WHO Indonesia, Health Profile
The general decentralization process implemented in 2001 has had many impacts on the health system, even though it was not designed specifically with the health sector in mind. In particular, health financing, health information system, human resources for health and service provision have been affected. Under decentralization, responsibility for health care provision is largely in the hands of regional governments.
The human resource situation in health has major deficiencies in numbers and quality of the health workforce.
Decentralization is one of many factors exacerbating long-standing problems with mal distribution and reportedly low productivity and quality of health workers. This in turn impacts on the quality, efficiency and equity of health care provision. Limited number of health workers affected health service in Indonesia. In 2006, ratio of general practitioners was 19.9 per 100,000 population while ratio of midwife per 100,000 population was 35.4.
Most general practitioners and midwifes are working in urban area, and limited number in remote area. In 2001, the Ministry of Health reorganized its human resource functions by establishing A new Institute for Empowerment and Development of Health Manpower to link and coordinate the previously separate centres in the development of an overall integrated strategic plan for health workforce development & a corresponding integrated information system.
Decentralization resulted in a partial breakdown of health information systems and led to an unclear division of reporting responsibilities.
Health Information System
As a result, no comprehensive data exist that cover the entire nation. The disruption of the information flow makes it difficult to develop strategies and monitor health programmes in provinces and districts. Exceptions do exist in some vertical programmes (tuberculosis, malaria or HIV-AIDS) where the Central Government retains the responsibility as the principal recipient of GFATM grants to the country.
Indonesia spends relatively little on health services. Estimated total expenditure on health (per capita, in 2003) was $ 33 in Indonesia .
Within that, public sector spending on health (per capita, in 2003) was estimated at $ 11 in Indonesia. The overall health financing situation in Indonesia is complex and incompletely documented. In 2003, around 34% of total health expenditure is undertaken by public sector agencies, while 66% is private. By far the largest single source of private expenditure is direct out-of-pocket payments by households, accounting for nearly half of the total expenditure.
Privately provided services are largely financed by out-of-pocket payments, with some insurance and employer-financed expenditure benefiting a minority of formal sector employees. Publicly provided services are financed by a mix of public budgets and user fees, in turn financed by a combination of households, employers and insurers. Until the advent of the new social insurance scheme for the poor, insurance coverage of the population was low, at well under 10%.
At primary health care level, Indonesia is generally regarded as having relatively adequate levels of provision, one public health centre for every 30 000 people on average.
If sub-centres are included, there is one public facility per 10 000 people. However, these averages conceal large variations in geographic accessibility, with people in remote interior or small island locations having particularly poor access. In addition to public facilities, private practices are operated by doctors, nurses and midwives, in many cases by the same personnel as are employed in public facilities. At the hospital level, Indonesia has low levels of bed provision at 62,5 beds per 100,000 population. Paradoxically, the utilization is also low, with bed occupancy rates in the vicinity of 56.2 % in both public and private facilities.
The private sector is increasingly important in the provision of health care in Indonesia, especially in big cities, with wide variations in quality of care. Furthermore, since there is no regulation of pricing or quality of service in place, users are vulnerable to excessive treatment and expenses.
The role of nongovernmental organizations (NGOs) in Indonesia has been growing during the last two decades but the exact number of NGOs providing health care services remains unknown.
While medicines to treat the vast majority of tuberculosis, malaria and HIV-AIDS cases exist, drugs are not reaching everyone due to limited affordability and availability as well as other factors. Despite the presence of a strong Drug Regulatory Authority, responsible for the registration of medicines as well as quality control and inspection, counterfeit drugs remain a big problem. The fight against counterfeit drugs is resource intensive and requires substantial cooperation of other sectors. At the same time, the use of traditional medicines (such as ‘jamu’) is popular and widespread in Indonesia. Yet procedures for quality control of traditional medicines are limited in scope, and difficult to implement, also because large numbers of small-scale manufacturers exist.