Sub-national health care financing reforms in Indonesia

Abstract

Indonesia has seen an emergence of local health care financing schemes over the last decade, implemented and operated by district governments. Often motivated by the local political context and characterized by a large degree of heterogeneity in scope and design, the common objective of the district schemes is to address the coverage gaps for the informal sector left by national social health insurance programs. This paper investigates the effect of these local health care financing schemes on access to health care and financial protection. Using data from a unique survey among District Health Offices, combined with data from the annual National Socioeconomic Surveys, the study is based on a fixed effects analysis for a panel of 262 districts over the period 2004-10, exploiting variation in local health financing reforms across districts in terms of type of reform and timing of implementation. Although the schemes had a modest impact on average, they do seem to have provided some contribution to closing the coverage gap, by increasing outpatient utilization for households in the middle quintiles that tend to fall just outside the target population of the national subsidized programs. However, there seems to be little effect on hospitalization or financial protection, indicating the limitations of local health care financing policies. In addition, we see effect heterogeneity across districts due to differences in design features.

Fifty years of Asian experience in the spread of education and healthcare

“…A major change in the system was introduced by the decentralization reforms of 2001, which gave the district authorities much more autonomy and transferred many administrative and financial responsibilities to them (Sparrow et al 2017). Then, in 2005, the federal government introduced the Jamkesmas SI programme for the poorest 30 per cent of the population.…”

Subnational regional inequality in the public health development index in Indonesia

“…In Indonesia, monitoring subnational regional inequality in key health indicators is particularly relevant because of the structure of the current health system. Following the end of the Suharto era in the late 1990s, Indonesia embarked on political, administrative and fiscal decentralization, with responsibility for major public services like health, education, and infrastructure devolving to local authorities at the district level [3][4][5][6][7][8]. Despite substantial increases in overall health funding in Indonesia as part of decentralization, evidence indicates variable public expenditure on health, and inequitable service access and quality of health services between districts in Indonesia [4,5,7,9].…”

“…Following the end of the Suharto era in the late 1990s, Indonesia embarked on political, administrative and fiscal decentralization, with responsibility for major public services like health, education, and infrastructure devolving to local authorities at the district level [3][4][5][6][7][8]. Despite substantial increases in overall health funding in Indonesia as part of decentralization, evidence indicates variable public expenditure on health, and inequitable service access and quality of health services between districts in Indonesia [4,5,7,9]. Heywood and Choi (2010) for example, reported a reduction in the level of performance of the health system between 2002 and 2007, as measured by changes in the use of maternal and child health services, and substantial variation in these indicators between 10 districts in Central and East Java [4].…”

“…Heywood and Choi (2010) for example, reported a reduction in the level of performance of the health system between 2002 and 2007, as measured by changes in the use of maternal and child health services, and substantial variation in these indicators between 10 districts in Central and East Java [4]. Sparrow and colleagues (2017), comparing data from 262 districts across Indonesia between 2004 and 2010 also noted substantial variability between districts in terms of impact of health financing on schemes and health service use [7].…”

Do Justice and Trust Affect Acceptability of Indonesian Social Health Insurance Policy? A cross-sectional survey of laypeople and health care workers

“…Many studies present strong evidence of the improvements of healthcare service post-JKN, such as the increase of Health-Facility Delivery, Skilled Birth Delivery (Brooks et al, 2017), and utilization of health services for the economically disadvantaged communities (Sparrow et al, 2017). Yet, the implementation of JKN still leaves much enigma, not only for patients but also for healthcare workers (HCWs) and policymakers (Fossati, 2016).…”