HEALTH FINANCING IN D.I. YOGYAKARTA PROVINCE, THE

ROLE OF PUBLIC AND PRIVATE SECTOR

BONDAN AGUS SURYANTO

Main issues of Health Care Policy

equity

efficiency quality

cost

Social value

DISTRICT VARIATIONS IN LIFE EXPECTANCY AT BIRTH, 2002

Below National Estimate

Above National Estimate

National Estimate: 66.3

Range: 58.8 – 72.5

JAVA ISLAND

MAP OF YOGYAKARTA SPECIAL REGION

CENTRAL JAVA PROVINCE

Health care system in Indonesia

Individual health care Public health care

Tertiary hospital

Secondary hospital

Private practitioner Community Health centre

Provincial Health Office

District Health Office

Third strata

Second strata

First strata

Community basedhealth Care

Which one will be dominant role in health care: the government or private sector ?

The availability of government resources: budget, Human resources, hospital, health center etc.Economic level of the population and the number of the poorThe number of Private Facilities and Private health workers. The coverage of health insurance: social and privateMarket system or wellfare system, Is it fit to overall national system?

Health expenditure trend, 1995-2007

Limited government budget

2010 National Target

• National average: 15.5 doctors per 100,000 population.• Provincial variation: 7.0 (Maluku) - 70.8 (DKI Jakarta).

Doctors: Variation by Province

Province DI Yogyakarta

Below National Average

Above National Average

2010 National Target

Poor efficiency --low motivation: most health workers engage in dual practice

012345678

Mean # of Hours/dayworking in Puskesmas

Mean # of hours/dayworking outside

puskesmas

YesNo

Source: GDS 1+

• National average: 62 hospital beds per 100,000 population• Provincial variation: 26 (Lampung) to 166 (DKI Jakarta)

Hospital Beds: Variation by Province

MoH, BPS, World Health Organization

Below National Average

Above National Average

• According to the inventory, 69% of all doctors work for the government, whereas 27% of doctors are in the private sector and state-owned corporations. The military accounts for the remaining 4% of doctors.• Three provinces have not reported any doctors working in the private sector -Kalimantan Tengah, Gorontalo, and Maluku Utara.• DKI Jakarta has 38.4% of doctors working in the private sector - it is the province with the highest ratio.

Doctors: Public vs. PrivateDoctors per 100,000 populationBy Sector and Province

0

10

20

30

40

50

60

70

80

Doctors per 100,000 population(S

ource: MO

H Inventory, 2001)

Public (Government + Military) Private & State Owned Corp.

• 37% of all hospital beds are in the private sector and state-owned corporations, while the military accounts for 9% and government-run hospitals for 54%.• Jakarta and Yogyakarta are the only two provinces with 50% or more beds in the private sector

Hospital Beds: Public vs. Private

MoH, BPS, World Health Organization

Hospital Beds per 100,000 populationOwnership by Province

0

20

40

60

80

100

120

140

160

180

Hospital B

eds per 100,000(S

ource: MO

H Inventory, 2001)

Public (Including Military) Private & Corporate

Inequity remains: U5MR and IMR 4 times higher among the poor

Socioeconomic Differences in Health Measures (Source: Gwatkin et al 200&)

IMR, Immunization, and Delivery Attendance by Socioeconomic Status

0 20 40 60 80 100

Low

2nd

3rd

4th

High

Wea

lth q

uint

ile

Percent/rate

Skilleddeliveryattendance

Fullimmunization coverage

Infantmortalityrate

Ambulatory Utilization Based On Need

From the analysis of SUSENAS 2001, DI Yogyakarta province has the second highest ambulatory utilization, 64%. Maluku has the lowest with 20.4% of visits. There are 12 provinces out of 29 provinces above the national average, 50.3%.

N ati onal Average

020

4060

80Am

bula

tory

utili

zatio

n ba

sed

on n

eed

(%)

Mal

uku

Sula

wes

i Ten

gah

Sula

wes

i Ten

ggar

aR

iau

Kalim

anta

n Se

lata

nSu

law

esi S

elat

anKa

liman

tan

Bara

tKa

liman

tan

Bara

tJa

mbi

Lam

pung

Sum

ater

a Se

lata

nKa

liman

tan

Teng

ahSu

law

esi U

tara

Ban

ten

Gor

onta

loM

aluk

u U

tara

Jaw

a Ba

rat

DKI

Jak

arta

Beng

kulu

Sum

ater

a U

tara

Jaw

a Ti

mur

Nus

a Te

ngga

ra T

imur

Jaw

a Te

ngah

Sum

ater

a Ba

rat

Nus

a Te

ngga

ra B

arat

Papu

aBa

ngka

Bel

itung

DI Y

ogya

karta Ba

li

Kabupaten KotaProvincial Average

Source: Susenas 2001

Variation across districts and provincesINDONESIA: Ambulatory care utilization (%)

Percentage of Population Treated Outpatient by Place/Method of Medical in DI Yogyakarta Province,

2003-2005

Place of treatment Year2003 2004 2005

(1) (2) (3) (4)Hospital 15,54 15,31 14,92

Medical Doctor 30,59 34,81 33,33Health Centre 27,45 24,08 33,57

Medical Traditional 2,26 1,96 1,65Paramedical 18,10 21,21 14,49

Others 6,07 2,49 2,05

Source: Susenas (National Socio Economic Survey) 2003,2004,2005

POVERTY

Total of the poor people by district/municipality, 1999-2004

year

municipality

Total(1000)

%Total province

populationTotal (1000)

%Total province

populationTotal

(1000)

%Total

population

village total

NotInsured46.08%

Cash Plan 0.19% Private Health

Insurance0.23% Healt Insurance

For University2.06%

National Health Insurance32.14%

YogyakartaSocial Health

Insurance5.83%

Health Insurance for Private Company13.47%

The coverage of Health Insurance in DI. Yogyakarta

Financial protection is limited due to high out of pocket spending (2004)

15%

8%

22%55%

Central Provincial District Private household

Source: WB Staff Calculations based on Data from MOF

-

10,000,000,000

20,000,000,000

30,000,000,00040,000,000,000

50,000,000,000

60,000,000,000

70,000,000,00080,000,000,000

90,000,000,000

100,000,000,000

Rup

iah

2004 2005 2006 2007

Tahun

Total DI Yogyakarta government budget for health 2004-2007

APBD

APBN

Challenges in Health system

Health system faces problems of: under-funding, limited HI coverage and financial protection, income and geographic inequities, fragmentation, allocative and technical inefficiencies, low productivity, and financial sustainability

Weak stewardship of entire health system (public and private) and weak public health system

The Existing Health Care system

individu

Government

Private

Financing

Provision

Government

Health insurance

For the poor &Civil servant

Health insurance for private employee

Private health sector

(the future) Health Care system(alternative1)

individu

Government

Private

Financing

Provision

Government

Health insurance for the poor& civil servants

Social health insurance

Private health sector

(the future) Health Care system (alternative 2):“socialized medicine”

individu

Government

Private

Financing

Provision

Government

Social securityPrivate Health insurance

Private health sector

(the future) Health Care System (alternative3):

individu

Government

Private

Financing

Provision

Government

Social Health Insurance

Health insurance for the poor& civil servant

Private health sector

HEALTH FINANCING SYSTEM IN DI YOGYAKARTA PROVINCE

Predominantly role of the government in stewardship, financing and providing health care is necessary in order to assure access, equity, and affordability of health services.Preventive care like immunization, Community disease control mostly has to be the responsibility of the Government, The role of Private practice should be encouraged to substitute the weaknesses of public health services such as low quality. .Social Health Insurance should be developed, to increase access of medical services especially for the poor.Government strengthen its stewardship by set up regulation, standard and quality assurance Government has to provide free/ cheap health services to The Poor and vulnerable people

PUBLIC PRIVATE MIX ALTERNATIVES

Encourage Private and Public mix by:Appointing doctor practitioners as one of health provider in health insuranceUtilize Government health facilities by doctor practitioner in the evening servicesEncourage local health worker in the community to provide health services according to their competence Set up “village health post” to provide health services in collaboration between community and local government Collaboration among health authorities, Private and public hospital, health centre and community in disease control like TB control, dengue etc.Collaboration among all public and private hospitals, health centre and red cross in emergency and disaster.

SOCIAL HEALTH INSURANCE IN DI YOGYAKARTA PROVINCE

D.I. Yogyakarta province has already established local health Insurance: JAMKESOS, abbreviation of social health insurance, as quasi government company, which is now giving heath insurance for:Poor peopleNeglected and street ChildrenHealth volunteer (cadres)People with HIV-Aids and dengue fever

JAMKESOS contract public and Private Hospital and health centre and Family physician as health provider

Health Care Quality Council(BADAN MUTU PELAYANAN KESEHATAN)

A government partner in regulating health careA non-structural government body who is developing to be independentNot as a part of health office, health professionals organization, or health care institutionto give recommendations to government based on result of health institution surveyto accredit and certify medical institution, mostly privateEncourage setting up health worker competence standard