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Cost sharing by participants at service points
Development of cost control and quality control systems
Efficiency and effectiveness of payment of health services provider provider payment.
Defining the basic package of public health and clinical services and ensuring it is costed
Strengthening planning and performance-based budgeting
Strengthening MoH capacity in health financing policy analysis.
Primary Health Care
The RA follows the GoI definition of the main task of a Puskesmas which is improving area widesub-district health status through: 1 promoting community participation and empowerment; 2
implementing public health programs; 3 providing individual clinical health care services; and 4 encouraging health oriented development healthy public policy. Since 1 January 2014, the
Puskesmas has a new function as the primary health care provider for the national health insurance members and now must be equipped to respond to the treatment of 150 different categories of health
conditions which focus the Puskesmas on curative care. This requires Puskesmas reforms related to human resources, management, equipment, financing, information systems, accreditation, referral
and reporting systems. These all need to be tested at the district level requiring collaboration between government at the provincial and national levels.
1.3 Program Framework
A revised program logic model was developed with key stakeholders in February 2015. This was based on lessons learnt through implementing the original program design. It now ensures priorities of
the partners are aligned towards a common goal and agreed end-of-program outcomes EOPOs. This guides investments of AIPHSS taking into account synergies with future donor funded programs
such as the Primary Health Care Strengthening and Maternal and Newborn Health Program PERMATA.
The goal of AIPHSS is to contribute to “improving the health status of poor and disadvantaged people in I
ndonesia”. The focus is on improving access to better quality health care by removing financial barriers to accessing health care services; and by improving local health service delivery including
providing effective public health care and promotion. There are five EOPOs that AIPHSS is expected to make a contribution toward in support of the
broader goal: 1. Effective national health insurance policy, rules and regulations implemented
2. Minimum service standards MSS are adhered to at all levels of health service delivery 3. Local health service centres achieve accreditation
4. Health resources equitably allocated at all levels of government 5. Good governance and supervision practiced at all levels of government
The implementation framework is based on the four health system building blocks outlined in the Reform Agenda. These are functional areas that guide investment aligned to Implementing Unit IU
work plans at the national and sub-national levels. These health system building blocks are:
1. Governance and Leadership, including health sector decentralisation 2. Health Financing
3. Human Resources for Health 4. Service Delivery
The program framework ensures that the interventions funded by AIPHSS under the RA contribute to achieving the end-of-program outcomes EOPOs. Each intervention is mapped against its
contribution to EOPOs see Annex 2 and scrutinised using a quality assurance process including a value for money assessment. Success is measured according to the quality of outputs e.g. policies,
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guidelines, standards and regulations etc. and how each of these are implemented by the GoI to achieve intermediate outcomes such as the extent to which:
An adequate, capable and supervised workforce is in place
Health legislation is enacted to implement the minimum service standards
Polices and decision making are based on evidence and accurate information
Good governance is practiced at all levels of government supported by improved communication and coordination
Strategic planning is improved and there is an improved ability to identify health system needs based on evidence
A key indicator of future success will be the percentage of AIPHSS activities that are funded in the national and regional budgets 2016-2017 for roll out at the national and regional levels. The source
of data for this indicator will be from national and regional budgets. For many activities this may not be measurable until 2017 due to budgetary planning cycles, however, the next 6 monthly progress report
and end of program report will use this as an indicator of sustainability and impact.
Other headline indicators key performance indicators or aggregated development results ADRs to be reported in the next report period and at the end of the program are given in Table 1 as outlined in
the revised ME Plan, June 2015.
The overall conceptual framework is illustrated in Figure 1.
Table 1. Key Performance Indicators
Indicator Measurement
Proportion of people covered by health insurance
Enrolment in health insurance over time to indicate participation levels.
Supporting indicators will include: Number of memberships being converted from local
e.g. Provincial health insurance system to national health insurance
Number of health facilities now incorporated with BPJS Puskesmas achieving the required
level of accreditation by passing all 9 chapters
Number and percentage as a total of all Puskesmas involved in the program achieving accreditation
Legislation, policies, regulations, manuals guidelines that have been
1 adopted and 2 implemented Number and percentage of legislative changes, policies,
regulations, manuals and guidelines supported by AIPHSS that have been adopted andor implemented within the life of the
program.
Percentage of AIPHSS activities funded in the national and regional budgets 2016-2017 for roll out at the national and
regional levels.
Change in District budgets allocated to health and the percentage allocated
to public health programs Change in budget allocations as a percentage increase from
the beginning of the program baseline. Change in health budget value in each district per capita.
Changes in the number of health workers by province disaggregated by
occupation, specialisation, location Difference in per capita ratio between number of health
workers on commencement and on completion of the program by occupation, specialisation, location and sex
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Indicator Measurement
and sex Technical assistance delivered as
planned by building block and contribution to end of program
outcome and level of result achieved Number and dollar value of TA delivered as planned and per
cent achieving intended results by building block and end of program outcome.
TA scored as less than satisfactory limited results achieved; satisfactory meets most requirements; highly satisfactory
meets all requirements, exceeding some
Number of Training programsworkshops and participants
sex disaggregated by building block and implementing units
– totalled every six months
Total malefemale participants totalled every 6 months attending workshops, meetings and training sessions
Total number of training sessions and workshops every 6 months by building block.
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Figure 1 Conceptual Program Framework
Improved health status of poor and
disadvantaged people in Indonesia
More people have improved access to better
quality health care and benefit from effective
public health and promotion services
Local health service deliver inclusive of
public health is improved
AIPHSSPERMATA Financial barriers to
accessing health services are
removed for the poor
Broader Goals
End of Program
Outcomes
Immediate Outcomes
Minimum service standards are
adhered to at all levels of health
service delivery Health resources
equitably allocated at all levels of
government Good governance
and supervision practiced at all levels
of government
Enabling Outcomes
Adequate, capable, well supervised and
monitored workforce in place
Health legislation to enforce minimum
service standards is enacted
Evidence based policies promote
equitable allocations Improved quality of
strategic planning
Improved ability to identify health system
needs Improved
communication and coordination
Service Delivery
Puskesmas Primary Health Care
Governance and Leadership
Decentralisation Policy and Planning
Human Resources for Health
Strategy and Policy Information Systems
Health Financing
National Insurance Health Accounts
Effective monitoring evaluation and
learning systems implemented in all
levels of government
Implementing the Reform Agenda
Outputs and Activities of
Implementing Units National and Sub
national
Health System Building Blocks
Appropriate, relevant and
accurate information provided in a timely
manner Evidence based
decision making between key
stakeholders Effective national
health insurance policy, rules and
regulations implemented
Local health service centres achieve
accreditation
Guidelines on delivery, standards
and procedures are implemented
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Box 1. Economic Growth and Health Outcomes
The recent UK Lancet Commission on Investing in
Health Jamison, et al., 2013 estimates that:
Up to 24 of economic growth in low- and middle-
income countries was due to better health outcomes.
Increasing life expectancy by one year can increase gross
domestic product GDP by 4 per cent.
Reductions in mortality account for about 11 per cent
of recent economic growth in low-income and middle-
income countries.
Investing in health yields a 9 to 20-fold return on
investment.
2 Relevance of AIPHSS
It is recognised that investment in health outcomes contributes to thriving stable and economically productive communities. For example increasing life expectancy by one year can increase gross
domestic product GDP by 4 per cent. Reductions in mortality account for about 11 per cent of recent economic growth in low-income and middle-income countries as measured in their national income
accounts
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. Australia’s investment in health will contribute to building economically productive communities in Indonesia. This leads to growing markets and trade within the region where Indonesia
is a key market and trading partner. Indonesia is approaching a middle class of 100 million by 2020. The World Health Report 2000 demonstrated the importance of investing in health systems
strengthening as an essential aspect of improving health outcomes for communities. Without sustained investments in
health systems strengthening the investments in vertical programs such as MNCH; Malaria, Tuberculosis and HIV
cannot be sustained if the backbone of the health system is not strengthened and maintained.
AIPHSS has reached a point where it is at its most relevant. This is evidenced by the alignment through the Reform
Agenda with national policy priorities and a close interaction with senior policy making levels in the MoH which ensures
the program has the potential to influence policy and adapt to policy change. The focus on revitalisation of primary
health care models, technical support for the national insurance scheme, changes to health legislation under
decentralisation, and the implementation of a new minimum services standards are key reform issues for the government
partners placing the AIPHSS at the centre of the health policy environment.
The program is also strongly aligned with DFAT’s new Health for Development Strategy 2015-2020 with
investment in strengthened, resilient public health systems being the highest priority. The AIPHSS program achieves
this through providing the GoI with access to flexible small scale funding which can be used for innovation and catalytic
activities which GoI systems cannot deliver quickly. The program is also valued for delivering rapid technical assistance and the provision of information and
evidence to inform the implementation of priority areas.
Currently the AIPHSS program is leading the way in how other development partners now want to address health systems strengthening to improve delivery of essential services. This is evidenced by
the senior staff from the USAID and the Global Fund for AIDS, TB and Malaria regularly consulting AIPHSS senior management on how to invest in and implement health systems strengthening at the
national level.
2.1 Contextual Analysis
