Overview of Health planning in

Indonesia
Purnawan Junadi
FKMUI 2018
Presented For Course of Planning and Development in Health,
Indonesian Case for Bangladesh Officers, 23rd July 2018
 Layout
1. Indonesian Present Situation
2. GOI structure, System and planning
3. Health System
4. Social Health Insurance and achieving UHC
5. Health Budget and expenditure
Indonesian aging population
WORLDWIDE GOVERNANCE INDICATORS
Government Effectiveness

KASN 4
CORRUPTION INDEX

KASN 5
SHI Coverage as of May 2018
 Indonesia’s Performance is Mixed
WHO-WB UHC monitoring framework UHC Preventive Indicators

Skilled
Family Tobacco
Country ANC birth DPT3 Water Sanitation
planning non-use
attendance
Brazil 80% 96% 99% 93% 83% 98% 81%
Cambodia 51% 89% 71% 97% 76% 71% 37%
China 85% 95% 100% 99% 75% 92% 65%
India 55% 75% 67% 83% 87% 93% 36%
Indonesia 62% 96% 83% 78% 62% 85% 59%
Lao PDR 50% 53% 40% 88% 65% 72% 65%
Malaysia 49% 97% 99% 97% 77% 100% 96%
Philippines 49% 95% 73% 79% 73% 92% 74%
Russia 68% 100% 100% 97% 59% 97% 70%
South Africa 60% 97% 94% 70% 80% 95% 74%
Sri Lanka 68% 99% 99% 99% 85% 94% 92%
Thailand 79% 98% 100% 99% 78% 96% 93%
Vietnam 78% 96% 94% 95% 76% 95% 75%
East Asia & Pacific 48% 90% 83% 86% 71% 87% 67%
Lower middle income 46% 86% 74% 86% 78% 83% 59%
UHC Treatment and Financial Protection
Indicators
Prepaid/poole
OOP<2 Neither pushed
d
Country ARV TB 5% nor further
Country share of total
consum pushed
health
ption into poverty
expenditure
Brazil 46% 59% Brazil 70% 97% 97%
Cambodia 71% 59% Cambodia 40% 97% 83%
China 52% 85% China 66% 87% 90%
India 36% 50% India 42% 99% 72%
Indonesia 8% 28% Indonesia 54% 99% 82%
Lao PDR 30% 28% Lao PDR 60% 100% 93%
Malaysia 21% 62% Malaysia 64% 100% 99%
Philippines 24% 73% Philippines 43% 100% 78%
Russia 29% 56% Russia 52% 100% 100%
South Africa 45% 53% South Africa 93% 100% 93%
Sri Lanka 19% 59% Sri Lanka 53% 100% 99%
Thailand 61% 45% Thailand 89% 100% 100%
Vietnam 37% 68% Vietnam 51% 95% 75%
East Asia & Pacific 38% 60% East Asia & Pacific 76% 98% 87%
Lower middle income 29% 56% Lower middle-income 60% 97% 84%
 Layout
1. Indonesian Present Situation
2. GOI structure, System and planning
3. Health System
4. Social Health Insurance and achieving UHC
5. Health Budget and expenditure
 The GOI System

DPD MPR DPR PRESIDEN BPK MA MK

Other
Minister
MENTERI2

Deconsentration Desentralization Co administration Functional Delegation

Local/ Village Gov BUMN

Governor Otonomic Region
Head Reg leg
Local Instituion

2
10
 Central and Regional Connection

Constitution of 1945 Central

Legislative Executive Judicative

DPR MPR DPD

PRESIDEN/ MA MK BPK
WAPRES
KPU Kementerian
KY
Negara
BANK dewan
pertimbangan
SENTRAL
TNI/POLRI

Lingkungan
PROVINSI Peradilan PERWAKILAN
Regional Umum BPK PROV
KDH DPRD
Agama

Militer
KAB/KOTA TUN

KDH DPRD

11
 KEMENTERIAN DALAM NEGERI

Government Affairs

Absolute
Internal Affairs Concurrent
Authority

1. Defense
2. Security 1. Maintain Indonesian
3. Moneter Integrity;
4. Justice 2. Maintain Harmony in
5. Foreign Affair Pluralism
6. Religion 3. Facilitating Democracy

Delegate to

Governor/Mayor or
Local Head administrator
 Health is Concurrent Business
Concurrent Authorities

Obligatory

Basic Services(!2:1) Not Basic (12:2) Optional (12:3)

1. Spatial planning;
1. Education; 2. Living environment; 1. Marine and
3. Food security;
fisheries;
2.Health; 4. Population administration and civil
registration; 2. Tourism;
3. Public Utilities; 5. Population and family planning control;
3. Agriculture;
6. Transportation;
4. Public Houses; 7. Labor; 4. Forestry;
8. Land;
5. Public safety & 9. Communications and informatics; 5. Energy and mineral
security; 10. Cooperatives, small and medium enterprises; resources;
11. Capital investment;
6. Social Work; 12. Youth and sport; 6. Trading;
13. Village community empowerment; 7. Industry; and
14. Empowerment of child protection women;
15. Statistics; 8. Transmigration.
16. Encryption;
17. Culture;
18. Library; and
19. State archives. 13
 Criteria to distribute authority
1. Externality (Spill-over)
– Who gets impact, those who have the authority to
take care of
2. Accountablity
– The administrative authority is the level of
government closest to the impact
3. Efficiency
– Regional Autonomy should be able to create efficient
public services and prevent High Cost Economy
– Economies of scale of public services
– Optimal service coverage (catchment area)
 Level of Government Authority

1. Central:
making norms, standards, procedures, monev, supervision,
facilitation and governance matters with national externalities,
national and international strategic affairs.
2. Province
organize and manage governmental affairs with provincial
externalities (cross-district / cities) in norms, standards, procedures
established by the Central govt
3. District/City
organize and administer government affairs with local externality
(in one District) within the norms, standards, procedures
established by the Central govt

15
 Distribution of Govt Budget

70%
National Central
70% overhead cost
Budget
30% Local
Regional Budget
Prov/Kab/Kota
30% public service
% Administrative cost of regional Budget A (N=220) yr 2003
100
80
60 Avg=50,3 %50,3%

40
20
0 109
127
145
163
181
199
19
37
55
73
91
1
 Layout
1. Overview Indonesian Present Situation
2. GOI structure, System and planning
3. Health System
4. Social Health Insurance and achieving UHC
5. Health Budget and expenditure
 Private and Public Health Services
(National Health System Act, 2012)
Private Health Services Private
Article 172: Focused on /Social Insurance
treatment Ar 115/177

Govt Budget
Poor & isolated
Ar 114/176
Public Health Services
Article 179: Focused on
Prevention
District Budget
Ar 114

Preventive Curative
 Budgetting regulation

Pelayanan Kesehatan Laws of

Perorangan JKN/BPJS
Article 172: Fokus Pengobatan
Dan Pemulihan

Central Govy

Pelayanan Kesehatan District Budgt

Masyarakat OOP
Article 179: Fokus Peningkatan
Kesehatan dan Pencegahan
District Budget

Preventive Curative SHI: Social Health Ins

MCS: Minimal Care std
 Public Health Care

Other
Health Care standard Central
Basic (Article 16 UU23/2014) Govt
Services

Minimal
Minimal Care Standard Govt ACT
Health
(Article 16 UU23/2014) 2/ 2018
Basic
Services
 How minimal is minimal

Other Other Other

Care Care Care
Services Service Service

District
Budget DAK
Central
Govt
(p 292
MCS MCS MCS
l Budget UU23/2014)
District
Budget
District
Budget

Rich District Average District Poor District

Why MSC: Flat Performance on
Child Health Care
 0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
Kep.Riau
DIY
DKI
Kaltim
Babel
Bali
Banten
Sulut
Jabar
Jatim
Sumsel
Jateng
Riau
Indonesia
37.2

36.8

2007
Jambi
Kalbar
Gorontalo

2010
Sumbar
Bengkulu
Papua

2013
Maluku
Sulsel
Stunting: 2007-2013

Malut
Sulteng
Kalteng
Aceh
Sumut
Sultra
Lampung
Kalsel
Pabar
NTB
Sulbar
NTT
Better Maternal services but
poor result

359
 Sistemic Problems

% Hypertension (interviewed) % Hypertension (measured)

 So where the focus of MCS?
Article 171
NHA 2010 -2014 Laws 36/2009

Public
Care
2/3

Private
Care
1/3

Sumber: Indonesia NHA 2014

 Public Good?
1. Infeasible Exclusion, Join Consumption
– Promotion, environmental protection
2. Externalitas:
– Immunization, TB/HIV
3. Secondary Prevention: Screening
4. Global Public Goods: HIV
5. Nation Survival: “Children As Public Good”:
MCH
 Services Provided by MCS vs SHI

MCS SHI Participant

1. Public and grup promotion 1. Personal education
2. Immunization for all 2. Immunization
3. Health screening and early 3. Early detection and prompt
detection treatment
4. Basic services for Mother 4. Comprehensive Care
and Children
5. Early treatment for Govt
prioritized diseases
 Implementation of MCS and SHI

MCS SHI
1. Arranger: District Govt 1. Arranger: BPJS
2. Main Executor: District 2. Main Executor: Private
Govt 3. Can be conducted by govt
3. Can delegate services to if necessary
appropriate private player 4. Cost: Capitation and Ina
4. Cost: at Cost CBG
 Life cycle approach (WHA
DO
A 2008) K
B
Sen PT
Early WR ANC
ior S A
Detection Preg
nant

Adu Govt delivery serv

Early
Detection lt deli
Promotion PNC
ver
Sp Prot referral
Prevention

Sch Health/ Teen New born care

Fam plan Baby Immnization
Nutrition
SCH IHC for Sick Ch
Ch5
Immnization
Sch Health
Nutrition
IHC for Sick Ch
ascobat/PTS/AIPHSS 2014
 MSC
Prov 8. SED on Hypertension;
1. HC at disaster; 9. SED on DM;
2. HC at outbreak; 10. Mental Health;
Kab 11. HC for TB;
1. ANC
12. HC for HIV risk persons
2. Delivery and PNC
3. Neonatal HC;
4. Ch 5 HC;
5. School Health
6. HC for adult; Note
7. HC for Senior; HC: health care
SED: screening and
early detection
 Layout
1. Overview Indonesian Present Situation
2. GOI structure, System and planning
3. Health System
4. Social Health Insurance and achieving UHC
5. Health Budget and expenditure
 ROADMAP TO UHC
86,4 mio PBI

257,5 mio (all

121,6 mio covered Activities:
Indonesian
by BPJS Keesehatan Transformation, Integration, Expansion people) covered
Coverage of various existing by BPJS
schemes 148,2mio 50,07 mio covered `Enterprises 2014 2015 2016 2017 2018 2019 Kesehatan
by other schemes
Big 20% 50% 75% 100%
Uninsured people 90,4 73,8 mio uninsured Middle 20% 50% 75% 100% Level of
mio people Small 10% 30% 50% 70% 100% satisfaction 85%
Micro 10% 25% 40% 60% 80% 100%

2012 2013 2014 2015 2016 2017 2018 2019

Transformation from 4 existing schemes to Integration of Jamkesda into BPJS Kesehatan
BPJS Kesehatan (JPK Jamsostek, Jamkesmas,
Askes PNS, TNI Polri )
and regulation of commercial insurance industry
Presidential decree Pengalihan
on operational Kepesertaan
support for TNI/POLRI ke BPJS
Army/Police Kesehatan

Procedure Company Membership expansion to big, middle, small and micro enterprises
setting on
mapping 20% 50% 75% 100%
membership B
and and
S 20% 50% 75% 100%
contribution socialization
K 10% 30% 50% 70% 100% 100%

Synchronization membership data:

JPK Jamsostek, Jamkesmas dan Askes
Consumer satisfaction measurement every 6 month
PNS/Sosial – single identity number
Benefit package and sevices review annually
39
SHI Coverage as of 2018
SHI Coverage, May 2018
No of Facilities contracted, 2018
No of Visits, 2018
Referral Proportion, May 2018
Rate of visits, May 2018
 Budget Coordination
Prevention Curative

SHI Primary Health facilities

Participant

Referral

Private Health Care

Public Health Care

Puskesmas Puskesmas
People
/clinic/dr /clinic/dr

People Hospitals Hospitals

 Govt fac doing too much private services

Gate Keeper No of visits %

Dr 14241500 12.01%
Army clinics 1419593 1.20%
Police Clinics 1016028 0.86%
Clinics 28843623 24.32%
Health Center 72001358 60.71%
Hospital type D 13634 0.01%
Dentist 1058219 0.89%
Total 118593953 100.00%

BPJS Data until Agustus 2016, annualized

 Puskesmas Overheated

Public Health Performances

100.00%

90.00%

80.00%

70.00%

60.00% Imunisasi
ASI 0-4 bln
50.00%
MOW
40.00% IUD
KB Suntik
30.00%
KB Pil
20.00%

10.00%

0.00%
Tahun 2013 Tahun 2015
sumber: SUSENAS
Adverse Selection
 Layout
1. Overview Indonesian Present Situation
2. GOI structure, System and planning
3. Health System
4. Social Health Insurance and achieving UHC
5. Health Budget and expenditure
 Source of Health Financing
Government Local government
(Minimum 5% of
APBN outside of (Minimum 10% of
Salary) APBD outside of salary)

Prioritized for the benefit of public services that amount

at least 2/3 (two thirds) of the state budget of APBN and APBD

Other
Private
Resources

Health financing aims to provide sustainable financing with sufficient quantity, equitably
allocated, and utilized effectively and efficiently to ensure the implementation of health
development and improve health status