2016年-世界发展银行全球_Indonesia_Health_Financing_System_Assessment___Spend_More_Spend_Right_Spend_Better_12页_1mb

Indonesia Health Financing System Assessment Summary

Core Content

The Health Financing System Assessment (HFSA) policy brief outlines the challenges and opportunities for improving Indonesia's health financing system to achieve Universal Health Coverage (UHC) by 2019. Despite notable progress in health outcomes and the implementation of the Jaminan Kesehatan Nasional (JKN) program, which covers over 60% of the population, the system faces significant inefficiencies, inequities, and sustainability issues.

Main Health Outcomes and Challenges

Key Health Improvements:

• Under-five mortality rate declined from 222 per 1,000 live births in 1960 to 27 in 2015.
• Infant mortality rate dropped six-fold to 23 per 1,000 live births in 2015.
• Life expectancy increased to 69 years in 2014, up from 63 years in 1990.

Persistent Challenges:

• Maternal mortality and childhood stunting remain unresolved.
• Non-communicable diseases (NCDs) are rising, especially among younger age groups.
• Aging population is expected to increase the burden on the health system.
• High out-of-pocket (OOP) spending (45% of total health expenditures in 2014) remains a major issue, contributing to household impoverishment.

Key Policy Recommendations: Spend More

To achieve UHC, Indonesia must increase public health financing:

• Raise additional public financing by:
  • Increasing government revenues through better tax collection and higher 'sin' taxes (e.g., on tobacco).
  • Encouraging labor formality.
  • Reprioritizing health in the government budget.
  • Expanding coverage of the nonpoor informal sector.
• Ensure adequate financing for the JKN benefit package by:
  • Clearly defining the benefits package.
  • Adjusting it to match current public financing resources, economic growth, and service delivery capacity.
• Improve accountability by:
  • Validating beneficiary lists at the district level.
  • Providing clear options for eligible poor and near-poor households who are denied coverage.

Key Policy Recommendations: Spend Right

Reforms should focus on targeting effective interventions:

• Strengthen primary care by:
  • Expanding preventive and promotive public health interventions.
  • Improving quality of health facilities and human resources through accreditation and certification.
• Reduce OOP payments by:
  • Expanding JKN coverage and reducing mistargeting of beneficiaries.
  • Integrating supply-side and demand-side financing.
• Improve provider readiness by:
  • Linking capitation payments to Minimum Service Standards (MSS) for puskesmas.
  • Providing autonomy to public health facilities while enhancing their capacity.
  • Including private providers in the JKN system.
  • Making diagnosis-related group payments conditional on service adequacy at the hospital level.

Key Policy Recommendations: Spend Better

Enhancing technical efficiency is crucial for sustainable health financing:

• Improve JKN capitation payments by linking them to provider performance to encourage preventive care.
• Enhance intergovernmental fiscal transfers by improving local government capacity in public sector management (PSM).
• Ensure greater accountability through independent verification systems and non-financial incentives for districts.
• Utilize MSS to ensure essential services at the sub-national level.
• Strengthen linkages between JKN and externally financed health programs to improve scalability and financial sustainability.

Understanding Health Financing Sources

Four main sources of health financing in Indonesia include:

1. Out-of-pocket (OOP): The largest source, accounting for 45% of total health spending in 2014.
2. Government budgetary supply-side spending: Second largest, at 1.5% of GDP.
3. Social Health Insurance (SHI): Third largest, accounting for 13% of total health expenditures.
4. External funding: Fourth largest, contributing only 1% of total health spending, but vital for priority programs.

Challenges in Health Financing

• Low public health spending (1.5% of GDP) and high OOP spending contribute to inequity and financial vulnerability.
• JKN coverage is limited, especially among the nonpoor informal sector, leading to issues of adverse selection and missing middle.
• Fragmented funding flows and decentralization complicate the implementation of UHC, with limited accountability and inefficient resource allocation.
• Supply-side constraints in rural and remote areas include shortages of skilled health personnel, outdated equipment, and inadequate infrastructure, limiting the effectiveness of JKN.

Future Outlook

Indonesia's health system is undergoing a rapid epidemiological transition, with NCDs becoming a major burden. This transition will require a shift in focus from curative to preventive and promotive care. To meet the UHC goals, the system must spend more, spend right, and spend better, ensuring equitable access, efficiency, and sustainability.

The HFSA aims to identify critical constraints and opportunities in the health financing system, offering evidence-based policy recommendations to support the long-term sustainability of UHC.