 2019. While an admirable and important goal, indicators need to be realistic and achievable in the time span envisaged. The cost of achieving the indicators needs to be identified and resources budgeted accordingly. Measuring actual progress requires a strong and reliable baseline set of data. Developing realistic and achievable indicators against the ultimate goal of 100 per cent coverage should be a priority in the medium term. In the meantime, progress towards achieving 100 per cent coverage against the existing baseline would be a meaningful and achievable indicator for Indonesia to pursue.

Table 19: Key targets for UHC for HRH

Key Indicators Target 2019 Means of Measurement

HRH density in deprived area : 2.28 /1,000 (WHO standard)

Realistic target relating to progress made towards achieving 100% goal for UHC to be determined.

National Research

Doctor: Nurse ratio: 5.0 in deprived area


National Research

HRH configuration in Hospital & Primary Care as required by regulation


National Research

HRH competency test conducted regularly for MD, Midwife, Nurse, Pharmacy, Nutritionist,

Realistic target relating to progress made towards achieving 100% goal for UHC to be determined. MoH survey

Team-based deployment conducted for deprived area


MoH survey

Compulsory deployment applied

Started in 2015 and effectiveness reviewed in 2017 MoH survey


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4.4.4 Institutional strengthening

No definite targets around institutional strengthening were agreed during the review. It is important that in the first year of the next RPJMN the MoHA and the MoH agree key targets with dates for institutional strengthening drawn from the following list.

Governance and System-level targets (the major policy objectives of the MoH)

• The share of APBN (National Budget) going into health • The percentage reduction of staff numbers in the central MoH • Policy (with regulation) on the distribution of functions and responsibilities on health

matters between central and local governments (province and district) in place • Policy (with regulation) on institutional arrangement between Provincial Health Offices

(PHOs) and Province Hospitals, District Health Offices (DHO), District Hospitals and puskesmas in place

• The existing NSPK is reviewed.

Input-level targets (the resourcing, capacity, and structure of the SKN)

• Management costs defined and percentage reduction agreed • Rate of replenishment as a per cent of decapitalisation • Revised SPM (Minimum Service Standard) in place • Policy (with regulation) in place on financial management of hospitals and puskesmas • Medical Advisory Board (as mandated by Law 36/2009 about Health) in place • Guidelines for community empowerment and integration with related sectors (under the

coordination of BPMD (Rural Community Development Agency)) established • Complaint resolution units at both health centres and hospitals established • The percentage increase in the number of health workers in remote and difficult

locations.

Output-level targets (access/coverage, efficiency quality and distribution)

• The percentage of the population covered under a single scheme managed by BPJS • The number of insured and number of those aware of their insurance coverage • Tariffs target the needs of the underserved population • The percentage of Jamkesda incorporated into BPJS • The percentage of private sector providers conforming to agreed quality standards • The percentage of appointments/clinics cancelled due to the unavailability of personnel • The percentage of health care facilities that meet agreed quality standards • The development and implementation of an accreditation system for primary health care

facilities.

4.4.5 Quality and safety Currently there is no baseline to describe achievements in quality and safety over the last RPJMN, and there has been little discussion among stakeholders to define what steps are appropriate. The recommended policy direction is to start consultation in Indonesia towards a coherent plan, rather than to prescribe solutions based solely on international experience.

The development of nationally-agreed, evidence-based, internationally comparable statistical measures of quality must be driven by national commitment and collaboration. This is an


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important step for any country which cannot be by-passed with technical short-cuts. Table 20 below however set out some key targets that could be adopted to drive the process.

Table 20: Targets to drive the introduction of quality assurance in the health sector

Policy 2015 2016 2017 2018 2019

National framework for Q&S issued for consultation x National quality policy approved x National implementation plan approved

x

BPJS/KARS agree formula to link payment to organisational and clinical performance

x

National resource centre established in MoH x Unit established to coordinate MoH quality activities x

MoH unit publishes first annual report on Q&S x Health technology assessment clinical guidelines commission fully resourced x

Patient safety commission fully resourced x KARS fully accredited by ISQua x Puskesmas accreditation compliant with ISQua standards

x

4.4.6 Pharmaceuticals and medical technology No definite targets were agreed during the review. It is therefore important that in the first year of the next RPJMN, BPOM, BPJS and the MoH agree on key targets with dates in order to strengthen the supply and use of pharmaceuticals and medical devices. The following could be taken into consideration when developing a performance-monitoring framework for pharmaceuticals and devices.

Selection of medicines and technologies • Harmonised lists of existing medicines and devices with treatment guidelines to ensure

alignment • A health technology assessment (HTA) strategy and determine human resource needs.

Supply chain management and monitoring • An IT system able to accurately measure consumption and expenditure of medicines.

This requires all public private sector facilities providing care under JKN to use a common IT system for payment

• The MoH drug management program, "One Gate Policy", in use at province and district levels

• Good distribution and warehouse practices in place with physical improvements and capacity building following MoH supply chain management (SCM) standards at both district and provincial levels

• A National/Provincial/District logistics network support system.

Medicines and technologies financing and procurement • Nationalised standards for medicines and technologies to be procured under JKN to

minimise ‘post-code prescribing’ • Prioritised procurement and selection of locally-produced WHO Prequalified Medicines


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• A bidding process in place which reduces the risk of collusion.

Medicines and technologies price setting and controls • A revised price setting structure which removes taxes on active pharmaceutical

ingredients and Value Added Tax (VAT) on essential medicines • Include all brands specified by insurance in price setting.

Regulation of quality, safety and efficacy of medicines and devices • A mechanism in place which incorporates and harmonises quality control standard

operating procedures (SOPs) between the three main players: BINFAR (procurement), the National Programs (management and forecasting), and BPOM (surveillance and testing).

Demand side initiatives • A strengthened organisation assigned to promote rational use of medicines at the MoH • Regular monitoring and feedback in place on drug use in health facilities • A strengthened Drug Therapeutics Committees operating in hospitals, and Pharmacy

Installation Unit operating in hospitals and health centres • The National Medicines Policy, National Essential Medicines List, National Medicines

Formulary, Therapeutic Guidelines and Antibiotics Guidelines incorporated into continuing medical education

• An information, education, and communication (IEC) program on rational drug use to disseminated through public.


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5 Policies and strategies

The overarching policy is to ensure equitable access to good quality prevention and curative services for the whole population. The situational analysis showed that health outcomes and resource inputs vary between and within provinces and districts and within socioeconomic groups with the poor being worst off. This is not always due to resources as budgets in poorly performing districts can be under spent, which suggests management may be an issue. The strategy has to be to tackle geographical and economic inequity and ensure best public health and clinical practices reach the poor and hard to reach. All policies need to address how they will do this and performance management and monitoring frame works need to measure this.

Strategy to reduce inequity Addressing inequity in health outcomes and ensuring best practice is delivered evenly across the country to all socioeconomic groups is essential in achieving the desired improvements in health outcomes. For multisectoral nutrition interventions Bappenas should take the lead in ensuring policies and strategies target the poor. Best practice guidelines for achieving geographic and socioeconomic equity need to be developed and a performance management framework needs to be designed in conjunction with the National Institute of Health Research and Development (NIHRD) to measure progress in this area. The TNP2K (Indonesian National Team for the Acceleration of Poverty Reduction) in the Vice President’s office (or its replacement by the incoming government) will play a key role in taking this work forward.

5.1 Population, family planning and reproductive health

Key policies for population, family planning and reproductive health The key policy objective for population, family planning and reproductive health should be to lower the fertility rate to replacement level as soon as possible, while respecting the rights of individuals and couples to have the number of children they desire. It is expected that continuing success in economic and social development (rapid economic growth, further lowering of mortality rates, urbanisation, further increase in educational enrolment ratios, growth of formal sector employment) will play a major role in delaying marriage and lowering desired family size, as has been the experience in other more developed countries. However, in order to more rapidly and effectively reduce the TFR, key strategies, which should come under the responsibility of multiple ministries, should be pursued.

Key population, family planning and reproductive health strategies The following two key strategies should be pursued to support the policy of lowering the fertility rate in Indonesia:

1. Raise the average age at marriage, with special emphasis on reducing teenage marriage, and enforcing the legal minimum age at marriage.

Early marriage is likely to result in early childbearing, and this will cut short the studies of many teenagers, and can also cause serious health issues for both the girl and her child, including increased risk of dying in childbirth. When marriage results from premarital pregnancy, it reflects a need for reproductive health information and family planning services to be available to unmarried young people. If marriage occurs when the girl is aged below


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16, it reflects the need to enforce the minimum legal age at marriage. Where the marriage is arranged without the consent of the bride, it reflects the need to enforce human rights legislation.

2. Revitalise family planning programs, in order to meet the reproductive health needs of the population and sharply lower the level of unmet need for family planning through more focused and efficient provision of family planning information and services.

The strategy should clearly delineate the respective roles of the BKKBN (National Population and Family Planning Board), Kemenkes and local government in (1) providing public sector family planning/reproductive health information and services, and in advocacy activities related to such activities; (2) supporting the private sector and community groups involved in provision of contraceptive supplies and services; and (3) promoting contraceptive use by couples in planning their families (demand creation)

The strategy should be based on meeting both unmet need for spacing and for those who have completed their families and would like to access long-term methods. It needs to cover the needs of unmarried youths as well as married teenagers. It also needs to address how family planning services will be financed under JKN and how commodities will be made available and what the respective roles of the public and private sector will be.

5.2 Nutrition The guiding framework to improve nutrition in Indonesia is provided by the 1,000 HPK Movement and Presidential decree 42/2013. Under this, the health sector will deliver the Community Nutrition Improvement Program to facilitate the continuum of health and nutrition care.

Key nutrition and food security policies Two key policies are proposed for nutrition and food security, the first for cross-sector coordination, which applies to a range of sectors and stakeholders, and the second specifically for the health sector.

1. Improve effective leadership, multi-sector coordination, and division of responsibilities to support the 1,000 HPK Movement at national and subnational levels.

2. Improve access to quality nutrition services across a continuum of care to address under-nutrition, focusing on the first 1,000 days of life, and overnutrition.

Key strategies for nutrition and food security In order to implement these policies, several key strategies are proposed.

For cross-sector coordination:

1. Strengthen multi-sector and multi-stakeholder coordination of the 1,000 HPK Movement at national and subnational level.

2. Develop five-year multi-sector Food and Nutrition Action Plans at national, provincial and district level.

3. Orient policy makers and planners in all key sectors on nutrition in the first 1,000 days of life, and the links between undernutrition and overnutrition.

4. Establish clear division of responsibilities and authorities for nutrition actions across all relevant sectors and reflect in sector-specific strategies and plans.


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For the health sector, there are a number of key strategies in the Community Nutrition Improvement Program to improve nutrition and food security.

1. Enhance the coverage and quality of a package of integrated health and nutrition services to address undernutrition and overnutrition

2. Promote appropriate health, nutrition, sanitary, hygiene and parenting behaviours 3. Strengthen competencies of nutritionists and health workers providing nutrition services 4. Strengthen the design, implementation and monitoring of laws, regulations and

standards for nutrition.

5.3 Maternal, neonatal and child health

Key policies to achieve improve maternal, neonatal and child health To improve maternal, neonatal and child health the priority policy is to ensure an effective and quality continuum of care for women and children, with particular focus on effective interventions during the first 1,000 days of a child’s life, from conception to two years (and covering the mother’s health prior to conception).

Key maternal, newborn and child health (MNCH) strategies

• Ensure availability of and access to quality continuum or care, including o Quality 24/7 basic obstetric and neonatal care (PONED) o Quality 24/7 emergency obstetric and neonatal care (PONEK) o Effective referral systems o Continuity of neonatal, infant and child care between different levels of care.

• Focus on reducing neonatal deaths by addressing two principal causes and risk factors: improved maternal care (particularly during delivery and postnatal care in the first 24 hours after delivery) and reducing the incidence of LBW.

• Improve maternal nutritional status prior to pregnancy and during pregnancy to reduce the risk of maternal and neonatal morbidity and mortality, and to break the intergenerational cycle of malnutrition.

• Strengthen the strategies to prevent and manage the main infectious diseases and malnutrition in infants and children under five, paying special attention to those provinces with particularly high mortality rates.

• Focus on reducing disparities based on by urban/rural residence, education level, and wealth quintiles, ensuring that sufficient resources are allocated to disadvantaged groups to reduce inequities in health outcomes.

• Increase demand for maternal, neonatal and child health (MNCH) services, in particular through improving the understanding by community health providers of “birth preparedness” and “emergency readiness” (P4K) and its implementation in communities.

• Increase community participation in health care, particularly through the strengthening the role of posyandu.

• Improve health information systems. Timely and reliable data is required to design and monitor effective programs. The responsibilities for collecting and reporting data should be clear for each level of the health system. Particular attention is needed to improve the quality of data on maternal mortality, including province, district and municipality-specific data.


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5.4 Communicable diseases

Key policies for communicable disease control Three policies are recommended:

1. Intensification of control activities of those communicable diseases with a large burden (TB, pneumonia, malaria, HIV/AIDS, diarrhoeal diseases)

2. Escalation of the program on IMCI 3. Eradication and control of NTDs (Filariasis, Schistosomiasis, Yaws, etc.).

Strategies The strategies are already in place but they should be reviewed, identify why they are not working and adjusted to ensure they reach the ‘hard to reach’. A particular effort needs to go into TB.

5.5 Non communicable diseases

Policies to address NCDs To accelerate the reduction of the burden of disease and injuries, policies need to be developed and agreed to cover the following:

1. Reduction of salt consumption 2. Reduction of the consumption of foods high in saturated fat and sugar 3. Regular consumption of fruits and vegetable 4. Routine physical activity 5. Early detection and control of hypertension and diabetes 6. Reduction of smoking rates

Polices to address these will be contentious with both the food industry and the tobacco industry and they should be involved in policy development. International experience would suggest that though working with the food industry can bring benefits, working with the tobacco industry is unlikely to achieve anything.

Tobacco control is a particularly strategic public health intervention for reducing premature death and disability especially amongst the poor in Indonesia; health workers are well placed to help reduce tobacco consumption. Raising the (real) price of tobacco is especially important as a means of preventing premature death and disability, whilst simultaneously raising revenue for the government. The Service Delivery and Supply-Side Readiness Report commissioned as part of this Health Sector Review notes that primary risk factor for a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases.

Indonesian households with smokers spend on average a sizable 11 per cent of their income on tobacco, which diverts spending away from more productive and essential spending on areas such as health (2 per cent of spending in households with smokers), food (11 per cent for fish, meat, and eggs), and education (3 per cent). Tobacco control is politically sensitive but remains one of the most strategic, affordable, and cost-effective public health interventions open to governments across the globe.

In contrast to the claims of the tobacco industry, tobacco taxes are not regressive (hurting the poor the most) over the medium term. Instead, the poor benefit the most in terms of


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reduced premature death and disability. All health workers need to be trained about the importance of tobacco control and techniques for quitting and need to use every opportunity to give a consistent message about the need to cease tobacco use.

Obesity is also becoming a major problem in Indonesia and the spread of readymade meals, which can be high in fat, salt and sugar needs to be addressed. In addition, soft drinks high in sugar content are being increasingly consumed. While BCC strategies aimed at individuals will work there also needs to be joint working with the food industry to reduce calories sugar and salt at source.

Recommended NCD strategies 1. National and sub-regional health institutions must prioritise fighting undernutrition,

promoting water sanitation, promoting tobacco free areas, and the surveillance of blood pressure and cholesterol levels in the general population.

2. Provision of health services at the local level should always consider the social and cultural context, because a significant proportion of the recipients of public health services are poor, have low education and low social status.

3. Revitalise School Health Services for education on risk factors and healthy life style. 4. Local media should be included in health promotion campaigns focusing on increasing

intake of healthy food, refraining from smoking, as well as on safe and responsible sexual behaviour and clean water sources and sanitation.

5. To combat cardiovascular disease emphasis is needed on lowering cholesterol and educating on lowering salt intake especially in processed foods.

6. Smoking/tobacco consumption: Raising the (real) price of tobacco is especially important as a means of preventing premature death and disability, whilst simultaneously raising revenue for the government.

7. Special preventive efforts by the health sector and other related sectors should be carried out for reducing road traffic injuries.

8. Development of quality services for NCDs and injuries; including promotive, preventive, curative and rehabilitative activities at all levels.

5.6 Health finance The overarching policy is the introduction of UHC through JKN by 2019. There are eight key policies to support this

Policies and strategies Policy 1: Reducing inequity in per capita spend on health

There are large variations in per capita spending between urban and rural populations and between provinces and municipalities that have persisted since 2008. There are also large variations in health spending per capita across the five central level insurance schemes and the 350+ Jamkesda schemes at the local levels.

Initial benefit incidence analysis has shown that Indonesians in wealthier quintiles disproportionately benefit from hospital care in Indonesia, and that this gap between rich and poor for hospital utilisation may be widening. Benefits from JKN participation run the risk of returning to the wealthy far more than to the poor. Only 15 per cent of the JKN budget for 2014 was allocated for primary care, which the poor are more likely to access. This is very low by international standards.


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Strategies

• Monitor JKN policies to ensure they do not disadvantage the poor. • Monitor JKN expenditure to ensure that they support MoH policies to reach the poor

and hard to reach. • Target other central health funds at poorer regions and districts. • Increase the share of JKN expenditure on primary care to 30 per cent by 2019.

Policy 2: Ensure JKN financing and reimbursement polices deliver health gains and are aligned with MoH health strategies to deliver key health outcomes and meet changing demand

During the review significant concerns were raised that the capitation formula for primary care would not adequately support essential activities in family planning and reproductive health, nutrition, MNCH and in the prevention and control of NCDs.

Strategies

• Review the capitation formula in the first year of the RPJMN to ensure it will support MoH programs in these areas.

• Carry out an evaluation of the introduction of the capitation formula in selected districts. • Agree reimbursement policies with the MoH including clinical protocols for the treatment

of NCDs and which expensive treatments (e.g. renal dialysis) will and will not be reimbursed by JKN.

Policy 3: Address inefficiencies in allocative and technical efficiency

Strategies

• Reduce expenditure on pharmaceuticals from the current level of 40 per cent of total health expenditure (THE) to Organization of Economic Cooperation and Development (OECD) levels of 20 per cent through BCC programs aimed at doctors and the public.

• Allocate a greater proportion of the social insurance budget to health promotion and disease prevention.

• Ensure JKN reimbursement mechanisms ensure patients are treated in primary or ambulatory care when appropriate.

• Ensure JKN reimbursement tariffs continue to reflect changes in clinical practice to minimise length of stay.

• Put in place performance-based intergovernmental fiscal transfers that are geared towards attainment of health outputs and/or outcomes.

Policy 4: Increase total public expenditure on health to meet changing demand.

Strategies

Consider new sources of revenue. A fiscal space analysis shows that new sources of revenues are possible through:

• a new tobacco tax which increases every year for the next 5 years, and could be earmarked for Health;

• a modest increase in the VAT tax; • the continued phase-out of the energy subsidy which was the equivalent of USD32

billion at the start of 2013 and is around USD20 billion at the start of 2014;


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• Raising or eliminating the income cap for contributions on civil servants and on private formal sector employers and employees. This both increases equity and progressivity by taxing upper income groups, and can generate new revenues.

Policy 5: Public-Private Partnerships should be expanded in health financing to increase funds for health. Strategies

• The government should support the expansion of the private supplemental insurance market. This could generate more funds flowing into the health sector.

• The government should allow companies to sell supplemental policies to provide Level 1 and Level 2 hoteling services, access to special drugs, more access to laboratory and diagnostic tests, as well as services abroad such as in Singapore.

• The government should develop a regulatory apparatus to monitor and regulate private insurance.

Policy 6: Consider public-private partnerships for building and running hospitals, laboratories, other facilities and equipment There is considerable international experience of governments contracting with the private sector to build and run health facilities. There are several models but they are all seen both as a way of raising money for the sector off the public finance balance sheet and as getting private sector management skills into the sector. The evidence for their success or otherwise is very mixed.

Strategies

Following research into the various models determine which model would work best in Indonesia and pilot it for one hospital with an appropriate evaluation framework in place. Policy 7: Continue to develop the management and pooling of funds

Strategies

• Cover the remaining informal sector of over 70 million people starting with pilots. • Unify the over 360 Jamkesda schemes which vary in benefits, eligibility criteria,

management and payment systems. • Review the governance of BPJS including relationship with MoH. • Clarify the respective roles and responsibilities of BPJS and MoH. • BPJS to develop a road map over the next year for strengthening its operations, and

extending coverage. The road map should be in three parts: o a general road map for the next five years to strengthen internal operations

and to create an environment of good governance with transparency and accountability mechanisms;

o a strategy to deepen and develop capacity in key areas such as actuarial analysis, payment systems, information systems, and quality assurance.

o A roadmap for how coverage will reach 100 per cent by 2019.

Policy 8: Use strategic purchasing as a policy lever for better health outcomes

Strategies

• Ensure the benefit package is updated regularly to ensure equity, to reflect the changing disease profile, to take account of changes in clinical guidelines and


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technology assessment, and to make sure the primary health care package is comprehensive.

• Use the contracting authority of BPJS to ensure compliance with clinical protocols, accreditation requirements coding standards and information requirements, client responsiveness and patient satisfaction.

• Introduce performance-related pay for key primary care interventions such as immunisation, screening for NCDs and good management of hypertension and diabetes.

• Review the hospital INA-CBGs payment system to address the concerns raised by the Finance team in this review. They include that it was developed outside of Indonesia, and based on United States clinical practice patterns and cost structures. In future years, the INA-CBGs will need to reflect local cost structures and clinical practice patterns. This will require development of a cadre of local experts who are not part of the hospital sector (as they are now), but who can objectively and empirically assess and refine the software groupers that generate tariffs. This requires a partnership across MoH, BPJS, and the universities or other experts in Indonesia.

5.7 Institutional strengthening There are two overarching polices.

Overarching policies Policy 1: To ensure that following the introduction of decentralisation and the introduction of JKN roles and responsibilities for the delivery of health policies, strategies and annual plans at all levels of government are clear.

Strategy

Review the respective roles and responsibilities of the key players in the health sector following the introduction of JKN. This will include clarifying who is responsible for meeting the targets at both national and regional level for the 2014-2019 RJPMN targets and the other targets set out in chapter four of this review.

Policy 2: To ensure key health outcomes are delivered by the successful implementation of policies and strategies at national provincial and district level.

Strategy

To put in place a performance management system that will allow the MoH to work with the MoHA to monitor performance in the decentralised system. This needs to be incorporated into the annual planning system with performance monitoring frameworks incorporated into annual MoH, provincial and district health plans with clear deliverables. These should be agreed annually between MoH and provinces and between provinces and districts.

Other policies and strategies In addition the review team came up with a number of other policies and strategies, which are summarised in Table 21.


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Table 21: Institutional arrangements under decentralisation

Policy Option Strategy Indicator / Target

• Formulate regulations on the clarity of distribution of health functions and authority between levels of government as referred to in the Local Government Act.

Revise regulations on the distribution of functions and authority.

Revision of regulation on distribution of function and authority to sub-nationals (completed in 2014).

• Identify the overall NSPK. Undertake NSPK inventory: update, revise those which are obsolete, and develop those which are not established.

1. Inventory of NSPK has been conducted, by 2015

2. Establishment of NSPK and revision the obsolete, by 2015-2017.

• Socialising NSPK and facilitation to the sub-national levels.

Dissemination of information and monitoring and evaluation of implementation.

Socialisation (2015) and monitoring and evaluation conducted every year.

• Formulate a policy that expressly regulates relationships between DHO with hospital or health centre.

Revise PP 41/2007 to set out clear and unequivocal relationship between DHO with District hospitals or health centres.

Publication of the revised PP as replacement of PP 41/2007 which set out clear and unequivocal relationship between DHO with District hospitals or health centres, by 2015.

• Strengthen policy on relationship between the MoH with PHO/DHO.

Develop a Permenkes referring to the revised PP 41/2007 that regulates the relationship between the MoH to PHO/DHO for clarity of coordination and facilitation.

Permenkes on relationship between MoH and DHO has been developed, referring to the revised PP 41/2007, by 2015.

• Develop a policy on which level of government administration is responsible for public hospitals.

Develop Permenkes which regulates the level of government that is responsible for the appropriate hospital.

Permenkes which regulates the level of government that is responsible for the appropriate hospital based on typology has been developed, by 2015.

• Develop a policy on financial autonomy for province/district hospitals and health centres.

Develop a joint ministerial decree between MoHA and MoH on financial autonomy for province/district hospitals and health centres.

A joint ministerial decree between MoHA and MoH on financial autonomy for province/ district hospitals and health centres has been developed by 2015.

• Strengthen business and operational planning in autonomous/semi-autonomous government entities (hospitals, DHOs, PHOs) to prepare tri-annual business plans and annual operational plans for submission up to the next hierarchical tier.

• Develop a Permenkes to require autonomous/semi-autonomous government entities (hospitals, DHOs, PHOs) to prepare tri-annual business plans and annual operational plans for submission up to the next hierarchical tier.

• Use Binwas to support business planning.

Permenkes has been developed.


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Policy Option Strategy Indicator / Target

• Adjust the SOP for the relationship between the MoH to DHO in the context of Indonesia being a unitary country.

To formulate Permenkes on SOP of relationship between MoH and DHO.

Permenkes on SOP of relationship between MoH and DHO has been developed, by 2015.

• Strengthen health systems based on PHC.

To formulate the operationalisation of health systems strengthening based on PHC.

A road map for health systems strengthening based on PHC has been developed, by 2016.

• Avoid the duplication of duties that belong to the local health authorities.

To conduct an assessment of MoH programme, to identify which programs belong to sub-national’s function.

An assessment to MoH program which overlaps with DHO function has been conducted. (every year).

• Regulate health information systems throughout the country.

To formulate a Permenkes on health information system.

A Permenkes on revision of Health Information System has been developed, by 2015.

• Harmonise MoH programs with DHO, especially in achievement of MSS.

To harmonise the MoH and DHOs’ programs, especially in achieving the MSS target.

DHO’s Strategic Planning are developed referring to MoH’s Strategic Planning.

• Strengthening coordination between MoH and MoHA in imposing sanctions.

To formulate a joint ministerial decree between MoHA and MoH in imposing sanctions when local authorities do not comply with the national health policy.

A joint ministerial decree between MoHA and MoH in imposing sanction to subnational who does not comply with the national health policy has been developed by 2015.

5.8 Supply side readiness Despite notable progress in recent years, additional improvements in the service delivery building block of Indonesia’s health sector are needed. Improved service delivery and supply-side readiness is critical to improving population health outcomes and for attaining universal health care by 2019.

Key policies and strategies for addressing and improving service delivery and supply-side readiness in Indonesia are outlined below.

Supply side readiness policies 1. A policy for working with the private sector based on a systematic independent

assessment of private sector service delivery and supply-side readiness. 2. A policy to overcome deficiencies existing in service delivery and supply-side readiness

based on research as to their cause. 3. Targeted investments to improve service delivery and supply-side readiness. 4. Improve the efficiency of public expenditure for health. 5. Ensure that clear supply-side implications are specified and socialised based on the JKN

benefit package. 6. Ensure continued focus on prevention and promotion - while building capacity for

curative and rehabilitative care, maintain focus on promotion and prevention, especially in terms of population/public health interventions.

7. Improve accountability in the context of decentralisation.


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8. Leverage demand-side financing to improve supply-side readiness at facilities. 9. Regular independent monitoring and evaluation of service delivery and service

readiness.

Strategies surrounding supply side readiness The private sector: A strategy needs to be developed for the role of the private sector. Its contribution to service delivery has risen rapidly, with over two-thirds of all outpatient utilisation now occurring at private facilities. One-third of inpatient beds are in private hospitals, and private facilities account for 40 per cent of all inpatient utilisation in the country. A rising number of private facilities are being contracted by BPJS to provide services under JKN.

Systematic information on the number and distribution private clinics needs to be compiled, and independent and regular private sector facility assessments need to be conducted. BPJS collects some information from private facilities from the perspective of credentialing, but these data are not public, are facility self-reported, and are not necessarily representative of all private facilities. A systematic independent assessment of private sector service delivery and supply-side readiness should be a top government priority.

A comprehensive assessment of why service delivery challenges remain: The analysis in the supply side readiness report has demonstrated what some of the key challenges in service delivery and supply-side readiness are and where they are most prominent with regard public sector provision of health services. A more systematic understanding is needed of why these deficiencies exist and what can be done to overcome them. This needs to include a comprehensive review of financing flows and management of resources at the facility level.

Clarify the supply-side implications of JKN benefit package: The government needs to ensure that clear supply-side implications are specified and dealt with in the JKN benefit package in terms of the equipment, training, diagnostic capabilities, and medicines to be provided at different levels of care, and to clearly specify accountabilities for this provision. In this regard, BPJS should only use public and private facilities that are accredited.

Regular independent monitoring and evaluation of service delivery and service readiness: The government should institutionalise the collection of regular and relevant facility-level data (in a sample of facilities, including private sector facilities) and ensure that data that are collected reflect national guidelines and norms, and can help shed light not just on where the deficiencies lie but also why they exist. Such data collection efforts should be independent and, ideally, separate from routine administrative data monitoring. If possible, data should also be collected from a sample of beneficiaries to ensure that service provision is occurring as intended and that patients are receiving the care they are entitled to. This will be especially critical over the period of expansion of UHC from 2014-2019.

Going beyond supply-side readiness: The focus in this assessment has been on the service delivery building block, focusing on general and service-specific availability and readiness of Indonesia’s health system. There are other dimensions of service delivery – including the ability and effort of providers – that capture higher dimensions of provision of care that should also be assessed and improved systematically and regularly, especially in light of the major UHC reforms currently under implementation. This should include efforts to ensure that the basic equipment in facilities are not just available but are also properly


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calibrated and utilized, and assessments of whether or not health workers have the necessary skills and motivation to provide high-quality services.

5.9 Human resources for health

5.9.1 Production of HRH

Policies

• Determine the projected gaps in Indonesia’s health workforce, taking into account skills needed to respond to the current and future burden of disease, the scale up of UHC, the effects of policy changes, geographical access and socio-economic inequity. Cost and budget for these projections, including training, and an estimate of the input from the private sector.

• Increase the budget of the MoE so that the numbers and categories of health workers are better aligned to current and future health needs. Determine the need for other health care workers – such as nutritionists, public health officials and health planners – in relation to scaling up UHC.

• Strengthen dialogue and information sharing between the MoEC, the MoH and the private sector.

Strategies

• A country coordination and facilitation mechanism to promote inter-ministry and inter-sectoral dialogue and planning would help reduce fragmentation of effort.

• As scaling up the number of health workers will take time, consider licensing qualified and accredited nationals under the Association of Southeast Asian Nations (ASEAN) Economic Community agreement to practice in Indonesia in areas of critical shortage.

5.9.2 Distribution of HRH Although the government uses a number of programs to increase the availability of medical staff in rural and remote areas, and numbers have improved, more still needs to be done.

Policy Improve the distribution of health workers, particularly in remote and underserved areas.

Strategies

• Give greater emphasis to deploying health worker teams (rather than individual specialists).

• Formalise the policies for deploying health workers to Eastern Indonesia and the minimum standards of service delivery expected there;

• Review the entrance standards and availability of bridging courses for potential entrants to medical colleges in remote areas.

• Trial and monitor compulsory deployment rules.


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5.9.3 Equity and financial protection

Policy Build on the strengths of Indonesia’s existing ‘dual practice’ system to align it more closely with the goals of UHC and the major health burdens facing Indonesia.

Strategies

• Strengthen the implementation of existing dual practice regulation. • Trial different provider payment mechanisms such as capitation to increase coverage of

immunisation and nutrition interventions.

5.9.4 Quality and performance of HRH

Policy Improve the quality and performance of health workers.

Strategies

• Provide investment and support to schools to meet government standards, and close those that do not.

• Strengthen the focus on competency. This would include conducting regular competency tests for medical doctors, midwives, pharmacists and nutritionists as an early priority, and increasing the competency of health workers in identifying risk factors for and supporting the prevention of NCDs.

• Review and update the curricula for health care workers so that more health workers are produced who can address the critical health burdens of Indonesia and the requirements of UHC including nutrition, maternal and child health, prevention and treatment of NCDs (especially reduction of tobacco).

• Investigate the underlying reasons for the low pass marks of graduating health workers. • Measure the productivity, efficiency and quality of key health personnel services as part

of the evidence base for reallocating scarce human resources to those functions and locations with the highest health payoff.

5.10 Pharmaceutical and medical technology Once pharmaceuticals and medical technology targets are identified for 2019, policies to achieve the targets for pharmaceuticals and medical technology should focus on two major areas:

(1) Improving the access, equity, availability, supply chain distribution of medicines and health technologies and their rational use by providers and consumers and

(2) Strengthening control of pre- and post-market medicines to ensure safety, efficacy and quality.

Suggested strategies to support these policies are outlined below.


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Policy area 1: Improving access, equity, affordability, availability, supply chain management, pharmaceutical services and rational use of medicines and health technologies.

• Improve the availability and affordability of essential medicines, especially generics. • Promote rational use of medicines and health technologies to providers and consumers. • Strengthen institutional capacities in SCM of medicines and technologies, including

monitoring and supervision. • Support systematic research and development of traditional medicines coordinated by

the National Institute for Health Research and Development. • Strengthen the development and self-reliance on traditional medicines. • Strengthen self-reliance on vaccines. • Strengthen pharmaceutical infrastructure and services in health offices and facilities. • Monitor price, consumption and expenditure on medicines. • Improve transparency and good governance in medicines selection, management and

use.

Policy area 2: Strengthening control of pre- and post-market medicines to ensure safety, efficacy and quality

• Strengthen medicines control in communities through a BCC programme • Strengthen human resource capacities in food and medicine control to be able to

address emerging issues • Strengthen cross sector partnership in medicine control with law enforcement agencies

and local authorities to enforce regulation • Continue improving transparency and good governance in medicine regulation and

registration • Improve the safety, quality and credibility of medicines and food products so that they

can compete on the international market.

In addition to these key policy areas, the following remaining issues need to be addressed.

1. JKN coverage The approach used to specify the medicines, devices and technologies covered under the benefits package of JKN still needs to be clarified.

2. Funding and payment mechanism for medicines/technologies used in primary care. There is still a lack of clarity about how medicines will be funded under JKN for use in primary care settings. Currently, no health systems provide global coverage of medicines/technologies using a capitation formula. Numerous aspects of the current system in Indonesia make it likely that the proposed payment model will result in increasing costs, poor quality prescribing and declining access to medicines. Therefore, it is suggested that other policy options for the payment of medicines and technologies should be considered; for example a modified fee for service system, limited list, or reimbursed products.

3. Control and enforcement of the supply chain Most countries with universal coverage schemes have had to take control of the supply chain for pharmaceuticals and devices. This includes registering the community pharmacies


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that are able to claim reimbursement, controlling supply chain mark-ups, and enforcing legislation with respect to dispensing doctors. Developing the stepwise strategy required to implement effective control of the supply chain, and the components of this, will be possible only when the policy choice about control is made.

4. Define the role of community and private sector pharmacies Community and private sector pharmacy roles should be well-defined, complementary to one another, and avoid overlap in order to effectively ensure access to medicines in the community. For example, public sector supply chain weaknesses can be overcome by allowing the private sector to take on this role; and the potential workforce made up of the 5,000 pharmacy students who graduate each year could be used to fill in gaps not currently filled.

5. Separation of prescribing and dispensing In order to promote rational prescribing, it is essential to remove perverse incentives such as allowing doctors to prescribe and dispense medicines directly to the patient. This is particularly relevant in an environment where pharmaceutical company promotional activities are not controlled. This is a sensitive issue and any change would require extensive stakeholder consultation once the policy choice is made.

6. Optimise the use of existing human resources and develop additional capacity for pharmaceuticals and supply chain management The introduction of JKN is an opportunity to re-evaluate the most effective use of pharmacists and other groups in the health workforce while considering appropriate task-shifting strategies to improve health outcomes. For example, allowing midwives to prescribe and administer a limited list of medicines could improve maternal health outcomes, and continuing to work with the People that Deliver partnership could improve the workforce currently managing the supply chain. Again, these changes would require extensive consultation with stakeholders.

7. Develop the infrastructure to support efficient and effective management of the pharmaceutical sector Efficient management of the supply of medicines and devices under JKN will require adequate data on the supply and consumption of these commodities. Developing a system to do this should be considered a priority at the national level, notwithstanding the decentralised responsibilities for delivery of health care. Along with IT and infrastructure, the human capacity required to implement the administration of JKN effectively with respect to the supply of medicines and devices must be identified. Once the policy choice is made, options for approaches to this task can be developed.

5.11 Quality and safety of healthcare

Policy

The policy is to ensure that all health care is of an appropriate quality and patient safety is guaranteed.

The following sections outline strategies to support this policy


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5.11.1 Develop an integrated plan or framework for quality in healthcare A national framework for quality in healthcare should be defined, consulted, published and accepted as a basis for operational planning and the development of quality systems. This should identify the roles of organisations and individuals, the contributions and interactions of improvement mechanisms, and the required educational and technical resources (especially performance data).

A schematic diagram indicating key elements of an integrated system is included below (Figure 32).

Preliminary mapping of national infrastructure suggests there is a need for a national steering group and a national resource centre.

Figure 32: Mapping the national health system

5.11.2 Establish a national policy group A national group representing consumers, providers, insurers, and professions is needed to provide a platform for coherent debate on cross-cutting issues and support active collaboration between government, regulators, managers, professions, funding mechanisms and the international community. It would be responsible for:

• Steering the drafting of a national framework and coordinated strategy for quality and safety;

• Developing a charter describing the rights of patients in terms of access, participation, information and security;

• Drafting specifications for a national system for defining and reporting adverse events and “near-misses” in patient care;

• Identifying priorities for the development of tools and systems for implementation in hospitals and puskesmas.


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5.11.3 Establish a national policy group While KARS and puskesmas accreditation should be the bodies responsible for developing and assessing compliance with organisational standards nationally, a separate independent agency is needed to develop consistent guidance, information, practical tools and comparative data for learning, improvement. Functions could include:

Producing clinical guidelines and pathways incorporating: • Technology assessment in collaboration with responsibilities for regulation of medical

devices, equipment, pharmaceuticals and blood products • Importing and developing clinical practice guidelines including the evidence-based use

of pharmaceuticals consistent with the national formulary • Evidence to support appropriateness, pricing and reimbursement by BPJS for patient

care • Service-specific standards for BPJS • Systems for dissemination, local adoption and related audit tools • Evaluation of uptake and impact of guidelines on patients and costs • Identifying priorities for epidemiological research.

Developing performance indicators on clinical process and outcome, institutional performance and health system performance.

Monitoring adverse events and clinical incidents through: • Design incident reporting system for healthcare institutions • Collate and analyse causes and trends in reported incidents • Identify and disseminate tools, systems and solutions to reduce risks • Feedback findings to reporting institutions.

Developing an information strategy for quality incorporating: • National and international guides, methods, tools and findings • Training • Quality and risk management systems • Clinical audit • Clinical coding.

5.11.4 Identify clear values and dimensions for quality in health services Internationally, the most quoted dimensions of health service quality are access, equity, efficiency, effectiveness, continuity and acceptability to the public (patient’s rights, changing attitudes and behaviours). The OECD has reduced these to three dimensions: effectiveness, efficiency and patient-centeredness.

By 2016, Indonesia should publicly identify the values and dimensions of quality in health services, and how these expectations will be fulfilled and evaluated by 2019.

It will be important for governments at all levels to put more information in the public domain.

5.11.5 Set minimum service standards Standards for delivery of services included in MSS should be consistent with – and explicitly linked to – organisational standards, which are applied to licensing or accreditation, and to clinical practice standards, which are based on health technology assessment.


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Responsibility for identifying, achieving and developing standards for health service and system performance should be made clear first at national level, then at provincial and district level.

Technical procedures for developing, adopting and adapting standards for clinical services should be developed and made consistent with international principles and practices (e.g. ISQua for accreditation standards, AGREE II for clinical guidelines).

Clinical practice guidelines and pathways should be based on evidence and technology assessment, independent of political or commercial interests.


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6 Health sector programs

This chapter sets out programs that will need to be put in place to deliver the policies set out above. The review did not finalise these programs, which need to be developed in the first year of the next RPJMN by the MoH, working as necessary with other ministries and the BPJS.

6.1 Population, family planning and reproductive health Three programs linked to the key policies for family planning and reproductive health need to be drawn up and implemented. They will rely on strong advocacy and BCC programs, which should be led by jointly BKKBN and MoH. Funding mechanisms for family planning activities need to be agreed with BPJS.

A program to help lower fertility rate to replacement level. This should include a BCC initiative promoting the benefit of small family size and an advocacy initiative to legislatures and policy makers at national, provincial and district/municipal level on the social and economic benefit of lowering fertility.

A program of support for later marriage. This should include a BCC and advocacy initiative to community and religious leaders to comply with the legal minimum age at first marriage (16 years) for girls, an advocacy program with government to enforce the implementation of 9 years of compulsory education, work with parents and adolescents about the danger in early marriage and childbearing and work with teenagers who are already married about the need to delay childbearing.

A program to revitalise the family planning program. The national family planning program needs to be reviewed and the revised version used as a basis for annual district and national delivery plans for family planning services. This needs to be done jointly between BKKBN and MoH, with their respective responsibilities clarified. Once the program is agreed, BKKBN, MoH and BPJS need to agree how the services will be financed and how the capitation formula can be used to support the programme. The following activities need to be incorporated:

• Strengthen political commitment to implement the family planning program, especially at the district/municipal level, with more effective collaboration at the district level

• Promote contraceptive use and meet the needs of couples who want to space or limit childbearing but who are not using contraceptives, of economically disadvantaged couples and unmarried people

• Assist the private sector (where 73 per cent of women access family planning services to meet the needs of its users), adopting a bidan-focused strategy

• Strengthen contraceptive supply chain management.

6.2 Nutrition

Health sector programs As part of the 1,000 HPK Movement and Presidential Decree 42/2013, the health sector should deliver the Community Nutrition Improvement Program to ensure the provision of a continuum of health and nutrition care. The focus will be on adolescent girls, pre-pregnant,


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pregnant and breastfeeding women and children under two years of age, and the essential interventions for these target groups are set out in chapter 7.

The Community Nutrition Improvement Program will coordinate closely with other programs within the health sector that are delivering services for the same target groups to ensure good integration and referral linkages. In addition the Program will coordinate with other sectors that are responsible for addressing other underlying causes of malnutrition.


Monitoring and evaluating maternal deaths periodically at national and sub-national level A method to identify maternal deaths periodically at national and sub-national levels has to be in place. Two options were considered in section 4: • Modification of the existing PWS-KIA. • Use of the existing MADE-IN/MADE-FOR method which has been tested in Banten

province. This involves documentation of women’s death by informants (kader and the neighbouring Head or Ketua RT) and reporting them to the local bidan. This method will allow for the estimation of the MMR at a district level and can be done periodically.

Reducing maternal mortality

High quality obstetric and neonatal care needs to be provided through ensuring that basic obstetric and neonatal care (PONED) and emergency obstetric and neonatal care (PONEK) comply with set standards and are accessible and available 24/7, and ensuring that there is an effective referral system in place.

To improve the quality of midwifery and obstetric care, the clinical competence of bidan working in the community and primary care and of doctors, specialists and other health providers needs to be ensured through adopting clear regulatory mechanisms. In addition supportive care (laboratory, equipment, medications, blood) needs to be available 24/7 in the different levels of health facilities.

Increasing the demand for and utilisation of health facilities will be achieved through improving the understanding by community health providers of ‘birth preparedness’ and ‘emergency readiness’ (P4K) and their implementation in the community.

Reducing neonatal mortality This requires an increase in the availability and accessibility of a quality continuum of obstetric and neonatal care 24/7. This also involves ensuring the clinical competence of bidan working in the community and primary care and of doctors, specialists and other health providers and making supportive care available 24/7.

The quality and coverage of neonatal visits, particularly during the first week postpartum, the understanding of community health providers of the importance of neonatal care, and the mother’s and family’s knowledge and practice of good neonatal care all need to be improved. Improving maternal nutritional status prior to and during pregnancy is part of a long term strategy to reduce neonatal mortality.


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Reducing infant and under five mortality The remaining challenges related to infant and child deaths are the prevalence of infections, poor nutritional status, low immunisation coverage and use of vitamin A supplementation and low participation in posyandu. Programs therefore need to focus on improving the availability and accessibility of services and programs to (a) reduce preventable diseases among infants and children and (b) improve their nutritional status.

Preventing diseases can be achieved through strengthening the IMCI and immunisation programs, increasing the use of oralite and promoting appropriate infant and child care. Improving nutritional status requires revitalising posyandu to facilitate the monitoring of nutritional status, promoting adequate food practices for infants, especially IMD, exclusive breastfeeding until six months and continued breastfeeding until two years; strengthening the vitamin A supplementation program for babies starting at six months; and promoting the use of MMN sprinkles (taburia).

It is important that the different levels of health care are effectively connected to provide the continuum of care.

Improving maternal, neonatal and child health The following programs are suggested to address the totality of MNCH: • Increasing the commitment of local government in terms of: developing regulations and

policies for the recruitment, distribution and quality of human resources; guaranteeing the availability, accessibility and quality of health services at different levels of care and the referral between them through appropriate financing; and thus strengthening the functioning of health facilities.

• Strengthening monitoring and evaluation, including that of health providers’ skills and competencies.

• Increasing the role of other sectors, including the private sector.

6.4 Communicable diseases CDC programs are already in place. The focus now needs to be on intensifying control activities of diseases with a large burden – including TB, pneumonia, malaria, HIV/AIDS and diarrheal diseases; escalating IMCI and eradicating or controlling NTDs such as filariasis, schistosomiasis, and yaws. The programs also need to be reviewed to assess why they are not working and adjusted so that they reach hard to reach populations, particularly in relation to TB.

6.5 Non-communicable diseases It is important that in the first year of the next RPJMN national programs are designed and started that focus on NCDs. They will need to operate at both the population and individual levels.

At the population level Public health programs aimed at reducing risk factors in the population as a whole are needed. These should increase awareness of key risks and encourage behaviour change through BCC programs targeting obesity, lack of exercise, excess salt, fat and sugar intake and smoking. There should be a separate BCC program for smoking for women, as they are particularly being targeted by the tobacco industry.


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These programs should be supplemented by programs to reduce nutrition risk factors at the source by working with the food industry to reduce fat, sugar and salt in key foods and to develop clear labelling of the calorific, fat, sugar and salt content on packaged food and in restaurants.

The program to reduce smoking prevalence should consider increased taxation and public health messages on packets or even plain packaging. There is little evidence that working with the tobacco industry is effective. However there needs to be an ongoing program ensuring evidence is available to make both policy makers and the public aware of the negative economic and health impact of smoking.

At the individual level

A program needs to be drawn up for screening for risk factors for NCDs at the primary care level and for giving one-to-one advice and support to make the necessary behaviour changes to modify them. This needs to be built into the capitation formula and should include screening for hypertension and diabetes.

As well as primary prevention, for the foreseeable future there will be a requirement for secondary prevention through the control of diabetes and hypertension. Clinical protocols and prescribing guidelines need to be agreed between the MoH and BPJS and enforced through JKN to control costs. The capitation formula needs to be reviewed to build in incentives for control of diabetes and hypertension.

Consideration should be given to designing and implementing a ‘health lifestyle’ program for those working in the government health sector with work place risk assessment, BCC and risk modification programs such as sliming clubs and physical activity sessions. This could be a national pilot for other government sectors and the private sector.

Secondary care for NCDs No matter how successful primary and secondary prevention is the changing burden of disease will require the secondary care sector to be able to deal with the increasing number of cases of cardiovascular and renal disease, cancer and road traffic accidents. Programs to deal with this including clinical protocols tied to reimbursement schedules under JKN, HRH training in these areas and more detailed work on future costs for the sector will be needed.

6.6 Health financing The first priority is to develop a road map for the move to UHC and implementing JKN. This will include developing several key programmes. Most will require joint working between the MoH, the MoF and BPJS. They include the following: • Quantifying the fiscal space for health i.e. the ability of Indonesia to increase public

spending on health, including identifying other potential sources of revenue for the health sector such as a tobacco tax

• Expansion of the coverage of JKN to 100 per cent by 2019 including bringing in existing schemes and ensuring coverage of the informal sector and the unemployed

• Mapping out how funding flows between BPJS and supply side subsidies e.g. DAK and Pad will change over time and what their respective roles will be

• Governance development of the BPJS • Ensuring earmarked funds for disease prevention and health promotion at central and

district level


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• Developing a reimbursement system for BPJS that will drive health gain at both the population and individual level. This includes re-examining both capitation and diagnosis related group (DRG)-based reimbursement systems

• A program of pilots to test key changes.

6.7 Institutional strengthening and decentralisation Priority programs include a legislative program, which establishes the requirement to submit business plans and facilitates inter-ministerial collaboration. A systems development program will include developing and implementing a contracting framework, which includes the creation of standard contracts for different service types. BPJS will develop contracts with existing Jamkesda schemes. A quality management system also needs to be developed and implemented, which will lead towards the accreditation of all health public and private facilities. Other elements in systems development include developing a business planning framework and aligning financial, information and governance pathways.

Capacity development will involve the appointment of a Chief Medical Officer, a Chief Nursing Officer, a Chief Pharmaceutical Officer and a Chief Scientific Officer, and leadership development, particularly at sub-national level. There is also a need to develop capacity in contract and service level agreement development, and in delivering quality, including that of clinical coding.

Infrastructure development will include capital investment in puskesmas and providing support for developing the role of UKBM in advocacy and planning.

6.8 Supply side readiness

To implement the supply-side strategies identified and deliver the assessments required, programs supporting the regular independent collection of data from health facilities need to be developed. The assessments needed include a systematic independent assessment of private sector service delivery and supply-side readiness to inform a strategy for the role of the private sector; an assessment of why service delivery challenges remain, including a comprehensive review of financing flows and management of resources at the facility level; and assessments of other dimensions of service delivery such as assessing the appropriateness of health workers’ skills and motivation, and the availability and utilisation of basic equipment.

6.9 Human resources for health Programs to achieve the HRH policies set out in section 5.7 will focus on the production, distribution and quality and performance of the health workforce.

6.9.1 Production of human resources for health

A program to boost the production of health workers would include:

• Refining and updating the health workforce gaps, taking into account skills needed to respond to the main current and future health burdens and where the main health gaps are in terms of providing accessible and equitable UHC, including geographical access and socioeconomic inequity.


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• Aligning the production, training, and competency testing of health workers to meet the identified gaps.

• Developing costs for projected health workforce requirements, and identifying the need for increasing the budget of the MoE to support this.

• Strengthening intersectoral dialogue and information sharing between the MoEC (the ‘producers’ of health workers), the MoH (the ‘users’ and employers of health workers) and the private sector (both producers and users of health workers).

• Exploring the licensing of qualified and accredited nationals under the ASEAN Economic Community agreement to practice for up to five years to meet critical health workforce shortages, especially in rural and remote areas.

6.9.2 Distribution of the health workforce

Programs to make the health workforce more equitable would include:

• Deploying teams that work together and complement each other in rural and remote areas. This would support the expansion of essential services and would attract health workers to these areas.

• Formalising the policies for deploying health workers to Eastern Indonesia and the minimum standards of service delivery expected there.

• Reviewing the entrance standards and availability of bridging courses for individuals in remote areas who have the potential to reach minimum competency standards as health workers.

• Trialling and carefully monitoring compulsory deployment rules. • Continuing existing government programs aimed at increasing the availability of medical

staff in rural and remote areas. These programs include higher financial incentives and shorter contract periods for rural and remote postings; recruitment based on ethnicity and location; and internship program.

6.9.3 Quality and performance of the health workforce The WHO framework for improving the quality of health workers’ competence is a good basis for considering future strategies to strengthen the quality and performance of health workers. Programs would include:

• Investing and supporting private training facilities to meet government standards, and closing those that do not.

• Conducting regular HRH competency tests for medical doctors, midwives, pharmacists and nutritionists.

• Supporting increased competency in identifying risk factors for NCDs such as diabetes and hypertension, and effectively counselling the broader public about how to reduce such risk factors and/or provide primary and secondary prevention strategies for NCDs.

• Measuring the productivity, efficiency and quality of key health personnel services as part of the evidence base for reallocating scarce human resources to those functions and locations with the highest health payoff.

6.10 Pharmaceutical and medical technology In order to improve pharmaceutical services and control of medicines, programs could take into consideration the two policy areas outlined in Section 5.10:


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Policy area 1: Improving the access, equity, affordability, availability, supply chain management, pharmaceutical services and rational use of medicines and health technologies. This could involve ensuring the availability of essential medicines (particularly generics), vaccines and health technologies in health facilities and ensuring supply chain management is efficient and responsive at all levels. Programs could aim to strengthen pharmaceutical services and infrastructures at district health offices and health facilities, promote the rational and cost effective use of medicines and technologies by providers and consumers, monitor the prices and consumption of and expenditure on medicines in the public and private sectors, and systematically research and develop traditional medicines.

Policy area 2: Strengthening control of pre- and post-market medicines to ensure safety, efficacy and quality Programs to support this policy area could include strengthening the control of medicines to meet international standards, improving human resource capacities in food and medicines control so that they are able to address emerging issues, supporting cross-sector partnerships in medicines control, and improving the safety and quality of medicines and food products so they are competitive on the international market.

Underpinning these programs will be improved transparency and good governance in the selection, regulation, registration, management and use of medicines.

6.11 Quality and safety of healthcare The development of a coherent integrated plan for quality and safety of health care will involve defining a national framework setting out the roles of organisations and individuals, the improvement mechanisms and the necessary educational and technical resources. This will likely require establishing a national steering group and a national resource centre, details of which are contained in section 5. The values and dimensions of quality in health services, and how these will be fulfilled and evaluated, need to be determined, together with a program to determine and adopt minimum service standards.

Once the national steering group and resource centre are in place, aspects of quality outlined in chapter 5 including accreditation of health care providers, regulation, inspection, patient rights and satisfaction will be brought together in a national program for quality in the health sector.


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7 Activities and indicators

Program planning to achieve the policies set out in chapter 5 will be carried out in the first year of the RPJMN by the MoH working as necessary with other ministries and the BJPS. During that process detailed activities and indicators will be developed. This chapter therefore provides an outline of suggested activities and a selection of indictors, where these have been identified in the HSR. Activities and indicators that have been included in previous chapters have been referenced, but have not been duplicated here.

7.1 Population, family planning and reproductive health Table 22: Policy 1: Lowering fertility to replacement level

Program Activities Indicators and data

1. Reinvigorate the promotion of benefit of small family size

• Mass campaign to the wider community and their leaders at the local level. Key message is that having small family size will improve the health of mothers and children.

• It is important to focus also on young couples.

Reduction of ideal family size among young couples. IDHS (three-five years).

2. Advocacy to legislatures, executives, at national, provincial and district/municipal level of social and economic benefits of lowering fertility

• Meetings, workshops, auditions, or round table discussions with executives, legislatives to advocate that: o Investment in population control and family

planning program reduces the cost of meeting basic needs for the future generations and therefore more money to increase access to children’s education and health services.

o In the long run reduction in number of births will reduce the unemployment rate.

• Build an advocacy team at the national and provincial level involving MoH, MoE, Ministry of Religion, Ministry of Interior, MoF etc. to implement this action.

Increase in political commitment to implement family planning as is indicated by an increase in the budget for family planning, especially at the district/municipal level.

Table 23: Policy 3: Support for later marriage (REMAJA)


1 IEC BCC to community and religious leaders to comply with the legal minimum age at first marriage (16 years) for girls

• The Provincial BKKBN representative invites collaborations with Governors, Bupati, Mayors and KPAI, and SKPD-KB to strongly advise Village and Sub-district Heads and the religious leaders and KUA to enforce the law on minimum age at marriage for girls (16 years).

Increase in age at first marriage especially among girls. IDHS (three-five years), SUPAS 2015.


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2 Advocate government to enforce the implementation of nine years compulsory education

• The Provincial BKKBN representative invites collaborations with Governors, DinDikBud, Bupati, Mayors, SKPD-KB and KPAI to strongly advise Village and Sub-district Heads, religious leaders and SKPD-KB to enforce the implementation of nine years compulsory education.

• IEC to parents to keep children in school at least until nine years of schooling.

Increase in education level up to nine years of schooling. Susenas (yearly).

3 IEC to parents and youth about the danger in early marriage and childbearing

• The Provincial BKKBN representative invites collaborations with Governors, DinKes, DinDikBud, Bupati, Mayors, Village and Sub-district Heads, SKPD-KB and KPAI to inform parents and youth about the danger of early marriage, early childbearing, unintended pregnancies which lead to unsafe abortion and maternal mortality.

Increase in age at first marriage especially among girls. IDHS (three-five years).

4 IEC to delay childbearing among teenagers who are already married

• Educate teenage couples to delay their first birth, to plan their families and have small family size.

Reduction in teenage fertility indicated by age specific fertility rate 15-19 years. IDHS (three-five years).

Table 24: Policy 5: revitalisation of the family planning program


1. Strengthen political commitment to implement family planning program, especially at the district/ municipal level

BKKBN at the central and provincial level and SKPD-KB to advocate DinKes, Bupati, Mayors and SKPD-KB that: • family planning is essential to improve mother and

child health; • investment in family planning program will be

beneficial in the near future as it reduces child development cost and therefore resources can be focused on meeting basic needs for children.

Increase in budget allocated for FP program at the district/municipal level. Reporting base.

2. Fostering more effective collaboration at the district level.

BKKBN at the provincial level provides technical support to SKPD-KB: • To identify potential and challenges and set

priorities in program planning and budgeting, and implementing family planning program

• Support the SKPD-KB to participate in developing family planning program, and budget in collaboration with other local stakeholders (DinKes, DinDikBud, Bupati, Camat etc.) and Bappeda at Kabupaten, and at municipal level for development and planning.

Increase in complying with the Minister of Health’s instruction on the collaboration between SKPD-KB and DinKes. Reporting base.


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3. Demand creation to promote contraceptive use

BKKBN at the provincial level in collaboration with DinKes lead SKPD-KB, bidan, PLKB, sub-district and village head, • To inform couples about the benefits of family

planning for the health of mothers, children and the welfare of the whole family.

• To promote contraceptive use on the basis of life cycle approach (couples who want to space or to limit childbearing).

• To provide information to couples about various contraceptive devices each with its benefit and risk.

• To support bidan and doctors at puskesmas to help couples choose the appropriate contraceptive method (effective counselling).

Increase in the use of contraceptives for family planning (CPR). Susenas (yearly), IDHS (three – five years).

4. Meeting the need for family planning of couples who want to space or limit childbearing but are not using contraceptives

BKKBN at the provincial level and SKPD-KB in collaboration with DinKes at Kabupaten level to: • Prepare accurate and timely data on number and

location of couples with unmet need for contraceptive services.

• To promote couples with unmet need to use appropriate contraceptive method (short term and long acting method)

• To advise couples to comply with regulation of using contraceptives (taking pills daily, etc.).

Reduction in percentage of couples with unmet need for contraceptives. Susenas (yearly), IDHS (three – five years).

5. Balancing method mix

BKKBN at the provincial level and SKPD-KB in collaboration with DinKes, bidan and puskesmas doctors at Kabupaten level to: • advise couples about the benefits of using long-

acting contraceptive methods, and that investment in long-term method use is more costly but yearly cost is cheaper;

• Inform couples to use contraceptive methods according to their needs (spacing or limiting). Couples who want to limit childbearing are advised to switch to long-term method;

Promote couples who have unmet need to use appropriate contraceptive method (short term and long acting method).

Increase in the percentage of couples using long-acting contraceptives. Susenas (yearly), IDHS (three – five years).


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6. Assist private sector to better meet the needs of the 73 per cent of users - a bidan-focused strategy

• BKKBN, MoH and IBI at province and district level to support efforts to increase number and distribution of bidan who are certified with CTU.

• BKKBN, MoH and IBI to support efforts to Improve and increase the training opportunities for qualified bidan with CTU certification and counselling competencies.

• BKKBN and MoH Assist IBI to increase number of Bidan Delima (midwife accreditation program).

• Increase in number and distribution of bidan with CTU certification and counselling.

• Increase in number and distribution of Bidan Delima.

• Reporting base.

7. Strengthen contraceptive supply chain management

• BKKBN and MoH at central, provincial and district level support SKPD-KB in efforts to improve field data as basis for providing contraceptive supplies (based on Pemenuhan Permintaan Masyarakat data).

• Keep accurate records on contraceptive availability to avoid stock outs.

• BKKBN promote the procurement system using e-catalogue for transparency.

• Improve storage warehouses consistent with gold standards needed to maintain the quality of contraceptives.

• Allocate funds for the management of the warehouses.

• Allocate funds for ‘handling cost’ and ensure that contraceptives reach the clients who need them.

• Availability of data needed to estimate number of contraceptives by method

• Improve recording and reporting system of contraceptive availability and need

• Increase in number of storages consistent with standards needed to maintain the quality of contraceptives

• Increase in funding for management of storage to maintain quality of contraceptives

• Increase in funding for handling cost (delivery to end users)

8. Meeting the needs of economically disadvantaged couples

• BKKBN allocates resources to support economically disadvantaged couples.

• BKKBN and DinKes provide access to services which are affordable to the poor.

• BKKBN at the central and provincial level support SKPD-KB and DinKes in raising awareness of poor couples about the benefits of using contraceptives for planning births.

• Support bidan and puskesmas doctors to reduce side effects or health related problems resulting from contraceptive use.

Increase in contraceptive use among the poor. IDHS (three – five years).


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9. Meeting the reproductive health needs of the unmarried

• BKKBN to support GENRE program at all levels of government administration which assist young people to pursue quality living and avoid risky behaviour including pre-marital unsafe sex.

• BKKBN supports NGOs to meet reproductive health information and service needs of youth.

• Strengthen coordination between government and partners (NGOs).

Increase in the coverage of reproductive health services of the unmarried. IDHS.

10. Financing of the family planning program

• Regular budget from APBN • When infrastructure and equipment needs at the

kabupaten level have been met, it is suggested that DAK is used for: o contraceptive supply chain management, o handling the operational cost of the family

planning program, o training of bidan to increase the number and

mprove the distribution of CPU certified bidan. • Training of bidan to increase the number and

improve the distribution of CPU certified bidan.

Increased budget and resources for contraceptive supply chain management, handling cost of operational family planning program, training of bidan to increase the number and distribution of CPU certified bidan. Reporting base

11. Family planning program under BPJS and JKN KB

How family planning will be financed under JKN needs to be discussed further.


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7.2 Nutrition

Table 25 below provides the activities for each of the strategies that will be used by the Community Nutrition Improvement Program to improve nutritional status. A set of indicators for each set of activities under each strategy is also provided.

Table 25: Nutrition activities and strategies

Strategy Activities Indicators

Enhance the coverage and quality of an integrated package of health and nutrition services to address undernutrition and overnutrition.

• Advocate with local governments to ensure adequate prioritisation and funding of nutrition services in support of the 1,000 HPK Movement and reducing overnutrition

• Ensure all essential nutrition interventions are included in the benefit package for UHC.

• Utilise the MSS of the health sector to build accountability for the delivery of the integrated package of nutrition-specific interventions.

• Scale-up enhanced service delivery mechanisms to reach adolescent girls, women and children, including vulnerable populations.

• Develop/update and roll out technical guidelines, treatment protocols, in-service training packages, and supportive supervision tools to improve quality of services.

• Develop and roll out tools and training courses to strengthen the management of nutrition services at the subnational level.

• Use nutrition information and data to improve program performance at district level, and conduct research to monitor and evaluate nutrition policies and programmes.

• Procure nutrition supplements and equipment to assess nutritional status to equip all health facilities and posyandu.

% pregnant women who received at least 90 days of iron-folate supplements. % of pregnant women who received two vitamin A supplements in the first 6 weeks after delivery. % of children aged 6-23 months who received 15 sachets of MNPs in the last month. % of severely wasted children aged less than five years who are treated for severe wasting. % of children aged 6-59 months who received a vitamin A capsule in the last six months. % of children aged 12-59 months who received a vitamin A capsule in the last 12 months. % of children aged 0-59 months with diarrhoea who receive zinc supplements. % of pregnant women with CED who receive supplementary feeding. % girls who receive iron-folate supplements.


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Strategy Activities Indicators

Promote appropriate health, nutrition, sanitary, hygiene and parenting behaviours

Intensify the use of multiple communication channels to reach the public with information and counselling services.

% infants aged less than six months who are exclusively breastfed. % infants aged 6-23 months who are fed a minimum acceptable diet (adequate diversity, adequate frequency, and milk). % household members aged at least 10 years who practice hand washing. % households that consume iodized salt.

Strengthen competencies of nutritionists and health workers providing nutrition services

• Update nutrition service standards for the health system that reflect current and emerging population needs to improve nutrition

• Standardise job descriptions of nutritionists and other health workers providing nutrition services

• Update and standardise the competencies and pre-service curricula of nutritionists and other relevant health workers.

• Accredit courses for pre-service training of nutritionists.

• Conduct in-service training on nutrition to refresh and update knowledge and skills of nutritionists and other relevant health workers.

Nutrition service standards for the health system established that reflect current and emerging population needs to improve nutrition. Standardised job descriptions of nutritionist and other health workers providing nutrition services are available. Competencies and pre-service curricula of nutritionists and other relevant health workers are standardised. System for accreditation of courses for pre-service training of nutritionists. % nutritionists and other relevant health workers who have received in-service training on nutrition in the last two years.

Strengthen the design, implementation and monitoring of laws, regulations and standards for nutrition.

• Revise the legislation on the marketing of breast milk substitutes to comply with all provisions of the International Code on the Marketing of BMS and subsequent resolutions.

• Develop/update standards for processed commercial complementary foods and mandatory fortified foods.

• Monitor laws, regulations and standards for BMS, fortified foods and processed foods high in saturated fats, trans fatty acids, free sugars, or salt.

Legislation in place that complies with all provisions of the International Code on the Marketing of Breast Milk Substitutes and subsequent resolutions. Laws, regulations and standards in place for processed commercial complementary foods, mandatory fortified foods, and other processed foods for the general population.


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Programs aimed at improving maternal, neonatal and child health are already in place, but more needs to be done to improve their impact.

Activities need to focus on:

1. Ensuring improved access to and availability of a continuum of good quality maternal and neonatal care 24/7, with effective referral mechanisms

2. Increased coverage of best practice in MNCH 3. Escalation of IMCI activities 4. Implementation of the community nutrition improvement program.

Maternal, neonatal and child health indicators are based on international health standards. These indicators can be used for national and sub-national, and by urban/rural residence, education level and wealth quintile. The HSR identified a range of indicators to measure progress in delivering MNCH policies, a sample of which are included below.

Essential nutrition interventions during the first 1,000 days of life

Adolescent girls and pre-pregnant women:

• IFA or multiple micronutrient supplements (MMS)

Pregnant women:

• IFA or MMS during pregnancy • Calcium supplementation for women at risk of low intake • Counselling on appropriate diet during pregnancy and breastfeeding • Balanced protein-energy supplements for undernourished pregnant women

Postpartum women:

• IFA or MMS during pregnancy for 40 days postpartum • Postpartum vitamin A supplementation • Counselling on appropriate diet during breastfeeding

Children:

• Monthly growth monitoring for children 0-23 months and twice-yearly height measurement for children 6-36 months

• Promotion of early and exclusive breastfeeding for six months and continued breastfeeding for up to 2 years

• Education on appropriate complementary feeding • Twice-yearly vitamin A supplements for children 6-59 months • Micronutrient powders for children 6 -23 months • Deworming for children 12-59 months (once or twice yearly depending on the

prevalence of soil-transmitted helminths) • Management of moderate and severe acute malnutrition • Zinc supplementation for children with diarrhoea


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General population:

• Food fortification (salt, wheat flour, vegetable oils and others) • Public education on appropriate sanitary and hygiene behaviours • Public education on balanced diet and healthy lifestyle, with priority to school-aged

children.

Table 26: Maternal health indicators

Outcome indicator Maternal Mortality Ratio

Output Indicators • Skilled birth attendance • Facility-based deliveries • Proportion of obstetric complications managed in-PONEK hospitals • Post-partum visit: the 1st 24 hour; day 2-7 after delivery; day 8-42 • Place of death • Case fatality rate (hospital) • C-Section rate (population level)

Input Indicators % of PONED puskesmas complying to standard and providing PONED services for 24/7 % of PONEK hospitals complying to standard and providing PONEK services for 24/7 Proportion of functional continuum of care facilities

Other indicators Maternal nutritional status and MUAC during pregnancy

Table 27: Neonatal health indicators

Outcome indicator Neonatal mortality rate

Indicators • Cause of neonatal death • LBW rate. • PNC within the first 24 hour, 2-7 days; 8-28 days

Notes Neonatal death is a very important contributor to the IMR and under five mortality. Therefore assessing it and its related factor is imperative.

Table 28: Infant health indicators

Outcome indicator Infant mortality rate

Indicators • Cause of infant death • Prevalence of diseases (ARI, diarrhoea, measles, pneumonia) • Measles vaccination at 1 year rates • Immunisation status • Vitamin A supplementation • Nutritional status of infant • IYCF practices


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Table 29: Children under-5 indicators

Outcome indicator Under-5 mortality rate

Indicators • Prevalence of diseases (ARI, diarrhoea, measles, pneumonia) • Vitamin A supplementation • Nutritional status of children under five • IYCF practices

7.4 Communicable diseases CDC programs and activities are well established. The focus needs to be on intensifying disease control and eradication activities, escalating the IMCI program and understanding why some programs are not working as well as they should so that this can be remedied. Indicators for childhood diseases include the complete immunisation rate, measles vaccination rate at 1 year of age, and the prevalence of diarrhoea, ARI including pneumonia and measles. Targets for adult communicable diseases have not been set, so indicators will be confirmed once this has been done.

7.5 Non-communicable diseases During the first year of RPJMN, policies to address NCDs need to be developed and agreed, and programs designed that focus on health promotion, prevention, treatment and rehabilitation. Activities and indicators will be developed as part of this program design process.

7.6 Health financing The following are a selection of proposed activities to achieve the policies set out in section 5.6:

Determining levels and percentage share of public sector spending

• Review figures on public sector financing in the HSR and replace with expenditure estimates from Bappenas.

• Quantify the fiscal space for health i.e. the ability of Indonesia to increase public spending on health, including identifying other potential sources of revenue for the health sector such as a tobacco tax.

• Study the economic impacts of productivity and macroeconomic growth from increasing coverage and achieving UHC.

Policy 1: Reducing inequity in per capita spend on health

• Develop and update a model looking at premiums needed for poor and near poor. • Establish a baseline to target and achieve a decrease in benefit-incidence and Out

of Pockets (OOPs). • Establish a baseline to measure improvements in meeting unmet need by rural,

urban, and highly populated Java and Sumatra regions. • Study and report on reducing informal payments by poor


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• Design and pilot conditional cash transfers (CCTs) and demand-side vouchers for the poor and rural populations to cover time and transportation costs.

• Study and develop adequate adjustment factors to increase capitation payment to primary health care (PHC) providers and facilities for each enrolled poor person.

• Establish baseline to reduce catastrophic expenditures for families.

Policy 2: Ensure JKN financing and reimbursement polices deliver health gains and are aligned with MoH health strategies to deliver key health outcomes and meet the changing demand

• Ensure availability of earmarked funds for disease prevention and health promotion at central and district level.

• Develop a reimbursement system for BPJS that will drive health gains at both the population and individual level. This includes re-examining both capitation and DRG based reimbursement systems.

Policy 3: Address inefficiencies in allocative and technical efficiency

• Put in place performance based intergovernmental fiscal transfers that are geared towards the attainment of health outcomes.

Policy 4: Increase total public expenditure on health to meet changing demand

• Review and study the pooling of funds under vertical programs such as HIV, TB, malaria

• Develop sustainability program for HIV/TB/malaria • Study and implement new VAT, looking at the impact on consumption, growth and

different income groups. Develop a policy and submit to Parliament.

Policy 5: Public-private partnerships should be expanded in health financing to increase funds for health

• Study global best practices and develop new legislation to foster and regulate private supplemental health insurance market.

• Develop a study and regulation on Co-Payments.

Policy 6: Consider public-private partnerships for building and running hospitals, laboratories, other facilities and equipment

• Design pilots for building hospitals and outpatient centres.

Policy 7: Continue to develop the management and pooling of funds

• Develop and finalise Road Maps for Improved Governance by BPJS, improved internal operations in actuarial forecasting, management and information system (MIS), quality, payment systems and for Jamkesda integration.

• Establish pilot programs for informal sector coverage. • Study and review pooling of other supply side subsidies under BPJS budgets and

payment mechanisms.

Policy 8: Use strategic purchasing as a policy lever for better health outcomes

• Design and implement a road map for technology assessment


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• Design pilots for selective contracting of NCD care.

The health finance report set out 67 recommendations and target indicators, a selection of which is set out below. Further work on refining indicators and identifying baselines and desired outcomes is required.

Table 30: A selection of health financing recommendations

• Levels and % share of public spending

• Desired Outcome

• Public sector financing for health increased

• Indicator • % GDP spend on health

• Time frame • Increase from 2% 2015, to 2.5% 2016, 3% 2017, 4% 2018, 5% 2019

• Agency lead

• MoF

• Notes • Annual % increases to be confirmed.

•

• Desired Outcome

• Increased allocation of share for primary health care under BPSJ

• Indicators • % share to primary health care

• Time frame • Increase from 18% 2015 to 22% 2016, 26% 2017, 28% 2018 and 30% 2019

• Agency lead

• BPSJ / MoH

• Notes • Numbers tracked through budgets and NHA studies

• Overall patterns of expenditures more equitable and pro-poor

• Desired Outcome

• More equitable expenditure across geographic regions achieved

• Indicators • Measures of unmet need by rural, urban and highly populated Java and Sumatra regions

• Time frame • 5% improvement each year from baseline established in 2014

• Agency lead

• MoH

• New sources of revenues

• Desired Outcome

• Institute co-payments

• Indicators • % of all publicly financed services from co-payments


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• Time frame • 2015: Develop study and regulation

• 2016: Institute co-payments

• 2017: 5% of publicly financed services from co-payments. Increase to 7% in 2018 and 10% in 2019

• Agency lead

• MoH/BPJS

• Increased financial protection

• Desired Outcome

• Reduce out of pocket expenditure

• Indicators • OOP % share of total health expenditure

• Time frame • Reduce from 40% 2014 to 37% 2016, 34% 2017, 31% 2018, 28% 2019.

• Agency lead • MoH / NHA team / MoSA

• Coverage, pooling and strengthening BPJS

• Desired Outcome

• Increase in coverage under BPJS

• Indicators • % covered under BPJS

• Time frame • 20% increase in coverage each year 2015 – 2019

• Agency lead • BPJS / MoF / MoH

• Strategic purchasing

• Desired Outcome

• Contracting at all levels of care strengthened

• Indicators • To be determined

• Time frame • 2015: Contracts with clear reporting rules developed

• 2016: Pilots for selective contracting of NCD care designed

• 2017: Piloting starts

• 2018: Pilots evaluated

• Agency lead • BJPS / MoH

• Public management of funds

• Desired Outcome

• Expenditure tracking systems in place

• Indicators • Contracts with BJPS or MoF

• Time frame • To be determined


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• Agency lead • BJPS / MoHA

7.7 Institutional strengthening

Once the targets suggested in section 4.4.4 are agreed, with dates and responsibility identified, activities will include developing policies, regulations, guidelines and an accreditation system for primary care facilities, revising NSPK and SPM, and setting up the Medical Advisory Board and Complaint Resolution Units. Activities will also need identified and undertaken to develop the strategies outlined in Table 21 in section 5.7.

The HSR identified rules-based indicators (measuring whether appropriate policies, strategies and approaches for health governance exist) and outcome-based indicators (whether rules and procedures are being effectively implemented or enforced, based on the experience of relevant stakeholders). The following selected shortlist of indicators has been identified.

Table 31: Selected institutional strengthening indicators

Indicator Score (1/0)

1. Existence of an up-to-date national health strategy linked to national needs and priorities

2. Existence and year of last update of a published national medicines policy

3. Existence of policies on medicines procurement that specify the most cost-effective medicines in the right quantities; open, competitive bidding by suppliers of quality products

4. TB—existence of a national strategic plan for tuberculosis that reflects the six principal components of the Stop-TB strategy as outlined in the Global Plan to Stop TB 2006–2015

5. Malaria—existence of a national malaria strategy or policy that includes drug efficacy monitoring, vector control and insecticide resistance monitoring

6. HIV/AIDS—completion of the UNGASS National Composite Policy Index questionnaire for HIV/AIDS

7. Maternal health—existence of a comprehensive reproductive health policy consistent with the ICPD action plan

8. Child health—existence of an updated comprehensive, multiyear plan for childhood immunisation

9. Existence of key health sector documents that are disseminated regularly (such as budget documents, annual performance reviews and health indicators)

10. Existence of mechanisms, such as surveys, for obtaining opportune client input on appropriate, timely and effective access to health services

Policy index; Sum of the scores of 10 indicators; Max score is 10 Scoring: If adequate policy does not exist or cannot be assessed: 0; if adequate policy is available: 1

Among the indicators developed to determine the capacity and efficiency of institutions involved in the SKN to achieve their objectives, the following six in Table 32 were highlighted in the HSR, which are sensitive, specific, significant and schematic.


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Table 32: Selected health financing indicators

Selected Indicator Notes

Regulation/Policy on distribution of function and responsibilities on health matters between central and local governments (province and district)

One of the significant weaknesses in the SKN is the lack of clarity about roles and responsibilities. This indicator reflects the extent to which this opacity has been resolved, using whatever means are available (Perpres, Menkes, existence of SLAs & business planning etc.).

Review the existing NSPK (Norm, Standard, Procedure, Criteria)

Gives evidence of the MoH’s role as responsible for policy and guidance.

Number of insured, and who evidentially know that they are

Gives evidence of progress towards achieving UHC and the effectiveness of social marketing.

Rate of replenishment as a % of decapitalisation Gives evidence of the robustness of JKN. Number of private sector providers conforming to agreed quality standards

Gives evidence of the engagement with the private sector, the legitimacy of a quality system and the refinement of the reimbursement framework.

Reduction in inequity (a basket of measures; IDR per capita, physicians per capita, nurses per capita, referrals per capita)

Using the WHO basket of measures to indicate commitment to reducing inequity through investment.

7.8 Supply side readiness Activities will focus on supporting the strategies outlined in section 5.8, including developing a strategy on the role of the private sector, assessing why service delivery challenges remain, and establishing independent monitoring and evaluation of service delivery and service readiness. These will require strengthening and institutionalising the collection of relevant data, in public and private facilities, and ensuring that the data collected reflect national guidelines and norms.

Indicators have been identified in the HSR for measuring general service readiness of health facilities and assessing service-specific readiness – see Table 33 below. These are international indicators, developed by WHO, which would need to be reviewed and applied to the specific national or local context during the HSR planning process.


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Table 33: WHO Indicators for measuring general service readiness of health facilities66

Domain Percentage of facilities with Basic amenities • Power (a grid or functional generator with fuel)

• Improved water source within 500 meters of facility • Room with auditory and visual privacy for patient

consultations • Access to adequate sanitation facilities for clients • Communication equipment (phone or SW radio) • Facility has access to computer with email/internet access • Emergency transportation

Basic equipment • Adult scale • Child/infant scale • Thermometer • Stethoscope • Blood pressure apparatus • Light source

Standard precautions for infection prevention

• Sterilization equipment • Safe final disposal of sharps • Safe final disposal of infectious wastes • Appropriate storage of sharps waste • Appropriate storage of infectious waste • Disinfectant • Single use —standard disposable or auto-disable syringes • Soap and running water or alcohol based hand rub • Latex gloves • Medical masks • Gowns • Eye protection (goggles, face protection) • Guidelines for standard precautions

Diagnostic capacity • Haemoglobin • Blood glucose • Malaria diagnostic capacity • Urine dipstick- protein • Urine dipstick- glucose • HIV diagnostic capacity • DBS collection • TB microscopy • Syphilis rapid test • General microscopy/ wet mounts • Urine test for pregnancy • ALT and Creatinine

Essential medicines • Amitriptyline 25 mg capsule/tablet • Amoxicillin 500 mg capsule/tablet • Atenolol 50 mg capsule/tablet • Captopril 25 mg capsule/tablet • Ceftriaxone 1 g/vial injection • Ciprofloxacin 500 mg capsule/tablet • Co-trimoxazole 8+40 mg/ml suspension • Diazepam 5 mg capsule/tablet • Diclofenac 50 mg capsule/tablet • Glibenclamide 5 mg capsule/tablet • Omeprazole 20 mg capsule/tablet • Paracetamol 24 mg/ml suspension • Salbutamol 0.1 mg/dose inhaler • Simvastatin 20 mg capsule/tablet

66 WHO. (2013a).


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Table 34: WHO Indicators for assessing service-specific readiness67 Health services Staff and training Equipment Diagnostics Medicines and commodities Family planning services

• Guidelines on family planning

• Staff trained in Family Planning

• Blood pressure apparatus

Combined oral contraceptive pills; Injectable contraceptives; Condoms

Antenatal care services

• ANC guidelines • Staff trained in ANC


• Haemoglobin • Urine dipstick-

protein

• Iron tablets • Folic acid tablets • Tetanus toxoid

vaccination Basic obstetric care • Guidelines for integrated

management of pregnancy and childbirth (IMPAC)

• Staff trained in IMPAC

• Emergency transport

• Examination light

• Delivery pack

• Suction apparatus (mucus extractor)

• Manual vacuum extractor68

• Vacuum aspirator or dilatation and curettage (D&C) kit

• Neonatal bag and mask

• Delivery bed

• Partograph

• Gloves

• Antibiotic eye ointment for newborn

• Injectable uterotonic (oxytocin)

• Injectable antibiotic (broad spectrum, usually gentamicin or penicillin and ampicillin)

• Magnesium sulphate (injectable) or injectable valium

• Diazepam (injectable)

• Skin disinfectant

• Intravenous solution with infusion set

Comprehensive obstetric care • Guidelines for CEmOC

• Staff trained in CEmOC

• Staff trained in surgery

• Staff trained in anesthesia

• Anesthetic equipment

• Incubator

• Blood typing

• Cross match testing

• Blood supply sufficiency

• Blood supply safety

Routine child immunisation • Guidelines for EPI

• Staff trained in EPI

• Cold box/vaccine carrier with ice packs

• Refrigerator

• Sharps container

• Single use-standard disposable or auto-disable syringes

• Measles vaccine

• DPT-Hib+HepB Vaccine

• Polio vaccine

• BCG vaccine

Preventative and curative care • Guidelines for IMCI

• Guidelines for growth monitoring

• Staff trained in IMCI

• Staff trained in growth monitoring

• Child/infant scale

• Length/height measuring equipment

• Thermometer

• Stethoscope

• Growth chart

• Haemoglobin

• Test parasite in stool (general microscopy)

• Malaria diagnostic capacity

• Oral rehydration solution packet

• Amoxicillin syrup/suspension

• Co-trimoxazole syrup/suspension

• Paracetamol syrup/suspension

• Vitamin A capsules

• Me-/albendazole cap/tab

• Zinc tablets Malaria • Guidelines for diagnosis

and treatment of malaria

• Guidelines for IPT

• Staff trained in malaria diagnosis and treatment

• Staff trained in IPT

• Malaria diagnostic capacity

• First-line antimalarial in stock

• Paracetamol cap/tab

• IPT drug

• ITN

Diabetes • Guidelines for diabetes diagnosis and treatment

• Staff trained in diabetes diagnosis and treatment


• Adult scale

• Measuring tape (height board stadiometre)

• Blood glucose

• Urine dipstick-protein

• Urine dipstick-ketones

• Metformin cap/tab

• Glibenclamide cap/tab

• Insulin injectable

• Glucose injectable solution

Cardiovascular disease • Guidelines for diagnosis

and treatment of chronic • Stethoscope • ACE inhibitors (e.g.,

enalapril)

67 WHO. (2013a). 68 A suction cup device used to assist with the delivery (also known as a Ventouse); not to be confused with suction aspiration

device used to clean the womb after a miscarriage.


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Health services Staff and training Equipment Diagnostics Medicines and commodities cardiovascular conditions

• Staff trained in diagnosis and management of chronic cardiovascular conditions


• Adult scale

• Thiazides

• Beta blockers (e.g., atenolol)

• Calcium channel blockers (e.g., amlodipine)

• Aspirin cap/taps

• Metformin cap/taps

• Oxygen Chronic respiratory disease

• Guidelines for diagnosis and management of CRD

• Staff trained in diagnosis and management of CRD

• Stethoscope

• Peak flow meter

• Spaces for inhalers

• Salbutamol inhaler

• Beclomethasone inhaler

• Prednisolone cap/tabs

• Hydrocortisone cap/tabs

• Epinephrine injectable

• Oxygen Blood transfusion • Guidelines on appropriate

use of blood and safe blood transfusion

• Staff trained in the appropriate use of blood and safe blood transfusion

• Blood storage refrigerator • Blood typing

• Cross match testing

• Blood supply sufficiency

• Blood supply safety

Comprehensive surgery • Guidelines for IMEESC

(WHO Integrated Management for Essential and Emergency Care)

• Staff trained in IMEESC

• Staff trained in surgery

• Staff trained in anaesthesia

• Anaesthesia equipment

• Spinal needle

• Suction apparatus

• Oxygen

• Thiopental (powder)

• Suxamethonium bromide (powder)

• Atropine (injectable)

• Diazepam (injectable)

• Halothane (inhalation)

• Bupivacaine (injectable)

• Lidocaine 5% (heavy spinal solution)

• Epinephrine (injectable)

• Ephedrine (injectable) Laboratory capacity in addition to primary lab tests

• Serum electrolytes

• Full blood count with differential

• Blood typing (ABO and Rhesus) and cross match (by anti-globulin or equivalent)

• Liver function test

• Renal function test

• CD4 count and percentage

• HIV antibody testing (ELISA)

• Syphilis serology

• Cryptococcal antigen

• Gram stain

• Urine dipstick with microscopy

CSF/body fluid counts

High-level diagnostic equipment

• X-ray

• ECG

• Ultrasound

• CT scan


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7.9 Human resources for health Key activities for achieving the policies to improve the production, distribution and quality of the health workforce will include:

• Developing realistic and achievable indicators against the ultimate goal of 100 per cent coverage, identifying the cost of achieving this, budgeting resources accordingly and developing a reliable baseline set of data against which progress can be measured.

• Quantifying the current and projected future gaps in the health workforce. • Supporting programs to improve workforce distribution outlined in section 6.9.2. • Developing a competency framework, and a process for conducting competency

tests on doctors, midwives, pharmacists and nutritionists, and for improving competency in NCD prevention and risk factor identification.

The indicators identified by the HSR to measure the effectiveness of HRH policy and management are set out in Table 35.

Table 35: Human resources for health indicators

•

• Selected Indicators

• HRH density in deprived area: 2.28 (WHO standard)

• GP:100,000 population; specialist:100,000 population; pharmacist:100,000 population; etc.

• Doctor: Nurse ratio

• HRH configuration in hospitals and primary care as required by regulation

• Team-based deployment conducted for deprived area

• HRH competency test conducted regularly for each type of health worker • Number and professions of health workforce in health care institution as required

by standard (regulation)

• Identification of new health professional in the health care institutions

• Production of health workforce as required in terms of quantity and quality to full fill the formation and configuration of HRH in the health care institutions (staging is started in 2015 and ended in 2019)

• Configuration and formation of health workforce in the health care institution as required by standard/regulation

• Availability of sustainable training program that would be conducted at least 2 times per year for each work force

• Every health worker working in health care institution has a certificate of competency test

• Health workforce length of stay is as written in the contract

• Availability of information and mapping of health workforce (public and private) based on working area and working institutions

• Notes • Data sources for measurement: National Research; MoH Survey


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7.10 Pharmaceutical and medical technology Once pharmaceutical and medical technology targets have been agreed upon, activities can be formulated to achieve them. The activities and indicators listed in Section 4.6.6 and the strategies in Section 5.10 outline a number of possible activity focus areas, which can be used to develop appropriate activities to achieve the sector’s targets including promoting the rational use of medicine and medical technologies; monitoring price, consumption and expenditure on medicines; and strengthening cross-sector partnerships to control medicines.

The indicators in Tables 36 and 37 were suggested in order to evaluate progress toward future targets.

Table 36: Policy area 1: Pharmaceutical services

Table 37: Policy area 2: Control of Medicines

•

• Desired Outcome

• Improved access, equity, affordability, availability, supply chain management, rational use of medicines and health technologies

• Indicators • % essential medicines and vaccines in health facilities

• % availability of priority essential medicines for priority illnesses • % availability of health technologies under the insurance benefit package in

primary health care facilities • % generic prescriptions in health facilities • Number of districts reporting medicines consumption and expenditures • Number of districts reporting medicines consumption and

expenditures

• % of health facilities with timely delivery of pharmaceutical services

• % of prescriptions that comply with national formulary/ therapeutic guidelines

• % availability of health technologies under the insurance benefit package in primary health care facilities

• % health technologies meeting standards • % manufacturing facilities of health technologies meeting good production

standards • Number of traditional medicines product undergoing (systematic)

research & development

•

• Desired Outcome

• Improved pre- and post-market medicines control to ensure safety, efficacy and quality


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7.11 Quality and safety of healthcare With no baseline to assess achievements in quality and safety over the last RPJMN, and little discussion among stakeholders, the first activity will be to start consultations on the development of a framework for quality. Dates and responsibilities for achieving the targets set out in section 4.4.5 need to be clarified during consultations.

Among the activities needed to achieve high quality and safe health care are:

• Establish a national quality policy group and develop the tasks assigned to it (see section 5.11.2)

• Establish a national resource centre and develop its capacity to carry out the functions suggested (see section 5.11.3). This would include developing clinical guidelines and protocols, performance indicators, systems to monitor adverse events, tools and processes to decrease risks, and an information strategy for quality

• Determine the values and dimensions for quality in health services • Develop minimum service standards.

Indicators to evaluate progress on national quality systems have been identified by the HSR, and target dates and responsibility for them need to be determined. A selection is provided below.

Table 38: A selection of quality and safety of healthcare indicators

• Indicators • % medicine and food products meeting quality standards in public and private sectors

• % medicines manufacturing facilities meeting GMP standard • % drugs inspector meeting the required competence standard • Number of manufacturers prequalified by WHO/GF • Number of local government which have commitment in enforcing

regulations on medicines through allocating local budget on implementing regulation

•

• Policy indicators

• National framework quality and safety issued for consultation (2015) and approved (2016)

• National quality policy issued for consultation (2016) and approved (2017)

Organisation indicators:

• Authority, responsibility, structure and budget for national commissions (HTA, PS) defined (2015)

• National resource centre established in MoH (2016) and becomes separate entity (2017)

Methods indicators

• Model patients’ charter published by MoH and visible in every facility (2015) • Management guidance on patient survey methods and complaints

procedures issued to providers (2015)

Resources indicators

• Clinicians have access to standardised data on clinical process and outcome (2017)

• Quality improvement methods specified in national curriculum for healthcare workers (2016)

Consolidated Report Health Sector Review

Documents

health outcomes

health information systems

safety of health care

public health challenges

private sector

hospital sector

changing demand

final report