The Indonesian Health System

OVERVIEW

DATA, GRAPHS AND TABLES

UPDATED DECEMBER 2010

Indonesia’s Health Sector Review

1

Next Update foreseen in March 2011 adding

the Actuarial Estimates and

Jamkesmas Review

Background2

The WB received requests for electronic copies of the various charts, tables and graphs included in the reports and papers produced for the Indonesia Health Sector Review

In response, this synthesis report has been created. It includes the key charts, tables and graphs that can be downloaded

This is a living document and updates will be inserted when new data become available

This document does not summarize all the work that was carried out, rather it includes mainly the data and graphs. For summaries and details please refer to the documents listed in the annex. Each slide includes the source document for easy reference

This review was put together by the World Bank Jakarta-based health team including Claudia Rokx, Pandu Harimurti, Puti Marzoeki, Eko Pambudi, George Schieber, Ajay Tandon and John Giles. Elif Yavuz was involved in earlier versions.

Indon es ia ’ s hea l th s ys tem per fo rmance i s cha l l enged by a chang in g env i r onment :On go i ng demogr aph i c and ep i demi o lo g i ca l t r ans i t i ons tha t a r e l i ke l y to i nc r ease demand and r esu l t i n mor e cos t l y and mor e d i ver se hea l th car e .Add i t i ona l p r essu re w i l l come f r om emerg i ng d i seases and ep i demics such as HIV /A IDS, H5N1 (Av i an I nflu en za ) and H1N1 ( Sw ine Influenza ) .The i mp l emen ta t i on o f Law No. 40 /2004 on Un i ve r sa l Hea l th I nsu rance Cover age ( UHI C) w i l l f u r the r i n cr ease demand and u t i l i za t i o n .

3

Indonesia’s Dynamic Environment

Indonesia’s population is growing: by 2025 there will be 273 million people and the elderly population will almost double to 23 million.

4

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74

75+

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

Population in Thousands 2000

0-45-9

10-1415-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-74

75+

-15,000 -10,000 -5,000 0 5,000 10,000 15,000

MalesFemales

Population In Thousands 2025

Source: BPS 2005.

The demographic transition may provide a ‘demographic bonus’ in the short term if those coming of working age are employed…

5

Source: Adioetomo 2007.

Dependency ratio, 1950-2050

0

10

20

30

40

50

60

70

80

90

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050year

ratio

to w

orki

ng-a

ge p

opul

atio

n

young

eldery

window of opportunity

demographic bonus

total

…but may also have serious implications for the delivery and financing of health care; doubling the need for care from aging alone.

6

World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.

Although communicable disease remains a large burden, with the changing age structure disease patterns will shift to noncommunicable disease and injuries, increasing and diversifying the demand for health care further.

Perinatal / Maternal Communicable Disease

Non-communicable Disease

Injuries0

10

20

30

40

50

60

70

SKRT'95

SKRT'01

Riskesdas07

Source: Riskesdas Survey 2007.

7

Changes in Burden of Disease in Indonesia

The obesity rate is rising and increased prevalence of risk factors will change the burden of disease – increasing the need for preventive measures.

Male

Females

Urban

Rural

Poorest

Quintile 2

Quintile 3

Quintile 4

Richest

0 5 10 15 20 25 30 35

7.7

29

23.6

15.7

15

16.8

17.8

19.9

23.2

Adult Obesity in Indonesia (%)

Source: Riskesdas Survey 2007.

8

Increased need will demand more resources for health. Fortunately, despite the global economic crisis, the macroeconomic picture is still favorable.

World Bank. 2009. Giving More Weight to Health in Indonesia.

Pre-crisis forecast

Post-crisis forecast

45

67

8R

eal G

DP

gro

wth

rate

2003 2005 2007 2009 2011 2013year

Source : IMF

9

Indon es ia ’ s hea l th s ys tem per fo rmance measu red i n te r ms o f hea l th ou tco mes , finan c i a l p r o tec t i on , consumer awareness and equ i ty and eff i c i ency i s m ixed : Indones i a s cor es h i gh l y on r edu c i ng ch i l d mor ta l i t y bu t l ow on r educ i ng mater na l mor ta l i t y.Inequ i t i e s i n hea l th ou tcomes be tween income l eve l s an d geograph i c a reas a re ve r y l a r ge and cons t i tu te a ma jo r p r ob l em fo r the hea l th sec to r ov er a l l .

10

Health System Performance

Indonesians live longer in 2010 and child mortality has fallen dramatically since the 1960s.

11

World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.

Life expectancy

Infant mortality

Under-five mortality

050

100

150

200

Infa

nt/u

nder

five

mor

talit

y ra

te

4050

6070

Life

exp

ecta

ncy

1960 1970 1980 1990 2000 2010year

Source : WDI 2009

But geographic inequities remain large: life expectancy varies between 60 in West Nusa Tenggara and 75 in Yogyakarta.

12


Indonesia performs well in terms of infant mortality relative to other comparable health spending level countries but less well for its income.

13

World Bank. 2009: Health Financing in Indonesia: A Reform Road Map.

China

IndiaLao PDR

Vietnam

Indonesia

Malaysia

ThailandBangladesh

Sri Lanka

Below average Above average

Bel

ow a

vera

geA

bove

ave

rage

Atta

inm

ent r

elat

ive

to in

com

e

Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008

INFANT MORTALITY (2008)

Despite significant reduction in IMR over time, some neighboring countries have performed better.

14


Indonesia

China

Sri Lanka

Vietnam Thailand

India

525

100

250

Infa

nt m

orta

lity

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010Year

Source: WDI 2009Note: y-axis log scale

Infant mortality, 1960-2009

And there are large inequalities between provinces and income levels.

15

0

20

40

60

80

100

120

DI Y

ogya

karta

Cen

tral

Jav

aC

entr

al K

alim

anta

nD

KI J

akar

taBa

li

East

Kal

iman

tan

Nor

th S

ulaw

esi

Eas

t Jav

aD

I Ace

hBa

ngka

Bel

itung

Jam

biR

iau

Wes

t Jav

a

Sout

h S

umat

raS

outh

Sul

awes

iLa

mpu

ngBa

nten

Ria

u Is

land

sW

est K

alim

anta

nW

est S

umat

ra

Sou

th-e

ast S

ulaw

esi

Wes

t Pap

uaPa

pua

Ben

gkul

uN

orth

Sum

atra

Cen

tral

Sul

awes

i

Gor

onta

loN

orth

Mal

uku

Sout

h K

alim

anta

nE

ast N

usa

Teng

gara

Wes

t Nus

a T

engg

ara

Mal

uku

W

est S

ulaw

esi

Dea

th fo

r eve

ry 1

000

live

birth

Infant Mortality Child Mortality

Source: DHS 2007.

In fact, some of Indonesia’s provinces are at par with some of the best and worst performing countries.

16

World Bank. 2009: Presentation on Health Financing in Indonesia: A Reform Road Map.

West Sulawesi

North MalukuRiau Islands

West Java

DKI Jakarta

West Nusa Tenggara

West SumatraSouth SumatraRiau

East KalimantanDI Yogyakarta

Bangladesh

Cambodia

Papua New Guinea

Uganda

Ukraine

Zimbabwe

China

Congo, Rep.

India

Niger

San Marino

Timor-Leste

Tanzania

Vietnam

050

100

150

Infa

nt m

orta

lity

per 1

000

live

birth

Indonesia Other countries Source: IDHS (2007) & WDI 2009

Infant mortality, 2008

Indonesia also performs less well on maternal mortality for its income level in international comparisons.

17


Bangladesh

China

India

Lao PDR

Sri LankaVietnam

Indonesia

MalaysiaThailand


Bel

ow a

vera

geA

bove

ave

rage

Atta

inm

ent r

elat

ive

to in

com

e

Attainment relative to health spending per capitaSource: WDI 2009 (MMR:Model WHO/UNICEF/UNFPA/The Worldbank), WHO 2008

MATERNAL MORTALITY, 2008

And will need extra efforts to achieve the MDG of reducing maternal deaths by 75 percent by 2015.

The World Bank 2010.”…End Then She Died”: Indonesia Maternal Health Assessment.

18

Underweight among children under five years of age has declined significantly…

19

1989 1992 1995 1998 1999 2000 2001 2002 2003 2004 2005 2007*0

5

10

15

20

25

30

35

40

6.3 7.211.6 10.5

8.1 7.5 6.3 8 8.3 8.6 8.85.4

31.2 28.3 2019

18.317.1 19.8

19.3 19.2 19.6 19.2

13

37.535.5

31.629.5

26.424.6

26.127.3 27.5 28.2 28

18.4

Moderate Severe

Underweight

Percentage

Source : Susenas 1989-2005, Riskesdas 2007

Source: Susenas various years.

…however, stunting rates, which are an indicator of chronic malnutrition, remain very high.

20

BangladeshChina

IndiaLao PDR

Sri Lanka

Vietnam Indonesia

Thailand


Bel

ow a

vera

geA

bove

ave

rage

Atta

inm

ent r

elat

ive

to in

com

e

Attainment relative to health spending per capitaSource: WDI 2009, WHO 2008

Stunting Among Children under 5 years old, 2000-2009

Health Spending Trends

BY ANY MEASURE INDONESIA’S PUBLIC SPENDING ON HEALTH IS LOW AND INEQUITABLY DISTRIBUTED:

INDONESIA’S PUBLIC HEALTH SPENDING AS A PROPORTION OF GDP HAS STAGNATED IN RECENT

YEARS AND COMPARES UNFAVORABLY WITH OTHER COMPARABLE INCOME COUNTRIES.

INDONESIA’S OUT-OF-POCKET (OOP) SPENDING IS ABOUT AVERAGE FOR ITS INCOME LEVEL AND HAS

IMPROVED IN RECENT YEARS.INDONESIA DOES REASONABLY WELL ON REDUCING

CATASTROPHIC SPENDING INCIDENCE BUT LESS WELL ON HEALTH INSURANCE COVERAGE AND EQUITY.PUBLIC SPENDING ON HEALTH IS INEQUITABLY DISTRIBUTED ACROSS PROVINCES AND INCOME

QUINTILES.

21

Despite substantial increases in government health expenditures as a share of GDP over recent years, Indonesian governments barely spends 1 percent of GDP on health.

2001 2002 2003 2004 2005 2006 2007* 2008* 2009**0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

Central Province District Series4 Share of GDP

22

Government health expenditures by level of government (2001-2009)

World Bank. 2008. Investing in Indonesia’s Health: Health Public Expenditure Review 2008.

Total and public health spending in Indonesia is low relative to other comparable income countries.

23


China

Cambodia

Lao PDR MalaysiaThailand

Vietnam

Samoa

Indonesia

05

1015

Tota

l Hea

lth S

pend

ing

(% G

DP

)

100 250 1000 10000 25000GDP per capita

Source: World Development Indicators 2009, WHO 2008Note: GDP per capita in current US$; Log scale

TOTAL HEALTH SPENDING VS INCOME, 2008

ChinaCambodia

Lao PDR

Malaysia

ThailandVietnam

Samoa

Indonesia

05

1015

Gov

ernm

ent H

ealth

Spe

ndin

g (%

GD

P)

10 100 250 1000 10000 25000GDP per capita


GOVERNMENT HEALTH SPENDING VS INCOME,2008

And government health spending as a share of the budget is even lower than total government expenditures as a share of GDP.


Indonesia

Indonesia

1020

3040

50

Gov

ernm

ent s

pend

ing

(% G

DP

)G

over

nmen

t hea

lth s

pend

ing

(% b

udge

t)

100 250 1000 2500 10000 25000GNI per capita (US$)

Source: WDI

Government spending vs income, 2004-2006

Government spending (% GDP)

Government health spending (% budget)

24

OOP spending, a measure of financial protection, is about average relative to comparators.

25


China

Lao PDR

Malaysia

Philippines

ThailandSamoa

Indonesia

Cambodia

Vietnam

020

4060

80

Out

-of-p

ocke

t hea

lth s

pend

ing

(% to

tal h

ealth

spe

ndin

g)

100 250 1000 10000 25000GDP per capita, current US$


OOP spending as share of total health spendingvs Income per capita, 2008

Financial protection, measured as the OOP share of nonfood spending has improved.

Source: Equitap Update 2009.

26

27

Malaysia (1999)

Taiwan (2000)

Indonesia (2006)

Thailand (2002)

Hong Kong (2000)

Sri Lanka (1997)

Philippines (1999)

Indonesia (2001)

Korea (2000)

Nepal (1996)

India (2000) China (2000) Bangladesh (2000)

Vietnam (1998)

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

Greater than 25 percent of nonfood expenditures Greater than 10 percent of total expenditures

% o

f hou

seho

lds

exce

edin

g th

resh

old

Catastrophic payments for health care are defined as OOP payments in excess of a substantial proportion of the household budget, usually 10-40 percent (Van Doorslaer et al. 2006; Xu et al, 2003)

By regional standards, the incidence of catastrophic health spending is low in Indonesia.


Equity of public spending on health could be improved; it is low in international comparisons and has not changed much since 2001.

28

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Shanxi province (China) 2003

Heilongjiang (C

hina) 2003

Zhejiang (China) 2003

Gansu (C

hina) 2003

Indonesia 2001

Indonesia 2006

India 1996

Mongolia*

Bangladesh 2000

Vietnam

2003

Malaysia 1996

Thailand 2002

Sri Lanka 2004

Hong K

ong 2002Po

ores

t qui

ntile

shar

e of

subs

idy

Poorest Quintile Share of Public Hospital Inpatient Subsidies in EAP Region


Inequities between provinces are also evident from differences in health expenditures.

29


District Public Health Expenditures by Province (2005)

Technical efficiency is low in Indonesia in global comparisons and there are large differences between provinces.

30

AusA

B

C

Cdn

CN

CZ

F

D

G

HKHIdnIrl

I

JRok

LMys

M

MngNl

N

PS

ECh

Tw

T

Tk

UK

US

V

averagecase-flow

averagebed occupancy

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

percent bed occupancy rate

case

-flow

(ca

ses pe

r bed

per

yea

r)

A: high case-flow low occupancy

C: high case-flow high occupancy

B: low case-flow low occupancy

D: low case-flow high occupancy

N A D

Sumut

Sumbar R i a u

J a m b i

Sumsel Bengkulu Lampung

Bangka Belitung DKI Jakarta

JabarJatengDIYJatim

Banten

B a l iNTB

NTT

KalBarKalseng

Kaltim

Sulut

SultengSulselSulteng Irian Jaya Tengah

Irian Jaya Timur

average case-flow

average bed occupancy

Kalteng

Maluku

Irian Jaya Barat

0

20

40

60

80

100

0 10 20 30 40 50 60 70 80 90 100

percent bed occupancy rateca

se-fl

ow (c

ase

per b

ed p

er y

ear)

A: high case-flow low occupancy

C: high case-flow high occupancy

B: low case-flow low occupancy

D: low case-flow high occupancy

Technical efficiency is ideally measured using case-mix unit cost data, however these are not available in Indonesia. Instead case-flow and average bed occupancy are used.


An a l ready s t r e tched hea l th sys tem w i l l i n cur fu r ther p ressur e due to i nc reased demand f r om ongo i ng demogr aph i c , nu t r i t i on and ep i demio l og i ca l t r ans i t i ons as we l l a s th e i n t r oduct i on o f un i ver sa l h ea l th i n sur ance cove r age .Indon es ia ’ s hea l th i n f r as t ru c tur e , a l though w i de l y ava i l ab l e f o r p r i mar y car e , does no t have suff i c i en t beds o r hea l th work er s to r espond to these i ncr eased needs .Phar maceu t i ca l supp l i e s ar e r easonab le bu t mos t Indones ian pay mor e than they need to an d mos t expend i tu r es ar e ou t o f pocke t .Ther e i s a p ress i ng need to address human r e sour ces d i s t r i bu t i on i nequ i t i e s and qua l i t y. Sat i s f ac t i on l eve l s o ve r a l l a re go od a l though the re i s a h igh l e ve l o f d i s sa t i s fac t i on w i th var i ous aspect s o f hea l th car e .

31

Indonesia’s Health Delivery System

Indonesia’s primary public health care system is extensive: more than 90 percent of the population has access to primary care facilities.

Source: MoH. 2008. Health Profile.

32

Ratio Puskesmas per 100,000 Population

While Indonesia has a well-developed primary health system, it has fewer hospital beds than comparators.

33


China

Cambodia

Lao PDRMalaysia

Philippines

ThailandVietnam

SamoaIndonesia

05

1015

Hos

pita

l Bed

s pe

r 1,0

00



HOSPITAL BED SUPPLY VS INCOME, 2000-2010

And Also Fewer Health Workers 34

World Bank. 2010. New Insights into the Provision of Health Services in Indonesia: A Health Work Force Study.

China

CambodiaLao PDRMalaysia

Philippines

ThailandVietnam

SamoaIndonesia02

46

8D

octo

r per

1,0

00



DOCTOR SUPPLY VS INCOME, 2000-2010

CambodiaLao PDRMalaysia

Philippines

ThailandVietnam

SamoaIndonesia

05

1015

20M

idw

ives

/Nur

ses

per 1

,000



MIDWIVEs/NURSES SUPPLY VS INCOME, 2000-2010

At the Puskesmas level most basic services are available.35

Quality Measures Public Settings Private SettingsPuskesmas Pustu Private

NursePrivate

MidwifePrivate

MDsAll

Settings

Structural qualityInternal water source (%) 89 71 80 84 89 84

Inpatient beds (%) 28 3 3 28 3 18Functioning microscope (%) 79 5 1 3 7 25

Tuberculosis service (%) 95 30 8 2 44 38Measles vaccines in stock (%) 97 51 5 48 11 51

Tetanus toxoid vaccine in stock (%)

97 55 9 59 12 55

Hepatitis B vaccine in stock (%) 92 52 6 54 16 52

Structural Indicators and Quality Scores for Prenatal, Child Curative and Adult Curative Care (by Clinical Setting)(2007)


Secondary and tertiary care have not progressed equally: the number of hospitals and hospital beds has grown slowly.

1995 1997 2000 2003 2005 20060

20000

40000

60000

80000

100000

120000

140000

MoH Province, district, municipal Armed forces, policeState-owned Private

Increase in numbers of hospital beds between 1995 and 2006 by ownership

36


There are 2.5 beds per 10,000, 3.5 Puskesmas per 100,000 and 5.6 hospitals per 1,000,000 Indonesians, however, on average, there are serious inequities among provinces.

37


Wes

t Pap

ua

Nor

th S

ulaw

esi

Mal

uku

Pap

ua Bal

i

Eas

t Kal

iman

tan

Wes

t Sum

atra

D I

Yog

yaka

rta

DK

I Jak

arta

Gor

onta

lo

Nor

th M

aluk

u

Nan

ggro

e A

ceh

Dar

ussa

lam

Sou

th S

ulaw

esi

Sou

th K

alim

anta

n

Cen

tral S

ulaw

esi

Cen

tral K

alim

anta

n

Eas

t Nus

a Te

ngga

ra

Ben

gkul

u

Wes

t Kal

iman

tan

Ban

gka

Bel

itung

Isla

nd

Jam

bi

Cen

tral J

ava

Nor

th S

umat

ra

Sou

th E

ast S

ulaw

esi

Sou

th S

umat

ra

Ria

u

Eas

t Jav

a

Wes

t Nus

a Te

ngga

ra

Lam

pung

Wes

t Jav

a

Ban

ten

Indo

nesi

a

0

200

400

600

800

1,000

1,200

0

2

4

6

8

10

Health Center Ratio bed per 10,000 Health center ratio per 100,000

# H

ealt

h ce

nter

Rat

io

The ratio of physicians to population also masks significant inequities among urban and rural areas.

Source: KKI 2008.

38

DPT3 immunization, often considered a good indicator of health system coverage, is low for Indonesia’s health expenditure level and may indicate low levels of efficiency.

Country Total health expenditure pc (US$)

DPT3 immunization coverage

Indonesia 26 70

Uganda 22 84

Rwanda 19 95

Tajikistan 18 85

Tanzania 17 90

Nepal 16 75

Pakistan 15 80

Bangladesh 12 88

39


Analysis of the number of staff per primary care facility illustrates inequalities at the facility level…

Facility

National

Java-Bali

Sumatra

Other Provinces

1997 2007 1997 2007 1997 2007 1997 2007

Puskesmas

Number of Doctors 1.51 1.90 1.68 1.96 1.19 1.85 1.09 1.62

Number of Doctors (%) 3.4 7.0 1.5 5.9 2.0 6.8 15.9 11.3

Number of Midwives 5.85 3.69 5.76 3.44 6.33 5.28 5.62 3.18

Number of Nurses 5.05 6.14 4.58 5.60 6.16 7.16 5.84 7.61

Pustu

Number of Midwives 0.98 0.81 1.06 0.76 1.13 1.17 0.44 0.21

Number of Nurses 1.08 1.06 1.02 1.09 1.16 1.08 1.16 0.89

Source: IFLS 1997; 2007.

40

…and quality, measured as diagnostic and treatment ability, varies between regions and geographic areas and has not improved much over time.

41

Service

National Java/Bali Sumatra Other Provinces

1997 2007 P= 1997 2007 P= 1997 2007 P= 1997 2007 P=

Prenatal Care Public 42 46 *** 45 47 ** 35 39 ** 38 49 *** Private 40 44 *** 43 46 *** 34 37 ** 39 46 ***Child Curative Care Public 56 64 *** 58 66 *** 48 56 *** 55 65 *** Private 55 59 *** 57 62 *** 50 52 54 60 ***

Adult Curative Care Public 49 56 *** 52 59 *** 43 48 *** 44 53 *** Private 46 53 *** 48 56 *** 40 51 *** 44 51 ***

Quality of Public Health Services in Indonesia 1997-2007 (by Region)

*** p<0.01, **p<0.05


In international comparisons Indonesia spends little on medicine per capita, and most expenses are out-of-pocket.

India

Indonesia

Cambodia

Philippines

Vietnam

Malaysia

Thailand

0 5 10 15 20 25

GovernmentPrivate

Source: WHO. 2004. The World Medicines Situation.

42

Over half of Indonesian districts spent less than US$0.55 per capita in 2007 and some spent less than US$0.10. Districts would need to spend around US$1.50 per capita or more on average (assuming the central government continues to provide around US$0.55 per capita for Puskesmas drugs) to provide all the primary care medicines recommended by WHO.

Spending on drugs per capita in US$

But most Indonesians pay more than they need to for their medicines when they buy from the private sector or from public hospitals.

Price ratio to median international indicator price

Originator brands Most sold branded generic

Lowest price generic

Private pharmacies 22-26 6-7 2.6

Public hospitals 22 1.7-6 2.15

Source: National Institute for Health Research and Development (NIHRD) Survey 2004.

43

Provision of health services by private health providers has grown significantly over the past decade.

At the national level, physician practices per 1,000 of population grew at 38.5 percent

The number of midwife practices per 1,000 population increased by 4.64 percent.

And the majority of physicians working in aPuskesmas supplementtheir income throughprivate service provision


44

And utilization of private health providers fell after Askeskin was introduced and the utilization of Puskesmas increased.

45

Changes in choice between public and private sector between 1999 and 2008

World Bank. 2009. Doctors, Midwives and Nurses: Health Work Force Review.

However, most Indonesians continue to seek ambulatory care from private providers when ill.

Publi

c Hos

p

Pusk

es/ P

ustu

Priva

te Hos

pital

Priva

te Clin

ic

Priva

te ph

ysici

an

Nurse

, Midw

ife

Trad

. Pra

ct.

0%10%20%30%40%50%60%70%80%90%

100%

20071997

Source: IFLS 1997 & 2007.

46

Overall consumer satisfaction with inpatient and outpatient services appears good…

47

58.1

65.259.7

32.2 31.3 32.3

7.73.3

7.2

1.2 0.2 0.90.9 0.0 0.00

10

20

30

40

50

60

70

GDS2 (N=7.916) Susenas-Inpatient (N=19.294) Susenas-Outpatient (N=2.657)

Satisfied Somewhat satisfied Somewhat unsatisfied Unsatisfied No response

Source: GSD2 and Susenas.

…although there is a high level of dissatisfaction with various aspects of the provision of health care…

family visit

cleanliness

freedom of choice

private consultation

involvement in Decision making

information availability

hospitality

waiting time

0 5 10 15 20 25 30 35

11.6

21.7

27.9

25.6

29.7

24.2

17.2

21.7

18.3

26.8

27.3

32.8

24.1

13.6

26.1

inpatient outpatient

percent

Source: Sakernas National Health Survey 2004.

48

Dissatisfaction With Various Aspects of Health Services (%)

…and many people continue to opt for self-treatment or forego treatment altogether.

49

Source: Susenas various years.

The new gover nment i s commi t ted t o i mp lement ing the r e fo r m and assur i ng a l l I ndones i an c i t i zens access to qua l i t y hea l th se r v i ces an d fin anc i a l p r o tec t i on aga i ns t the i mpover i sh i ng effect s o f l a r ge unpr ed i c tab l e med ica l ca r e cos t s .Fu lfi l l i n g th i s commi tment w i l l r equ i re the dev e l opment , i mp lementa t i on , and mon i to r i ng o f po l i c i e s affec t i ng a l l a spec t s o f the h ea l th sys tem – bas i c pub l i c hea l th p r ogr ams ; de l i ve r y sys tems and l og i s t i ca l capac i t y ; qu a l i t y and d i s t r i bu t i on ; o r gan i za t i on , management , and accoun tab i l i t y ; pharmaceu t i ca l s ; finan c ing ; pub l i c—pr i va te par tne rsh i ps and a l l l e ve l s o f gove r nment .

50

Health Financing Reform

Background51

The 2004 Social Security legislation (Law No. 40) envisages coverage of the entire population through a mandatory health insurance system evolving from the existing insurance programs.

As of 2009 the government has covered some 76 million poor and near poor through the Jamkesmas program, funded through the central government budget.

However, progress over the last five years has been slow in developing the final configuration of the health insurance system and the transition plan to provide health insurance to the remaining 50+ percent of the population who currently lack coverage remains to be developed.

Many local governments have developed their own financing schemes, some for the uncovered non-poor.

The health insurance reform is complicated by the big bang decentralization reform that took place in 2001 which transferred most of the authority and responsibility for assuring service delivery capacity to local governments.


Health insurance systems in Indonesia since 2008.

Current Insurance Systems

Ministry of Labor

Ministry of Finance

Ministry of Health

Ministry of Defense

Jamsostek Private insurance

Askes, HMOs

Military personnel

Social security Social HMO

Commercial health

insurance

PT Askes:- Civil servants- Commercial

HMOs

Jamkesmas (scheme for the poor)

Types:

Coverage (millions

of people)

Free health services

Technical oversightFinancial oversight

4.16.6.

including personal accident

Civil servant: 14Commercial HMOs:

2276.4

Source: Gotama and Pardede. 2007. Adapted and updated by World Bank staff.

52

The Current Health Policy Baseline for Health Financing Reform: System Strengths.

53

The country has favorable demographic circumstances with dependency ratios falling over the next 30 years

There are high educational and literacy levels The government is committed to reform Health spending levels are not excessive The country achieves reasonable health outcomes, financial

protection and consumer satisfaction There is substantial experience with health insurance programs There is an extensive primary care delivery system Pharmaceuticals are generally available


54 Half the population lacks health insurance coverage Health financing and delivery systems are highly fragmented Human and physical infrastructures are limited and face quality and

efficiency problems Salary and capital subsidies to public health providers preclude the

development of a ‘level playing field’ for both public and private providers to compete on the basis of price

Critical data for decision making are lacking, including national and subnational health accounts, detailed information on the numbers, risk profiles of the insured and the uninsured, and unit cost information

Design features of the Jamsostek and Askes programs result in high OOP costs for program beneficiaries and limit operational effectiveness and sustainability

Local contributions vary widely, current intergovernmental fiscal redistributions may not adequately reflect local fiscal capacity and need, and the fiscal capacity of districts vary widely.

The Current Health Policy Baseline for Health Financing Reform: System Challenges.


55

Framework to Assess HI Financing Options.

What is the ‘ultimate’ HI system of Universal Coverage (UC) under Law No. 40: single unitary Social Health Insurance (SHI); or multiple systems under a single set of rules; or a unitary general revenue funded system (e.g., Jamkesmas for

all)? What are the specific details of this system with respect to:

single or multiple funds; eligibility of different groups including informal sector workers; benefits covered including cost sharing and referral

requirements; financing including public subsidies and regional contributions; provider payment and cost containment; quality assurance; Administration; and the role of the private sector.

What are the transition policies to get to (UC)?


56

Future Vision 1: Jamkesmas for All: An Indonesian NHS.

This approach approximates a National Health Service like that in Sri Lanka.

It reflects the fact that more than half of the population is currently poor or near poor, and thus has a very limited ability to pay.

It also recognizes the inherent difficulty of identifying the 61 percent of workers who are in the informal sector and having them pay premiums.

By picking up formal sector workers through general revenues, firms might be more competitive as their 3-6 percent payroll contributions would be eliminated and/or could be replaced by more efficient and equitable broad-based taxes.


57

Future Vision 2: A Single Integrated SHI Fund.

This approach approximates the ‘new’ national SHI model (now called Mandatory Health Insurance (MHI)) where the SHI is funded through both wage-based contributions for public and private sector workers (and retirees) and government general revenue contributions for the poor and other disadvantaged groups.

Under this approach there would be a single standardized national HI fund (although one could also establish multiple funds as in Germany or Japan).

The poor would be financed through the GoI budget, while government and private sector workers would be funded as now through wage-based contributions.

The GoI would need to decide if informal sector workers would be covered by the GoI like the poor (as in Thailand) or whether mechanisms can be developed to make them contribute some share of their earnings.


58

Future Vision 3: MHI through a Single Set of Rules Applying to Multiple SHI and NHS Type Programs.

This approach could be considered as a variant of Option 2 or a combination of Options 1 and 2.

Existing programs would be scaled up to include the entire population.

All the poor and other disadvantaged groups would be covered through Jamkesmas.

All private sector workers would be covered through Jamsostek (possibly though elimination of the opt out, employer size, and wage ceiling restrictions and adding requirements to cover retirees).

Civil servants and civil service retirees would be covered through Askes (or the Askes program could be folded into Jamsostek, or conversely).

A decision would need to be made about how to handle informal sector workers.

The three programs would have separate administrative structures but would operate under the same set of rules concerning issues such as benefits and contracting/provider payment.

There might be cross-subsidies required across programs on the financing side.World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.

59

No Matter Which Option is Chosen, The Devil Will Be in The Detail.

Administrative and governance arrangements Defining the benefit package Determining eligible groups Determining purchasing/contracting arrangements and cost

containment policies Estimating actuarially sound premium levels Determining financing sources Defining revenue collection mechanisms Defining transition steps to new system Developing and implementing monitoring and evaluation

procedures


T he p ur p o s e o f t he a c t ua r i a l e s t i ma t e s w a s t o r e s p o nd t o t he G o I re q u e s t t o a s s i s t i n d e v e l o p i ng b a se l i ne e s t i ma t e s f o r t he c o s t o f e x i s t i ng he a l t h i n s u ra nc e p r o g r a ms a nd t o p e r f o r m a n a c t ua r i a l an a l y s i s t o c o s t d i ff e r e n t o p t i o ns f o r a t t a i n i ng U HI C.

I t d e mo ns t r a t e s t he i mp o r t a nc e o f t he d e c i s i o ns t o b e t a ke n r e g a r d i ng t he d e t a i l a s ea c h d e c i s i o n i nfl ue nc e s t he l e v e l o f fi na nc in g ne e d e d .

T he e x e r c i s e i n c l ud e d t he d e v e lo p me n t o f a b a s e l i ne b a s e d o n t he 2 0 0 8 A s ke s c l a i ms d a t a , t he c r e a t i o n o f a r a ng e o f b a se l i ne s a nd t h e c r e a t i o n o f v a r i o u s s c e na r i o s .

60

Actuary Estimates Update in March 2011

I n a l l l i k e l i h o o d , a n d f o r a v a r i e t y o f r e a s o n s , I n d o n e s i a w i l l n e e d t o b o o s t h e a l t h s p e n d i n g i n t h e n e a r f u t u r e a s i t e x p a n d s a c c e s s t o c a r e t h r o u g h t h e e x p a n s i o n o f J a m k e s m a s , t h e h e a l t h i n s u r a n c e s c h e m e f o r t h e p o o r a n d t h e n e a r p o o r.

I n a d d i t i o n , p r o j e c t i o n s b a s e d o n d e m o g r a p h i c a n d e p i d e m i o l o g i c a l c h a n g e s i n t h e c o u n t r y i n d i c a t e t h e r e i s l i k e l y t o b e a s i g n i fi c a n t i n c r e a s e i n t h e d e m a n d a n d n e e d f o r h e a l t h s e r v i c e s a n d m o r e s o p h i s t i c a t e d c a r e .

D e s p i t e a t r i p l i n g o f t h e p u b l i c b u d g e t f o r h e a l t h o v e r t h e p a s t fi v e y e a r s , t h i s i n c r e a s e d n e e d , c o m b i n e d w i t h t h e f a c t t h a t I n d o n e s i a r e m a i n s a c o m p a r a t i v e l y l o w s p e n d e r o n h e a l t h , i n d i c a t e s t h a t t h e r e w i l l c o n t i n u e t o b e u p w a r d p r e s s u r e o n r e s o u r c e s f o r t h e h e a l t h s e c t o r i n t h e n e a r f u t u r e .

61

More Resources for Health; Assessing Fiscal Space

Visualizing fiscal space for Indonesia: different means by which government spending on health can increase.

World Bank. 2009. Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

62

Conducive macroeconomic conditions

Reprioritization

Sector-specific foreign aidOther sector-specific resources

Efficiency

12345678

Fiscal space for health(increase as % of government health spending)

One of the most important determinants of fiscal space for health is economic growth which has a positive outlook in Indonesia.

63

Pre-crisis forecast

Post-crisis forecast

45

67

8R

eal G

DP

gro

wth

rate

2003 2005 2007 2009 2011 2013Year

Source: IMF

Since the outbreak of the crisis, the IMF has lowered its growth and inflation forecasts for the country, although growth remains in the 6-7 percent range per annum over the period 2008-2013.


Higher revenues provide extra resources, but Indonesia’s revenues as a percentage of GDP (19 percent) are low in comparison with other lower-middle-income countries.

Lower income

Middle income

Upper middle

Higher income

0 5 10 15 20 25 30 35 40

Revenue (% of GDP), 2003-2006

64


Given current low levels of spending for health compared to other sectors, a good case can be made for reprioritizing in favor of health.

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008*0%

1%

2%

3%

4%

5%

6%

7%

Agriculture

Education

Health

Govt Apparatus National Defense

Infrastructure

Subsidies

Interest payments

% o

f G

DP

With subsidies declining again (in 2009) there might be increased space for the health sector

65

World Bank. 2009. Presentation on Giving More Weight to Health: Assessing Fiscal Space for Health in Indonesia.

Indonesia’s has not depended significantly on external resources for health in recent years.

1995 1997 1999 2001 2003 20050

2

4

6

8

10

12

External resources (% of total health spending)

Source: WHO.

66

In addition to increasing budgets for health, effective fiscal space may be generated by increasing the efficiency of spending.

Sri Lanka is often presented as an example of a country that has been able to attain excellent health outcomes with relatively low levels of resources, in part because of the underlying efficiency of its health system.

67


Indonesia

Sri Lanka

Abo

ve a

vera

geB

elow

ave

rage

Above average Below average-3-2

-10

12

3P

erfo

rman

ce re

lativ

e to

per

cap

ita h

ealth

spe

ndin

g

-3 -2 -1 0 1 2 3Performance relative to income percapita

Under-five mortality

Indonesia

Sri Lanka

Abo

ve a

vera

geB

elow

ave

rage

Above average Below average-3-2

-10

12

3P

erfo

rman

ce re

lativ

e to

per

cap

ita h

ealth

spe

ndin

g

-3 -2 -1 0 1 2 3Performance relative to income percapita

Maternal mortality

Source: WDI 2009

Performance relative to income and health spending, 2008

Local variation in performance across districts further indicates potential efficiency gains.

Kab. Tana Toraja

Kab. Ciamis

Kab. Morowali

Kab. Subang

Kab. Parigi Moutong

Kab. Bombana

Kab. Pakpak Bharat

Kab. Madiun

Kota Ambon

Kab. Lombok Barat

Kab. Asmat

Kota Singkawang

Kab. Bangka Tengah

Bangladesh

Japan

Nepal

Papua New Guinea

Somalia

Timor-Leste

Indonesia

India

Niger

Pakistan

Chad

Turkey

Uganda

Vietnam

020

4060

8010

0D

PT3

imm

uniz

atio

n

Indonesia Other countries

DPT3 immunizationKota Padang Panjang

Kab. Kediri

Kab. Bantul

Kab. Barito Selatan

Kab. Hulu Sungai Utara

Kab. Nias Selatan

Kab. Yahukimo

Kota Kediri

Kab. Semarang

Kab. Kuningan

Kab. Barru

Kab. Purbalingga

Kab. Wonosobo Burundi

Bangladesh

Pakistan

Senegal

Ukraine

Bhutan

China

Ethiopia

Indonesia

CambodiaTanzania

020

4060

8010

0S

kille

d bi

rth a

ttend

ance


Skilled birth attendance

Source: SUSENAS & WDI

Global comparison of Indonesian districts, 2005

Kab. Tana Toraja

Kab. Ciamis

Kab. Morowali

Kab. Subang

Kab. Parigi Moutong

Kab. Bombana

Kab. Pakpak Bharat

Kab. Madiun

Kota Ambon

Kab. Lombok Barat

Kab. Asmat

Kota Singkawang

Kab. Bangka Tengah

Bangladesh

Japan

Nepal

Papua New Guinea

Somalia

Timor-Leste

Indonesia

India

Niger

Pakistan

Chad

Turkey

Uganda

Vietnam

020

4060

8010

0D

PT3

imm

uniz

atio

n


DPT3 immunizationKota Padang Panjang

Kab. Kediri

Kab. Bantul

Kab. Barito Selatan

Kab. Hulu Sungai Utara

Kab. Nias Selatan

Kab. Yahukimo

Kota Kediri

Kab. Semarang

Kab. Kuningan

Kab. Barru

Kab. Purbalingga

Kab. Wonosobo Burundi

Bangladesh

Pakistan

Senegal

Ukraine

Bhutan

China

Ethiopia

Indonesia

CambodiaTanzania

020

4060

8010

0S

kille

d bi

rth a

ttend

ance


Skilled birth attendance

Source: SUSENAS & WDI

Global comparison of Indonesian districts, 2005

Source: Susenas and WDI.

68

At l eas t 10 ,000 women con t inue to d i e o f ch i l db i r th -r e l a ted causes ever y year i n I ndones i a . Even though sk i l l ed b i r th a t tendance has i nc r eased s i gn i fican t l y, mor e needs t o be done to acce l e ra te a r educ t i on i n dea th s and ach i eve MDG5.A l a r ge number o f women con t i nue to de l i ve r a t home w i thou t p ro fe ss i on a l he l p . Hi gh l eve l s o f uncer ta i n ty abou t med i ca l e xpenses con t i nue to de lay the dec i s i on t o seek car e a t a f ac i l i t y. Even when women reach a f ac i l i t y on t ime , qua l i t y o f management i s po or and dea th r a te s a t f ac i l i t i e s r ema in h igh , e spec ia l l y, bu t no t on l y, i n poor a r eas .

69

Focus on MDG 5: Reducing Maternal Death

There has been an impressive improvement in skilled birth attendance since 1987, but the poor continue to lag behind. 70

Disparities exist between province, economic quintiles, and education levels.

0

20

40

60

80

100

Mal

uku

Wes

t Sul

awes

i N

orth

Mal

uku

East

Nus

a Te

ngga

ra

Papu

a B

ante

n G

oron

talo

So

uthe

ast S

ulaw

esi

Wes

t Pap

ua

Sout

h Su

law

esi

Cent

ral S

ulaw

esi

Wes

t Kal

iman

tan

Wes

t Nus

a Te

ngga

ra

Sout

h Su

mat

ra

Cent

ral K

alim

anta

n W

est J

ava

Jam

bi

Lam

pung

B

engk

ulu

DI A

ceh

East

Kal

iman

tan

Sout

h K

alim

anta

n Ea

st Ja

va

Wes

t Sum

atra

B

angk

a B

elitu

ng

Cent

ral J

ava

Nor

th S

umat

ra

Ria

u N

orth

Sul

awes

i R

iau

Isla

nds

Bal

i D

I Yog

yaka

rta

DK

I Jak

arta

perc

enta

ge

Delivery assistant & place by province

% SBA % Facility base deliveryData source : IDHS 2007

71

Most poor women continue to deliver their babies at home with traditional birth attendants (TBAs) where the risk of maternal death is highest…

72

Poorest Poorer Middle Richer Richest0

102030405060708090

100

- 100 200 300 400 500 600 700 800

ANC/Prof del ANC/No prof del No care (No ANC/No prof del)No ANC/Prof del MMR

% A

NC

/Pro

fess

iona

l del

iver

y

Mat

erna

l Dea

th

per

100,

000

Live

Bir

ths

Source: DHS 2007.

…even though midwives are almost everywhere and are equally distributed.

Note: All types of midwives included. Source: Indonesia Health Profile 2008.

Government target is 100 midwives per 100,000 population by 2010.

73

Midwife availability has increased significantly, however, TBA remains the preferred choice of provider for childbirth.

World Bank. 2010. Presentation on “…and then she died..” Indonesia Maternal Health Assessment.

74

DIY

WJ

CJ

DKI

EJ

DKI

WJ

CJ

DIY

EJ

4060

8010

012

0%

Del

iver

y by

hea

lth p

rofe

ssio

nal

20 40 60 80100Ratio midwife per 100000 pop

SBA VS Ratio midwife, 2007

DKI DIY

EJ

WJ

CJ

DKI

WJ

CJ

DIY

EJ

4060

8010

012

0%

Del

iver

y by

hea

lth p

rofe

ssio

nal

200 400600Ratio TBA per 100000 pop

SBA VS Ratio TBA, 2007

Source: Skilled Birth Attendant (SBA) (IDHS, 2007), Ratio midwife (Indonesia health Profile, 2007)Ratio Traditional Birth Attendant (TBA) (PODES, 2008)Note Abbreviation: DKI=DKI Jakarta, WJ=West java, CJ=Central Java, DIY=Yogyakarta, EJ=East Java

There is a serious shortage of Ob-Gyns in Indonesia and the few there are cluster in richer urban areas.

75

Although more than 70 percent of pregnant women receive antenatal care by skilled providers, the quality of care varies widely.

76

World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.

Although Riau scores high on ANC in general, tetanus vaccination is very low and an important part of ANC. It is insufficient to rely only on ANC numbers

Ob-Gyns provide the most comprehensive services but reach only a limited population.

77

Antenatal Care Services by Type of Assistance in West Java (DHS 2007)

World Bank. 2010. “…and then she died..”. Indonesia Maternal Health Assessment.

Four areas for priority action to improve the health status of Indonesian mothers: Being implemented in ongoing pilots.

1. Improving coordination between public and private sector services at provincial and district levels

2. Strengthening coordination between community-based services and hospital services

3.Reducing financial barriers to utilization of maternal health services

4. Improving clinical skills and quality assurance

Increase research into near miss and maternal death for better understanding of the local contributing factors. Use this analysis to determine whether factors such as access to SHI, ANC, and place of delivery had an impact on outcomes

• Improve vital statistics registration, particularly for deaths among women of reproductive age

• Address the unmet need for access to emergency obstetric care among the large majority of the female population

• Conduct a hospital assessment for maternal health to identify barriers to care within the facility context

• Review the social insurance coverage amounts to expand what is reimbursed and to cover the true cost of having a delivery with a skilled provider.

• Review reimbursement mechanisms in the case of referral upwards to a hospital for complications.

• Improve the quality of the skilled provider, particularly the Bidan di Desa by building on existing initiatives (such as Bidan Delima) and linking quality of care to accreditation and certification.

• Look at the implementation of the comprehensive emergency obstetric services to find areas of improvement.

World Bank. 2010. Presentation on “…and then she died..”. Indonesia Maternal Health Assessment.

78

I M PA C T S T O D AT E :C o v e r a g e h a s e ff e c t i v e l y b e e n i n c r e a s e d a n d a n e s t i m a t e d o n e -t h i r d o f t h e p o p u l a t i o n i s c u r r e n t l y b e i n g c o v e r e d , a c c o r d i n g t o o ff i c i a l d a t a ( S u s e n a s s u r v e y d a t a i n d i c a t e s l o w e r c o v e r a g e r a t e s ) .Fo r t y - t h r e e p e r c e n t o f t h o s e c o v e r e d a r e p o o r a n d n e a r - p o o r h o u s e h o l d s .U t i l i z a t i o n o f h e a l t h s e r v i c e s a m o n g J a m k e s m a s b e n e fi c i a r i e s h a s i n c r e a s e d , e s p e c i a l l y f o r i n p a t i e n t s e r v i c e s .J a m k e s m a s h a s a p r o t e c t i v e e ff e c t o n t h e O O P h e a l t h e x p e n d i t u r e s o f t h e p o o r a n d n e a r - p o o r ; t h o s e w i t h J a m k e s m a s c o v e r a g e h a v e l o w e r O O P p a y m e n t s ( a m e a s u r e o f fi n a n c i a l p r o t e c t i o n ) a n d J a m k e s m a s b e n e fi c i a r i e s h a v e a l o w e r i n c i d e n c e o f c a t a s t r o p h i c m e d i c a l e x p e n d i t u r e s w h e n c o m p a r e d w i t h t h o s e w i t h n o i n s u r a n c e o r t h o s e w i t h o t h e r f o r m s o f i n s u r a n c e .G e o g r a p h i c a n a l y s i s s h o w s s i g n i fi c a n t i n c r e a s e s i n i n p a t i e n t u t i l i z a t i o n i n t h e p o o r e s t p r o v i n c e s ( N T T, Pa p u a , M a l u k u ) .

79

Focus on JamkesmasUpdate in March 2011

I n v e s t in g i n I n d o n e s i a ’ s H ea l t h : C h a l l e n g e s a n d O p p o r t u n i t i e s f o r F u t u r e P u b l i c S p e n d i n g . H e a l t h P u b l i c E x p e n d i t u r e R e v i e w – J u n e 2 0 0 8 I n d o n es ia ’ s D o c to r s , M id w i v e s a n d N u r s es : C u r r e n t S t o c k , I n c r e a s i n g N e e d s , F u t u r e C h a l l e n g e s a n d O p t i o n s . H e a l t h H u m a n R e s o u r c e s R e v i e w – J a n u a r y 2 0 0 9 G i v i n g M o r e We i g h t t o H ea l t h : A s s e s s i n g F i s c a l S p a c e f o r H e a l t h i n I n d o n e s i a – J a n u a r y 2 0 0 9 H e a l th F i n a n c i n g i n I n d o n es ia : a R e f o r m R o a d M a p – J u n e 2 0 0 9 N e w I n s i g h t s i n t o th e P r o v i s i o n o f H e a l t h Se r v i c es i n I n d o n es ia : a H e a l t h Wo r k Fo r c e S t u d y – O c t o b e r 2 0 0 9 ‘ a n d t h e n s h e d i ed ’ : I n d o n e s i a M a t e r n a l H e a l t h A s s e s s m e n t – D e c e m b e r 2 0 0 9

Annex: World Bank Studies for the HSR

80

Forthcoming:

Actuar ia l Cost ing of Universa l Heal th Insurance Coverage in Indones ia : Op t i ons an d Pre l im i nar y Resu l t s – J anuar y 2011 Enhancing Heal th Equi ty and Financ ia l Protect ion in Indones ia : How We l l Does Jamkesmas do? Jamkesmas Rev i ew Paper - Mar ch 2011

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Annex: Forthcoming World Bank Studies

Phar maceu t i ca l s : Why Re for m i s Needed – Mar ch 2009 Acce l e r a t ing I mpr ovement i n Mater na l Hea l th : Why Re for m i s Needed – June 2010 F i nanc i ng Un ive r sa l Cover age : Assess ing F i sca l Space i n Indon es ia – Ju l y 2010 Ach iev i ng Un ive r sa l Coverage : D i ffer en t S tages o f Harmon i za t i on o f I mp l ement i ng Hea l th I nsu rance In fo r mat i on Sys tems – Augus t 2010Forthcoming: Hea l th Pr o fe ss i ona l Educat i on i n In dones ia : W hy Re form i s NeededMater na l Hea l th Meet s Hea l th F inanc in g

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Annex: World Bank Policy Notes Series

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The Indonesian Health System