Indonesia National Health Accounts 2016 Presented in INAHEA 5 th Conference Jakarta, 31 October 2 November 2018

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1 Indonesia National Health Accounts 2016 Presented in INAHEA 5 th Conference Jakarta, 31 October 2 November 2018

514 districts How much money is spent on health?

9 GDP at Current Price Trillion rupiah 12,406.

2 Total Area (km 2 ) = 1,913, Number of Islands = 17,504 Indonesia in Brief Population = 258,7 milion 34 provinces 514 districts How much money is spent on health? Unit YEAR OF 2016 Life Expectancy Rate Years 70.9 GDP at Current Price Trillion rupiah 12,406.8 Per Capita of GDP at current price Million rupiah 48.0 Source : Indonesia Statistics Office StatisticalYearbook of Indonesia Health Status Infant Mortality Rate (IMR) 24/1000 (2017) Maternal Mortality Rate (MMR) 305/ (2015) Source : Indonesian Health Profile, 2017.

3 You can only manage what you can measure Financial planning Efficiency Value for Money Financial protection Absorptive capacity Monitor progress

4 Subsystems of National Health System (Presidential Decree 72/2012) Health Effort on Personal and Community Research and Development on Health HEALTH FINANCING Health Workforce Pharmaceutical, medical devices and food supply Management, Information and Regulation on Health Community Empowerment

Principles Priority Programs: -SPM -PISPK

5 Health Development and Health Financing Ensuring implementation of health development Health Financing Sufficient Fairly and evenly allocated Effectively and efficiently utilized and properly distributed Availability Sufficiency Effectiveness and efficiency Sustainability Fairness and transparency Principles Priority Programs: -SPM -PISPK -SDG s -GERMAS Spending for operational & investation PBI premium for National Health Insurance How to monitor health spending in a country? Improving the health status

6 Health accounts is a TOOL to monitor health spending HA An international standard of accounting framework: System of Health Accounts 2011 (a refined methodology that refers to System of National Accounts/SNA 2008) Health Accounts A systematic and comprehensive approach to mapping the flow of health sector funds in a country/area over a defined period of time. (where the money comes from, who manages the money, what the money spent for, and who the beneficiaries are) NHA National Health Accounts PHA Provincial Health Accounts DHA District Health Accounts SHA methodology with some modifications according to local specific needs

7 Regulation for National Health Accounts Production Law No. 33/2004 and No. 23/2014 concerning Decentralization Government Regulation No. 38/2007 : subnational responsibility in supporting the health financing Law No. 23/2014 concerning Subnational Governance Minister of Home Affairs Regulation No. 13/2006 and 59/2007 concerning Subnational Financial Management Minister of Health Decree No. 922/2008 : needs of NHA, PHA and DHA production Bappenas : NHA, PHA, DHA institutionalization Minister of Health Decree No. 122/2018 concerning NHA Team Work Agreement between Health and other ministries regarding NHA production Source: Head of Center for Health Financing and Health Insurance, April 2018

8 Health Accounts capture snapshots of this health financing flow How are resources RAISED? Revenues of financing schemes (FS) Financing schemes (HF) HOW funds are managed? WHO manages funds? Financing Agents (FA) Health Providers (HP) Who DELIVERS health good and services? What INPUTS are consumed in the delivery of health services? Factors of Provision (FP) Functions (HC) What TYPE of services are delivered What are the population CHARACTERISTI CS? Beneficiaries

9 The Complexity of financial flows in Health System in Indonesia District Health Office (DHO) Hospitals (Public, Private, Parallel Health System) Providers of Ambulatory Health Care (GPs, Specialists, Clinics) Providers of Ancillary Services Retailers and Other Providers of Medical Goods Providers of Preventive Care Providers of Health Care System Administration and Financing Rest of Economy External agencies Rest of the World Donor Financing

10 Data Sources on NHA production MOH The National Narcotics Agency Military Manpower Religion National Education, The Indonesian National Police Coordinating Ministry for Human Development & Cultural Affairs The National Family Planning Coordinating Board Foreign Affairs Law & Human Rights Research, Technology, & Higher Education Social Affairs Youth & Sports Affairs The National Agency of Drug & Food Control Transportation Prov. gov t Sub National District gov t BPJS K Social Security Funds Integrated Jamskesda Pvt Health Insurance Domestic NGOs Non-Profit Institutions serving households (NPISH) Donors (foreign NGOs) Parastatal companies Private companies Households Corporations Public Non-Public NHA

11 Indonesia Health Expenditures, Financing Schemes Public schemes % 30.4% 33.3% 35.5% 38.3% 44.4% 48.7% Health % 4.2% 4.7% 4.8% 4.4% 5.4% 5.5% Other Ministries % 2.7% 2.5% 2.8% 2.3% 2.3% 2.2% Provincial Government % 4.4% 4.7% 4.7% 4.2% 4.6% 5.6% District Government % 13.0% 14.7% 15.1% 13.6% 15.5% 18.2% Social Security % 6.1% 6.7% 8.1% 13.8% 16.7% 17.3% Non-Public schemes % 69.6% 66.7% 64.5% 61.7% 55.6% 51.3% Private insurance % 2.8% 3.2% 3.3% 3.0% 2.8% 3.2% NPISH % 0.8% 0.8% 0.7% 0.7% 0.9% 1.0% Corporations (Parastatal & Pvt companies) % 11.4% 11.8% 13.8% 17.1% 13.7% 12.1% OOP % 54.7% 50.9% 46.7% 41.0% 38.1% 35.0% Total Health Expenditures/THE (Rp trillion) % 100% 100% 100% 100% 100% 100% THE as share of GDP 3.1% 3.1% 3.0% 3.1% 3.2% 3.2% 3.3% THE per capita ribu ribu juta juta juta juta juta Health care financing schemes provide an information of financing arrangements through which people obtain health services.

12 IDR Trillions Overview of Health Financing Schemes in Indonesia, % 46.7% % 38.1% 50.9% 54.7% 17.3% 54.8% 16.7% 13.8% 8.1% 6.7% 23.7% 5.5% 6.1% 20.1% 16.3% 17.4% 19.4% 19.8% 17.8% Central government schemes Local government schemes Social health insurance schemes Enterprise financing schemes Other private schemes Household out-of-pocket payment Total Local Government Schemes experienced an increase and had a substantial contribution to the total of health expenditures There is an indication of success on the implementation of Social Health Insurance Program where the household out-of-pocket financing scheme has decreased from year to year, while the Social Health Insurance Scheme has increased every year.

is under Singapore, Brunei Darussalam, Malaysia and Thailand.

13 Trend of Proportion Current Health Expenditure (CHE) per Capita is Increased, 2016 Source: WHO Global Health Expenditure Database, updated in 2015 Health Expenditure per capita in Indonesia is under Singapore, Brunei Darussalam, Malaysia and Thailand. Health Expenditure per Capita in Thailand is about two times of Indonesia, which has been achieved universal health coverage since 2002.

14 THE per capita (Rp) MMR per live births Increasing Health Expenditure per capita is in line with Declining Maternal Mortality Ratio 1,600,000 1,400,000 1,200,000 1,000, , , , , THE per capita Maternal mortality ratio (per live births) Source: World Development Indicators, (Accessed on Thursday, 23 August 2018, at WIB)

15 Overview of Health Financing Schemes by Sources in Indonesia, % 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 5.3% Health 2.7% 2.2% 2.8% Other ministries Public schemes The majority of public financing scheme come from APBN funds. Approximately 77% of health spending in district governments come from APBN funds Provincial government schemes 3.0% 1.1% 14.1% District government schemes 3.1% 3.3% 1.5% 0.4% 8.9% Social health insurance schemes 0.5% 2.7% Voluntary health insurance schemes Non Public Schemes NPISH financing schemes 12.1% Enterprise financing schemes APBN APBD of Province APBD of District Corporations Households NPISH Donor 35.0% Household out-of-pocket payment

16 Overview of Providers and Function, % 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Hospitals: 57.5 % 2.6% 0.0% 17.2% 37.7% Hospitals 0.6% Ambulatory: 25.8 % 2.0% 5.6% 17.6% Providers of ambulatory health care Retailers & providers Medical goods: 7.4 % 7.4% Retailers and other providers of medical goods Health expenditure is spent mostly for curative care (inpatient and outpatient) provided at hospitals and providers of ambulatory health care (puskesmas, clinics, etc.). Preventive care is only about 9.6% of total health spending Providers of Preventive: 4.3 % Adm: 4.4 % 1.4% 4.0% 3.0% Providers of preventive care Providers of health care system administration and financing 0.2% Other providers Capital Governance, and health system and financing administration Preventive care Medical goods Ancillary services Rehabilitative care Outpatient curative care Inpatient curative care

17 THANK YOU

ZIMBABWE HEALTH FINANCING. GWATI GWATI Health Economist: Planning and Donor Coordination MOHCC Technical team leader National Health Accounts.

ZIMBABWE HEALTH FINANCING. GWATI GWATI Health Economist: Planning and Donor Coordination MOHCC Technical team leader National Health Accounts. ZIMBABWE HEALTH FINANCING GWATI GWATI Health Economist: Planning and Donor Coordination MOHCC Technical team leader National Health Accounts. Our approach to HFP Development Key steps in the development