HFSA Indonesia Short 12282016 FINAL
INDONESIA
HEALTH FINANCING SYSTEMS ASSESSMENT
SPEND
MORE,
RIGHT &
BETTER
OUTLINE
Background
Macro-fiscal Context
Population Health Outcomes
UHC
Health Financing
Overall Health Financing
Government Budgetary Supply Side
Social Health Insurance
OOP
External Financing
Summary and Policy Options
BACKGROUND
Indonesia has made significant progress…
GDP PER CAPITA AND POVERTY TRENDS IN INDONESIA, 1995-2015
LOWER MIDDLE INCOME WITH
THE GNI PER CAPITA:
US$3,238 (2015)
WITH POSITIVE
MACROECONOMIC OUTLOOK,
INDONESIA IS PROJECTED TO
ATTAIN UPPER MIDDLE
INCOME STATUS IN THE NEXT
TWO YEARS
OVERALL DECLINE IN
POVERTY, BUT RISING
INCOME INEQUALITY
Broadly conducive macroeconomic environment is
expected over the next five years
With economic growth
projected at a respectable
Fiscal deficit to GDP ration (%)
FISCAL DEFICIT AND DEBT to GDP RATIO, 2012-2015
20
5-6% per year
Levels of deficit and debt appear to
be at manageable level
Despite economy growth and
poverty reduction: Level of
informality in the labor markets
remains high
OVER 60%
OF THOSE EMPLOYED
CONTINUE TO BE
CLASSIFIED AS NONSALARIED WORKERS
10
Solomon Islands
0
Philippines
China
Rusia
Indonesia
Thailand
Lao PDR
Cambodia
Nigeria
South Africa
Malaysia
Brazil
Papua New Guinea
Sri Lanka
India
Vietnam
-10
Ghana
-20
0
25
60
100
Debt to GDP ratio (%)
150
Government revenues are low …
NATIONAL REVENUE IS LOW:
17% of GDP in 2015
LOWER COMPARE TO BOTH
REGIONAL AND BY INCOME
GROUP
90%
Centralized collection:
RAISED BY CENTRAL LEVEL IN
2013, BUT EXPENDITURES ARE
HIGHLY DECENTRALIZED
GOVERNMENT REVENUES AND EXPENDITURES AS SHARE OF GDP, 2015
Complex inter-fiscal transfers
SUB-NATIONAL GOVERNMENT REVENUES, 2013
DECENTRALIZED
SPENDING:
ASYMMETRY
BETWEEN REVENUE
COLLECTION AND
SPENDING
Transfer from
Central to Sub
national 6% of
GDP
~40% of spending
at the regional level
LOCAL FINANCING
CATEGORY
Rp trillion
Share of total (%)
Rp trillion
Districts
Share of total (%)
Provinces
DAU
284
54%
31
15%
DAK
30
6%
2
1%
DBH
68
13%
32
15%
Own source
58
11%
102
49%
Other
Total
88
527
17%
100%
40
206
19%
100%
Health is getting more attention with increase of share
government spending at central level …
CENTRAL GOVERNMENT EXPENDITURE BY FUNCTION, 2013-2015
2013
Expenditure category
General public services
Fuel subsidies
Electricity subsidies
Non-energy subsidies
Interest payments
Premiums for poor/near-poor
Economic affairs
Defense
Education
Health
Social protection
Other
Total
2014
IDR trillion
Share (%)
706
210
100
45
113
8
108
88
115
18
17
86
1,137
62%
18%
9%
4%
10%
1%
10%
8%
10%
2%
2%
8%
100%
IDR
trillion
798
240
102
50
133
20
97
86
123
11
13
76
1,204
2015
Share
(%)
66%
20%
8%
4%
11%
2%
8%
7%
10%
1%
1%
6%
100%
IDR trillion
Share (%)
695
65
73
74
156
20
216
102
156
24
23
103
1,320
53%
5%
6%
6%
12%
2%
16%
8%
12%
2%
2%
8%
100%
POPULATION &
HEALTH OUTCOMES
Indonesia have become healthier over the past
several decades
KEY POPULATION HEALTH OUTCOMES IN INDONESIA
Increase in life expectancy from
45 in 1960 to 69 years in 2014
The under-five mortality rate has
declined from 222 in 1960 to 27
per 1,000 live births in 2015
Infant mortality has declined sixfold since 1960, down to 23 per
1,000 live births in 2015
Challenges still remains while undergoing a rapid
epidemiological transition
BURDEN OF DISEASE BY CAUSE IN INDONESIA, 1990-2013
CHALLENGES REMAIN
7%
9%
9%
8%
Maternal Mortality (MMR
126/100,000), SDGs target less
than 70/100,000 live births by 2030
27%
37%
58%
49%
56%
Stunting 36%, SDGs target to
reduce by 40% by 2025
60
EMERGING CHALLENGES
Related to socio-demographic and
lifestyle, including ageing
Communicable
65
70
75
0
20
Life expectancy at birth (year)
40
60
80
100
4+ANC visits (%)
Percentage of districts (%)
Epidemiologic Transition:
Emergence of overnutrition; NCDs
Noncommunicable
Percentage of districts (%)
Injuries
Percentage of districts (%)
Disparity of health outcomes
43%
Percentage of districts (%)
Communicable diseases continue
growing and at the same time
National commitments to achieve
targets
66%
33%
0
20
40
60
80
Institutiona l delivery rate (%)
100
0
20
40
Stunting rate (%)
60
80
UNIVERSAL
HEALTH
COVERAGE
What is UHC?
How can we measure progress towards attaining it?
Recently updated/elaborated UHC definition: “…ensuring that all people can
use the promotive, preventive, curative, rehabilitative, and palliative health
services they need, of sufficient quality to be effective, while also ensuring
that the use of these services does not expose the user to financial hardship.”
Indonesia’s Performance is Mixed
WHO-WB UHC monitoring framework UHC Preventive Indicators
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income
Family
planning
ANC
80%
51%
85%
55%
62%
50%
49%
49%
68%
60%
68%
79%
78%
48%
46%
96%
89%
95%
75%
96%
53%
97%
95%
100%
97%
99%
98%
96%
90%
86%
Skilled
birth
attendance
99%
71%
100%
67%
83%
40%
99%
73%
100%
94%
99%
100%
94%
83%
74%
DPT3
Tobacco
non-use
Water
Sanitation
93%
97%
99%
83%
78%
88%
97%
79%
97%
70%
99%
99%
95%
86%
86%
83%
76%
75%
87%
62%
65%
77%
73%
59%
80%
85%
78%
76%
71%
78%
98%
71%
92%
93%
85%
72%
100%
92%
97%
95%
94%
96%
95%
87%
83%
81%
37%
65%
36%
59%
65%
96%
74%
70%
74%
92%
93%
75%
67%
59%
UHC Treatment and Financial Protection Indicators
Country
ARV
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income
46%
71%
52%
36%
8%
30%
21%
24%
29%
45%
19%
61%
37%
38%
29%
TB
59%
59%
85%
50%
28%
28%
62%
73%
56%
53%
59%
45%
68%
60%
56%
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle-income
Prepaid/pooled
share of total
health
expenditure
OOP
HEALTH FINANCING SYSTEMS ASSESSMENT
SPEND
MORE,
RIGHT &
BETTER
OUTLINE
Background
Macro-fiscal Context
Population Health Outcomes
UHC
Health Financing
Overall Health Financing
Government Budgetary Supply Side
Social Health Insurance
OOP
External Financing
Summary and Policy Options
BACKGROUND
Indonesia has made significant progress…
GDP PER CAPITA AND POVERTY TRENDS IN INDONESIA, 1995-2015
LOWER MIDDLE INCOME WITH
THE GNI PER CAPITA:
US$3,238 (2015)
WITH POSITIVE
MACROECONOMIC OUTLOOK,
INDONESIA IS PROJECTED TO
ATTAIN UPPER MIDDLE
INCOME STATUS IN THE NEXT
TWO YEARS
OVERALL DECLINE IN
POVERTY, BUT RISING
INCOME INEQUALITY
Broadly conducive macroeconomic environment is
expected over the next five years
With economic growth
projected at a respectable
Fiscal deficit to GDP ration (%)
FISCAL DEFICIT AND DEBT to GDP RATIO, 2012-2015
20
5-6% per year
Levels of deficit and debt appear to
be at manageable level
Despite economy growth and
poverty reduction: Level of
informality in the labor markets
remains high
OVER 60%
OF THOSE EMPLOYED
CONTINUE TO BE
CLASSIFIED AS NONSALARIED WORKERS
10
Solomon Islands
0
Philippines
China
Rusia
Indonesia
Thailand
Lao PDR
Cambodia
Nigeria
South Africa
Malaysia
Brazil
Papua New Guinea
Sri Lanka
India
Vietnam
-10
Ghana
-20
0
25
60
100
Debt to GDP ratio (%)
150
Government revenues are low …
NATIONAL REVENUE IS LOW:
17% of GDP in 2015
LOWER COMPARE TO BOTH
REGIONAL AND BY INCOME
GROUP
90%
Centralized collection:
RAISED BY CENTRAL LEVEL IN
2013, BUT EXPENDITURES ARE
HIGHLY DECENTRALIZED
GOVERNMENT REVENUES AND EXPENDITURES AS SHARE OF GDP, 2015
Complex inter-fiscal transfers
SUB-NATIONAL GOVERNMENT REVENUES, 2013
DECENTRALIZED
SPENDING:
ASYMMETRY
BETWEEN REVENUE
COLLECTION AND
SPENDING
Transfer from
Central to Sub
national 6% of
GDP
~40% of spending
at the regional level
LOCAL FINANCING
CATEGORY
Rp trillion
Share of total (%)
Rp trillion
Districts
Share of total (%)
Provinces
DAU
284
54%
31
15%
DAK
30
6%
2
1%
DBH
68
13%
32
15%
Own source
58
11%
102
49%
Other
Total
88
527
17%
100%
40
206
19%
100%
Health is getting more attention with increase of share
government spending at central level …
CENTRAL GOVERNMENT EXPENDITURE BY FUNCTION, 2013-2015
2013
Expenditure category
General public services
Fuel subsidies
Electricity subsidies
Non-energy subsidies
Interest payments
Premiums for poor/near-poor
Economic affairs
Defense
Education
Health
Social protection
Other
Total
2014
IDR trillion
Share (%)
706
210
100
45
113
8
108
88
115
18
17
86
1,137
62%
18%
9%
4%
10%
1%
10%
8%
10%
2%
2%
8%
100%
IDR
trillion
798
240
102
50
133
20
97
86
123
11
13
76
1,204
2015
Share
(%)
66%
20%
8%
4%
11%
2%
8%
7%
10%
1%
1%
6%
100%
IDR trillion
Share (%)
695
65
73
74
156
20
216
102
156
24
23
103
1,320
53%
5%
6%
6%
12%
2%
16%
8%
12%
2%
2%
8%
100%
POPULATION &
HEALTH OUTCOMES
Indonesia have become healthier over the past
several decades
KEY POPULATION HEALTH OUTCOMES IN INDONESIA
Increase in life expectancy from
45 in 1960 to 69 years in 2014
The under-five mortality rate has
declined from 222 in 1960 to 27
per 1,000 live births in 2015
Infant mortality has declined sixfold since 1960, down to 23 per
1,000 live births in 2015
Challenges still remains while undergoing a rapid
epidemiological transition
BURDEN OF DISEASE BY CAUSE IN INDONESIA, 1990-2013
CHALLENGES REMAIN
7%
9%
9%
8%
Maternal Mortality (MMR
126/100,000), SDGs target less
than 70/100,000 live births by 2030
27%
37%
58%
49%
56%
Stunting 36%, SDGs target to
reduce by 40% by 2025
60
EMERGING CHALLENGES
Related to socio-demographic and
lifestyle, including ageing
Communicable
65
70
75
0
20
Life expectancy at birth (year)
40
60
80
100
4+ANC visits (%)
Percentage of districts (%)
Epidemiologic Transition:
Emergence of overnutrition; NCDs
Noncommunicable
Percentage of districts (%)
Injuries
Percentage of districts (%)
Disparity of health outcomes
43%
Percentage of districts (%)
Communicable diseases continue
growing and at the same time
National commitments to achieve
targets
66%
33%
0
20
40
60
80
Institutiona l delivery rate (%)
100
0
20
40
Stunting rate (%)
60
80
UNIVERSAL
HEALTH
COVERAGE
What is UHC?
How can we measure progress towards attaining it?
Recently updated/elaborated UHC definition: “…ensuring that all people can
use the promotive, preventive, curative, rehabilitative, and palliative health
services they need, of sufficient quality to be effective, while also ensuring
that the use of these services does not expose the user to financial hardship.”
Indonesia’s Performance is Mixed
WHO-WB UHC monitoring framework UHC Preventive Indicators
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income
Family
planning
ANC
80%
51%
85%
55%
62%
50%
49%
49%
68%
60%
68%
79%
78%
48%
46%
96%
89%
95%
75%
96%
53%
97%
95%
100%
97%
99%
98%
96%
90%
86%
Skilled
birth
attendance
99%
71%
100%
67%
83%
40%
99%
73%
100%
94%
99%
100%
94%
83%
74%
DPT3
Tobacco
non-use
Water
Sanitation
93%
97%
99%
83%
78%
88%
97%
79%
97%
70%
99%
99%
95%
86%
86%
83%
76%
75%
87%
62%
65%
77%
73%
59%
80%
85%
78%
76%
71%
78%
98%
71%
92%
93%
85%
72%
100%
92%
97%
95%
94%
96%
95%
87%
83%
81%
37%
65%
36%
59%
65%
96%
74%
70%
74%
92%
93%
75%
67%
59%
UHC Treatment and Financial Protection Indicators
Country
ARV
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle income
46%
71%
52%
36%
8%
30%
21%
24%
29%
45%
19%
61%
37%
38%
29%
TB
59%
59%
85%
50%
28%
28%
62%
73%
56%
53%
59%
45%
68%
60%
56%
Country
Brazil
Cambodia
China
India
Indonesia
Lao PDR
Malaysia
Philippines
Russia
South Africa
Sri Lanka
Thailand
Vietnam
East Asia & Pacific
Lower middle-income
Prepaid/pooled
share of total
health
expenditure
OOP