2009年-世界发展银行全球_Indonesia_-_Giving_More_Weight_to_Health___Assessing_Fiscal_Space_for_Health_in_Indonesia_60页_2mb

Summary: Assessing Fiscal Space for Health in Indonesia

Core Content

This report assesses the fiscal space available for health spending in Indonesia, focusing on how the government can increase resources for health in the context of its evolving health system and future needs. It is part of a broader Health Financing Economic and Sector Study (P107276) by the World Bank, aimed at informing Indonesia's next five-year National Development Strategic Plan (2010-2014). The paper outlines various mechanisms to enhance fiscal space for health, including macroeconomic adjustments, budget reallocation, foreign aid, mandatory health insurance, and improving the efficiency of health spending.

Main Objectives

• Define fiscal space for health.
• Analyze the mechanisms through which additional health funding can be generated.
• Provide insights into the current health financing landscape and future trends.
• Highlight policy implications for increasing health resources and improving health outcomes.

Key Findings

Health System Performance

• Indonesia has made significant progress in health outcomes, including increased life expectancy (from 41 years in 1960 to 68 years in 2006), reduced infant mortality (from 128 to 26 per 1,000 live births), and under-five mortality (from 216 to 34 per 1,000 live births).
• However, performance in maternal mortality and child malnutrition remains poor, with maternal mortality ratio (MMR) at 420 per 100,000 population in 2005, one of the highest in the region.
• National averages mask large regional and income disparities. Health indicators are worse in poorer eastern provinces compared to wealthier western provinces.

Health Financing

• In 2006, total health expenditure per capita was about US$34, or 2.2% of GDP.
• Government spending accounted for 50.4% of total health expenditure, with 5.3% of the government budget allocated to health.
• Private spending made up 49.6% of total health expenditure, and out-of-pocket spending was the largest component at 32.9%.
• Health insurance coverage remains low, with only 38.6% of the population covered in 2006, and less than 40% of the population having health insurance.

Fiscal Space Mechanisms

The paper outlines five key mechanisms for increasing fiscal space for health:

1. Conducive Macroeconomic Conditions
   Economic growth and increased government revenue can lead to higher health spending. A hypothetical scenario suggests a 4% increase in real government health spending from macroeconomic improvements.

2. Reprioritization of Health in the Budget
   Shifting spending priorities within the government budget can increase health funding. A 5% increase is estimated from this approach.

3. Health-Specific Foreign Aid and Grants
   Increasing aid from international organizations can contribute to health financing. This is considered a 1% increase in potential fiscal space.

4. Earmarked Taxes and Mandatory Health Insurance
   Implementing taxes on specific goods (e.g., alcohol, cigarettes) or introducing mandatory health insurance can generate additional resources. These mechanisms are estimated to provide 1% of potential fiscal space.

5. Improving Efficiency of Health Spending
   Enhancing the efficiency of existing government health spending can free up resources. This includes designing interfiscal transfers that target health outcomes, and could contribute to a 1% increase in fiscal space.

Fiscal Space Constraints

• Despite a tripling of public health spending over five years, Indonesia remains a low spender on health relative to its income and regional peers.
• The global financial crisis complicates future fiscal space predictions, but the paper focuses on analyzing potential mechanisms rather than precise forecasting.

Policy Implications

• Health is currently a low priority in the government budget. Policy options include:

  • Reducing fuel and other subsidies in favor of targeted health spending.
  • Implementing a universal health insurance system with cross-subsidization.
  • Introducing earmarked taxes or a VAT top-up for health.
  • Increasing the share of health in the government budget.
  • Improving the efficiency of health spending through better resource allocation and management.

• It is emphasized that increasing resources alone is not sufficient to improve health outcomes; the effectiveness of spending is equally important.

Conclusion

The report concludes that Indonesia has several options to expand fiscal space for health, including macroeconomic adjustments, budget reallocation, increased foreign aid, and improved efficiency. However, it also stresses that without effective implementation, additional resources may not translate into better health outcomes. The analysis is intended to support policy dialogues and inform future health financing strategies in Indonesia.