2016年-世界发展银行全球_Indonesia_Health_Financing_System_Assessment___Spend_More_Right_and_Better_148页_4mb

Summary of Indonesia's Health Financing System Assessment

Core Content

This report provides an in-depth assessment of Indonesia's health financing system, emphasizing its role in achieving Universal Health Coverage (UHC). It highlights the progress made and the key challenges that still exist in ensuring equitable and efficient health financing.

Main Points

UHC Progress and Challenges

• Indonesia has made significant strides toward UHC, with nearly 160 million people (over 60% of the population) covered by JKN by 2015, and the goal of universal coverage expected by 2019.
• Despite this, challenges persist in achieving full UHC, particularly in service coverage and financial protection.
• Key health outcomes have improved over time:
  • Life expectancy increased from 49 years in 1960 to 69 years in 2014.
  • Under-five mortality dropped from 222 per 1,000 live births in 1960 to 27 in 2015.
  • Infant mortality decreased six-fold since 1960, reaching 23 per 1,000 live births in 2015.
• However, maternal mortality remains high at 126 per 100,000 live births, far exceeding the 2030 SDG target.
• Malnutrition is still prevalent, with 37% of under-five children stunted and 12% wasted.
• Inequalities in health outcomes persist across regions and income levels.

Health System Overview

• Indonesia has a decentralized health system, with 34 provinces, 514 districts, and ~72,000 villages.
• Public sector dominates in rural and secondary care, while private provision is increasing, even for primary care.
• Geographical challenges are significant due to the country's 6,000+ inhabited islands.

Health Financing Structure

• The main sources of health financing include:
  • Out-of-Pocket (OOP) spending: Remains the largest component of total health expenditure (THE), accounting for over 45% since 1995.
  • Government budgetary spending: The second largest source, but still very low at 1.5% of GDP.
  • Social Health Insurance (SHI): JKN is the main SHI program, covering over 60% of the population, but accounts for only 13% of THE.
  • External financing: Accounts for 1% of THE but is vital for specific programs like immunization, HIV, TB, and malaria.
• OOP spending remains a major barrier to UHC, as it deters poor utilization and reduces the redistributive capacity of the health system.
• Catastrophic OOP spending affects 1% of households, while 8% of all households (7 million) are impoverished or pushed into poverty due to high OOP payments.

Key Challenges in Health Financing

• Low public financing: Indonesia's health spending is among the lowest globally, at 3.1% of GDP.
• Fragmented fiscal transfers: District-level spending varies widely due to complex and fragmented intergovernmental transfers.
• Limited coverage of nonpoor informal workers: These individuals face challenges in enrolling in JKN, leading to mistargeting and financial sustainability concerns.
• Inadequate supply-side readiness: Many health facilities lack the capacity to deliver essential services, especially in preventive and promotive care.
• Poor provider payment mechanisms: JKN's passive payment system lacks explicit links to outputs and outcomes, undermining efficiency and effectiveness.

Case Study: Immunization

• Service delivery is a key area of focus, with challenges in ensuring coverage, readiness, and sustainability.
• Financing and JKN integration is crucial for maintaining immunization programs.
• Introduction of new vaccines is supported by external financing (e.g., Gavi), but requires careful planning and coordination.

Policy Recommendations

• Make the benefit package explicit to ensure consistency and efficiency.
• Improve supply-side readiness to enhance service delivery.
• Strengthen primary care and focus on prevention and promotion.
• Reduce OOP payments by expanding and deepening coverage.
• Enhance intergovernmental fiscal transfers to ensure equitable resource allocation.
• Strengthen JKN linkages with externally financed health programs.
• Enhance cross-subsidization from pooled health resources.
• Increase government health spending as a necessary condition for UHC, through:
  • Improving tax collection.
  • Reprioritizing health in the national budget.
  • Increasing efficiency and utilizing earmarked tobacco taxes.
  • Strengthening complementary subnational financing.
  • Formalizing the informal sector to expand coverage.
  • Encouraging enrollment in the formal sector.

Key Information

• GNI per capita (2015): US$3,238 (US$10,680 in PPP terms).
• THE (Total Health Expenditure): 3.1% of GDP, among the lowest in the world.
• JKN coverage: Expected to reach 100% by 2019, but challenges remain in financial sustainability and equity.
• OOP spending: Over 45% of THE since 1995, with 8% of households facing poverty due to high OOP costs.
• Noncommunicable diseases (NCDs): Account for 70% of the disease burden, expected to rise with an aging population.
• Informal labor sector: Over 60% of employed individuals are non-salaried workers.
• Public health expenditure: 10% of district budgets, but not all districts prioritize it as a revenue generator.
• Health facility readiness: Only 30% of puskesmas can perform hemoglobin tests, and 50% can perform urine tests.

Conclusion

To achieve Spend More, Spend Right, and Spend Better, Indonesia must:

• Increase public financing for health.
• Improve efficiency and equity in health spending.
• Enhance service readiness and provider payment mechanisms.
• Ensure the sustainability of externally financed programs through integration with JKN.
• Focus on primary health care and population-level interventions.