Health Policy

Model for Thinking About Health

To improve health it is important to focus policy attention
on four different areas. In each area there may be
public or private policy actions that can make a positive
difference. These areas are:
• Health—Before Care (genes, individual behavior and social and
physical environment)
• Access to Health Care (coverage, income, provider hours,
transportation)
• Health Care Delivery (quality of care, appropriateness of care,
safety of care)
• Monitoring Health Trends/Evaluating Policies
A key assumption is the need to view health as an investment and
not just as a liability cost to government and employers
2
 Indonesia’s population is growing: by 2025 there will be 273 million people and
the elderly population will almost double to 23 million.

Males
75+
75+ Females
70-74
70-74
65-69
65-69
60-64
60-64
55-59
55-59
50-54
50-54
45-49
45-49
40-44
40-44
35-39
35-39
30-34
30-34
25-29
25-29
20-24
20-24
15-19
15-19
10-14
10-14
5-9 5-9

0-4 0-4

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

Population in Thousands 2000 Population In Thousands 2025

3
Source: BPS 2005., world bank 2010
…but may also have serious implications for the delivery and financing of health
care; doubling the need for care from aging alone.

4
World Bank. 2009. Health Financing in Indonesia: A Reform Road Map.
 Applying the model to helping the
uninsured
• What should happen to reduce threats to the
health of the uninsured before care is needed?
• What should happen to increase the chance
that the uninsured afford coverage?
• What should happen to increase the ability of
the uninsured to access care?
• What should happen to make sure that the
uninsured get safe, appropriate care?
• What can we do to reduce unnecessary health
spending, freeing up money for expanding
coverage?
5
 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.

Changes in Burden of Disease in Indonesia

70

60

50 SKRT'95

40 SKRT'01

Riskesdas07
30

20

10

0
Perinatal / Maternal Communicable Disease Non-communicable Injuries
Disease

Source: Riskesdas Survey 2007. 6

Inequities in health outcomes
between income levels and
geographic areas are very large and
constitute a major problem for the
health sector overall.
• Infant Mortality
• Child Mortality
 Indonesians live longer in 2010 and child mortality has fallen dramatically since
the 1960s.

70
Under-five mortality

200
Infant/underfive mortality rate

150
60
Life expectancy

Infant mortality

100
50

50
Life expectancy
40

0
1960 1970 1980 1990 2000 2010
year
Source : WDI 2009

World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
9
 Despite significant reduction in IMR over time, some neighboring
countries have performed better.

Infant mortality, 1960-2009

250
100

Indonesia India

Vietnam Thailand
25

China
Sri Lanka
5

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
Source: WDI 2009
Note: y-axis log scale

World Bank. 2009: Health Financing in Indonesia: A Reform Road Map. 10

 Death for every 1000 live birth

20
40
60
80
100
120

0
DI Yogyakarta

Source: DHS 2007.

Central Java
Central Kalimantan
DKI Jakarta
Bali
East Kalimantan
North Sulawesi
East Java
DI Aceh
Bangka Belitung
Jambi
Riau
West Java
South Sumatra
South Sulawesi
Lampung

Infant Mortality
Banten
Riau Islands
West Kalimantan
West Sumatra
South-east Sulawesi
West Papua
Papua
Child Mortality

Bengkulu
North Sumatra
Central Sulawesi
Gorontalo
North Maluku
South Kalimantan
East Nusa Tenggara
West Nusa Tenggara
Maluku
West Sulawesi
And there are large inequalities between provinces and income levels.

11
• Life Expectancy
 But geographic inequities remain large: life expectancy varies between
60 in West Nusa Tenggara and 75 in Yogyakarta.

World Bank. 2008. Investing in Indonesia’s Health: Health Expenditure Review 2008.
13
• Financial Protection - OOP
 OOP spending, a measure of financial protection, is about average
relative to comparators.

OOP spending as share of total health spending

vs Income per capita, 2008
80

Cambodia
Lao PDR
60

Vietnam Philippines
China
40

Malaysia

Indonesia
20

Thailand
Samoa
0

100 250 1000 10000 25000

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

World Bank. 2009. Health Financing in Indonesia: A Reform Road Map. 15

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

Spending on drugs per capita in US$

Thailand

Malaysia

Vietnam

Philippines

Cambodia

Indonesia
Government
India Private

0 5 10 15 20 25

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.

Source: WHO. 2004. The World Medicines Situation. 17

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 Originator brands Most sold branded generic Lowest price generic
international indicator
price

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. 18