M H BPS St ti ti W ld H lth O i tiMoH, BPS Statistics, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE ASSESSMENT IN INDONESIA
11
ASSESSMENT IN INDONESIAresults and future use for benchmarking
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Why assess district health system performance Indonesia?Indonesia?
WHO Health System Performance Assessment WHO Health System Performance Assessment (HSPA) framework as template.(HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking (Possible uses for benchmarking (work in progresswork in progress).).
22
oss b e uses o be c a g (oss b e uses o be c a g ( o p og esso p og ess))
MoH, BPS, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking ((work in progresswork in progress).).
33
oss b e uses o be c a g (( o p og esso p og ess))
MoH, BPS, World Health Organization
Why Assess District Health SystemWhy Assess District Health SystemWhy Assess District Health System Why Assess District Health System Performance in Indonesia?Performance in Indonesia?
DecentralizationDecentralization in 2001 redefined role of central in 2001 redefined role of central MoH and districts: created new challenges visMoH and districts: created new challenges vis--àà--vis vis districtdistrict--centre information flowscentre information flows..
MoH currently in MoH currently in national health planning processnational health planning process..
Interest in what existing data can say about districtInterest in what existing data can say about districtInterest in what existing data can say about district Interest in what existing data can say about district performance and what the implications would be for performance and what the implications would be for district benchmarkingdistrict benchmarking..
Who is the Who is the target audiencetarget audience for results of health for results of health system performance assessment?system performance assessment?
44MoH, BPS, World Health Organization
Indonesia: General Background and Context
PostPost--crisis economic recoverycrisis economic recovery continues:continues:
Indonesia: General Background and Context
Country/RegionCountry/Region GNI per capita GNI per capita GDP growthGDP growth(PPP, 2002)(PPP, 2002) (1995(1995--2002)2002)
IndonesiaIndonesia $ 2,990$ 2,990 0.5%0.5%East Asia & PacificEast Asia & Pacific $ 4,160$ 4,160 5.4%5.4%
DecentralizationDecentralization: continuing boundary changes; Number : continuing boundary changes; Number of districts before decentralization: 292. After: 440.of districts before decentralization: 292. After: 440.
I t ti l fI t ti l f ill i d l t lill i d l t lInternational focus on International focus on millennium development goalsmillennium development goals(MDGs): large proportion are health(MDGs): large proportion are health--related indicators related indicators for MDGs (e.g., skilledfor MDGs (e.g., skilled--birth attendance, immunization, birth attendance, immunization, etc.).etc.).
55
etc.).etc.).
MoH, BPS, World Health Organization
Indonesia: Health System Background
National health goalsNational health goals, similar to those identified by WHO HSPA., similar to those identified by WHO HSPA.
and Context
National health goalsNational health goals, similar to those identified by WHO HSPA., similar to those identified by WHO HSPA.
Relatively Relatively lowlow health expenditure per capitahealth expenditure per capita
Relatively Relatively lowlow health expenditure as percent of GDPhealth expenditure as percent of GDPCountry Country Health expenditure Health expenditure Health percent of GDPHealth percent of GDP
(PPP, 2001)(PPP, 2001)BangladeshBangladesh $58$58 3.5%3.5%IndonesiaIndonesia $77$77 2.4%2.4%
$$IndiaIndia $ 80$ 80 5.1%5.1%VietnamVietnam $ 134$ 134 5.1%5.1%PhilippinesPhilippines $ 169$ 169 3.3%3.3%ThailandThailand $ 254$ 254 3.7%3.7%
OutOut--ofof--pocket (OOP) expenditure: 70%; 20% population “insured”.pocket (OOP) expenditure: 70%; 20% population “insured”.Variety of Variety of reformsreforms in last 10 years: to improve staff distribution, in last 10 years: to improve staff distribution, insurance coverage provider performance (quality) etcinsurance coverage provider performance (quality) etc
66
insurance coverage, provider performance (quality), etc.insurance coverage, provider performance (quality), etc.
MoH, BPS, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking ((work in progresswork in progress).).
77
oss b e uses o be c a g (( o p og esso p og ess))
MoH, BPS, World Health Organization
WHO Health System Performance
OO WHO HSPA d fi d h ll l f h l hWHO HSPA d fi d h ll l f h l h
Assessment (HSPA)
OutcomesOutcomes: WHO HSPA defined three overall goals of health : WHO HSPA defined three overall goals of health system:system:
Improving health (level and distribution).Improving health (level and distribution).Enhancing responsiveness to legitimate nonEnhancing responsiveness to legitimate non health expectationshealth expectationsEnhancing responsiveness to legitimate nonEnhancing responsiveness to legitimate non--health expectations health expectations of population (level and distribution).of population (level and distribution).Assuring financial risk protection.Assuring financial risk protection.
Health system efficiencyHealth system efficiency: WHO HSPA framework relates: WHO HSPA framework relatesHealth system efficiencyHealth system efficiency: WHO HSPA framework relates : WHO HSPA framework relates health system outcomes to resource inputs: the goal being to health system outcomes to resource inputs: the goal being to identify the maximum achievable outcomes relative to identify the maximum achievable outcomes relative to resource inputs. resource inputs.
Health system functionsHealth system functions: WHO HSPA framework relates : WHO HSPA framework relates variations in efficiency to differences in the way a health variations in efficiency to differences in the way a health system carries out its four core functions: system carries out its four core functions: provisionprovision, , financingfinancing, , resource generationresource generation, and , and stewardshipstewardship..
88
gg pp
MoH, BPS, World Health Organization
WHO HSPA Framework
Stewardship
FUNCTIONS THE SYSTEM PERFORMS GOALS / OUTCOMES OF THE SYSTEM
p(oversight) Responsiveness
(to people’s non medical
expectations)ResourceI
N Coverage
Health
p )developmentN
P
g
HealthService delivery(provision)
U
TFinancing
(collecting, pooling and purchasing)
Financial risk protection
S Provider Performance
99MoH, BPS, World Health Organization
Relating Inputs to Outcomes:
Maximum possible
g pMeasuring Efficiency
me
nt
Same output
CD
oa
l att
ain
m
Less efficientMore efficient
p
A B
Ove
rall
g
More inputs
1010MoH, BPS, World Health Organization
Inputs to overall goal
Wh A H lth S t P f ?
Monitor and evaluateMonitor and evaluate attainment of health systemattainment of health system
Why Assess Health System Performance?
Monitor and evaluateMonitor and evaluate attainment of health system attainment of health system outcomes outcomes –– and the efficiency of the health system and the efficiency of the health system –– in in a way that allows comparison over time and across a way that allows comparison over time and across systems. systems.
Build an evidence baseBuild an evidence base on the relationship between the on the relationship between the design and organization of the health system and design and organization of the health system and performance, e.g., identification of characteristics of a performance, e.g., identification of characteristics of a
llll f i h lth t (d t i t f h lthf i h lth t (d t i t f h lthwellwell--performing health system (determinants of health performing health system (determinants of health system performance).system performance).
Feedback into the policy debate.Feedback into the policy debate.
Empower publicEmpower public with information relevant to their wellwith information relevant to their well--being.being.
1111MoH, BPS, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking ((work in progresswork in progress).).
1212
oss b e uses o be c a g (( o p og esso p og ess))
MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
1313MoH, BPS, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking ((work in progresswork in progress).).
1414
oss b e uses o be c a g (( o p og esso p og ess))
MoH, BPS, World Health Organization
Health Information System: Indonesian Data Sources
CENSUS 2000.CENSUS 2000.SUSENAS and other household surveys.SUSENAS and other household surveys.MoH inventories: human resources; facilities.MoH inventories: human resources; facilities.National health accounts.National health accounts.Public health expenditure reviewPublic health expenditure reviewPublic health expenditure review.Public health expenditure review.Indonesia Human Development Report 2001, 2004.Indonesia Human Development Report 2001, 2004.
SystemSystem--wide perspective: used wide perspective: used populationpopulation--basedbased data where data where possible; possible; privateprivate-- and publicand public--sectorsector data where available.data where available.
1515MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
1616MoH, BPS, World Health Organization
DISTRICT VARIATIONS IN LIFE EXPECTANCY AT BIRTH, 2002
National Estimate: 66.3
Range: 58.8 – 72.5
1717
Below National Estimate
Above National Estimate
Kabupaten KotaProvincial Estimate
INDONESIA: Life Expectancy At Birth 2002
75h
(Yea
rs)
Provincial Estimate
National estimate
2010 Tar get
6570
ctan
cy a
t birt
h60
Life
Exp
ec
at an en ra ah ur at at ra lo a lu ku an at ur g g bi a eh u an ah ah ur ali
ra ta ta
Teng
gara
Bar
am
anta
n Se
lata
Ban
teM
aluk
u U
tar
ulaw
esi T
enga
engg
ara
Tim
ulim
anta
n Ba
raJa
wa
Bara
wes
i Ten
ggar
Gor
onta
lPa
puBe
ngku
lM
aluk
mat
era
Sela
taum
ater
a Ba
raJa
wa
Tim
uLa
mpu
nan
gka
Belitu
nJa
mb
umat
era
Uta
rD
I Ace Ria
ulaw
esi S
elat
aJa
wa
Teng
am
anta
n Te
nga
liman
tan
Tim
u BaSu
law
esi U
tar
DKI
Jak
art
DI Y
ogya
kart
Nus
a Te
Kalim Su
Nus
a Te Ka
Sula
w
Sum Su Ba Su Su
Kalim Ka
l S
Source: Recalculated from IHDR2004
1818
There are significant differences in average life expectancy across provinces;8 provinces exceed the Healthy Indonesia 2010 target of life expectancy of 67.9
Life Expectancy versus Income Deciles and Education Deciles
75 75
707
707
657
Life
exp
ecta
ncy
657
Life
exp
ecta
ncy
606
606
6
1 2 3 4 5 6 7 8 9 10
6
1 2 3 4 5 6 7 8 9 10Income deciles Education deciles
1919
Across districts there is a socio-economic gradient (as expected): on average, districts with higher income and education levels have higher life expectancy.
Life Expectancy and Health Service ProvisionLife Expectancy and Health Service Provision
After Controlling for Income and EducationLife Expectancy and Health Service Provision By District
No Control VariablesLife Expectancy and Health Service Provision By District
n Y
ears
)
After Controlling for Income and Education
n Y
ears
)
No Control Variables
Life
Exp
ecta
ncy
(in
Life
Exp
ecta
ncy
(in
Slope = 1.6 Slope = 1.1L
Health Service Provision IndexNote: The relationship is statistically signif icant
L
Health Service Provision IndexNote: The relationship is statistically significant
p p
From the figure above, districts with higher levels of health service provision appear to have higher life expectancy levels on an average.
The figure above suggests a linkage between health outcomes and health system factors, even after controlling for the effects of socio-economic
2020MoH, BPS, World Health Organization
e pecta cy e e s o a a e age a te co t o g o t e e ects o soc o eco o cfactors such as income and education.
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
2121MoH, BPS, World Health Organization
Catastrophic Expenditure
Reduce other basic expensesOut-of-pocket health
p p
It can mean thathouseholds expenses
Push some house-holds into povertyForgo health
expenditures defined as more than 40% of household non-subsistence spending
households
gservices and suffer illness
spending
% households % households % households
3.0
4.0
ds 6,000,000
8,000,000
3.0
4.0
ds 6,000,000
8,000,000
3.0
4.0
ds 6,000,000
8,000,000
% households with catastrophic
% householdsimpoverished
% householdsnot seeking care
0.0
1.0
2.0
1999 2000 2001
% H
ouse
hold
0
2,000,000
4,000,000
, ,
0.0
1.0
2.0
1999 2000 2001
% H
ouse
hold
0
2,000,000
4,000,000
, ,
0.0
1.0
2.0
1999 2000 2001
% H
ouse
hold
0
2,000,000
4,000,000
, ,
2222
1999 2000 2001 1999 2000 2001 1999 2000 2001
Catastrophic Expenditureym
ents Kabupaten Kota
Provincial Estimate
INDONESIA: Catastrophic Health Payments6
810
tast
hrop
ic Pa
y
National estimate
24
6f H
Hs
with
Cat
0Pr
opor
tion
o f
Uta
raPa
pua
enga
hBa
nten Ba
ligg
ara
Tim
urel
atan
Ria
uel
atan
elat
anBa
rat
Mal
uku
Bara
tJa
mbi
Uta
rael
itung
enga
hTi
mur
Uta
raBa
rat
Bara
tm
pung
akar
tang
kulu
akar
taTi
mur
enga
hon
talo
Mal
uku P
Kalim
anta
n Te B
Sula
wes
i Ten
gKa
liman
tan
Sum
ater
a S e
Kalim
anta
n Se
Sula
wes
i Se
Kalim
anta
n MJa
wa J
Sum
ater
a B
angk
a B e
Sul
awes
i Te
usa
Teng
gara
Su
law
esi
Sum
ater
a us
a Te
ngga
ra
Lam
DKI
Ja
Ben
DI Y
ogya
Jaw
a Ja
wa
T eG
oro
2323
Nu Nu
Source: Susenas 2001
Catastrophic ExpenditureIndicators for the ten provinces with lowest Indicators for the ten provinces with lowest
catastrophic expenditurescatastrophic expenditures
p p
Percent of households facing catastrophic expenditureby province
5
Combined life expectancyby province
72
2
3
4
5
Perc
ent
63
66
69
72
Year
s
National AverageNational Average
0
1
Mal
uku
Uta
ra
Papu
a
liman
tan
Teng
ah
Bant
en Bali
ulaw
esi
engg
ara
liman
tan
Tim
ur
umat
era
Sela
tan
Ria
u
liman
tan
Sela
tan
57
60
Mal
uku
Uta
ra
Papu
a
liman
tan
Teng
ah
Bant
en Bali
Sula
wes
ien
ggar
a
liman
tan
Tim
ur
umat
era
Sela
tan
Ria
u
liman
tan
Sela
tan
Kal T S T e Kal T Su S
Kal S Ka
T S Te KaT S S
KaS
• The ten provinces with lowest levels of catastrophic expenditures have been presented here• Only four of the provinces that perform well on catastrophic expenditure have higher than average life
t hil i i h lif t i id bl b l th ti l
2424
expectancy, while six provinces have life expectancies considerably below the national average• This means that catastrophic expenditures cannot be looked at (as an outcome) in isolation – thereby having implications for benchmarking
Catastrophic Expenditurep p
Predicted effects of changes in poverty, health
PP If i d b 1% If i d b 1% 27 00027 000
insurance, and levels of household health spending, on catastrophic expenditure (2001):
Poverty.Poverty. If poverty increased by 1%, If poverty increased by 1%, 27,00027,000 more more people would face catastrophic expenditures.people would face catastrophic expenditures.
InsuranceInsurance If insurance coverage increased by If insurance coverage increased by Insurance.Insurance. If insurance coverage increased by If insurance coverage increased by 1%, 1%, 83,00083,000 more people would be protected from more people would be protected from catastrophic expenditurescatastrophic expenditures
Health Spending.Health Spending. If households spent 1% more If households spent 1% more of their budget on health, of their budget on health, 1.5 million1.5 million more more people would face catastrophic expenditurespeople would face catastrophic expenditures
2525
people would face catastrophic expenditurespeople would face catastrophic expenditures
MoH, BPS, World Health Organization
Catastrophic ExpenditureFactors that protect or increase risk of catastrophic spending
Risk of facing catastrophic expenditure
Factors that protect or increase risk of catastrophic spending
g p p
-34%
-29%
-100% -50% 0% 50% 100% 150% 200% 250% 300% 350%Increase riskProtect
Company
Others
-3%
-10%
-19%
-27%
MaleEdu
UrbanAskes/JamsostekCompany
12%
-1%3%
20%22%
MaleHhsize
Health cardJPKM
Exppc 22%
33%43%
98%154%
Health fund
Senior memberChild
Exppc
2626
154%
305%Use public
Use private
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
2727MoH, BPS, World Health Organization
Health System ResponsivenessNational Level Results
Evaluation of health systems responsiveness by users
h th
e Ambulatory Inpatient
20
25
30d
expe
rienc
e w
ithce
: MC
SS
200
0)
5
10
15
sers
repo
rting
ba
th s
yste
m (S
our c
0
Prom
ptAt
tent
ion
Dig
nity
Com
mun
icat
ion
Auto
nom
y
Con
fiden
tiality
Cho
ice
Basi
cAm
enitie
s
Acce
ss to
supp
ort
Perc
ent o
f us
heal
• Basic amenities in health facilities, choice of health care provider, and patient autonomy in decision making appear to be the three main concerns when considering the quality of health services in Indonesia• Timely attention is a bigger problem in ambulatory health services than in inpatient care
C C
2828
• Choice and dignity are significantly larger concerns in inpatient care than in ambulatory services
MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
2929MoH, BPS, World Health Organization
D t V i ti b P iDoctors: Variation by ProvinceDoctors per 100,000 population By Province �
50
60
70
80 Doctors per 10(Source: M
O
Province DI Yogyakarta
2010 National Target
10
20
30
40
50 00,000 populationH
Inventory, 2001)
2010 National Target
0
Below National Average
Above National Average
• National average: 15.5 doctors per 100,000 population.• Provincial variation: 7.0 (Maluku) - 70.8 (DKI Jakarta).
3030
• Doctors form 7% of the total health system workforce, and 15% of all health professionals in Indonesia.
Doctors: Variation by Province and District
Variation across districts and provincesINDONESIA: Doctors per 100000 population
300
pula
tion
Kabupaten KotaProvincial Average
100
200
per 1
0000
0 po
p
N ati onal Average2010 Tar get
0D
octo
rs p
aluk
uU
tara
Bara
tpu
ngTi
mur
ntal
oBa
rat
ante
nap
uagk
ulu
ngah
Aceh
Bara
ttu
ngat
anTi
mur
Ria
uam
biat
anga
rang
ahng
ahBa
rat
atan
Uta
raTi
mur
Uta
ra Bali
karta
karta
Ma
Mal
uku
Usa
Ten
ggar
a B
Lam
psa
Ten
ggar
a Ti
Gor
onKa
liman
tan
BB
a PaBe
ngKa
liman
tan
Ten
DI A
Jaw
a B
Bang
ka B
elit
Kalim
anta
n Se
lJa
wa
Ti R JaSu
mat
era
Sel
Sula
wes
i Ten
ggJa
wa
Ten
Sula
wes
i Ten
Sum
ater
a B
Sula
wes
i Sel
Sum
ater
a U
Kalim
anta
n T
Sula
wes
i U
DI Y
ogya
kD
KI J
ak
3131
Nus
Nus K K S
Source: MOH Inventory 2001
DISTRICT VARIATION IN DOCTORS PER 100,000 POPULATION
Source MOH Inventory 2001Source MOH Inventory 2001
National Average: 15 5National Average: 15.5
Range: 1.6 – 285.9
3232
Below National Average (15.5)
Above National Average (15.5)
Missing Data
Doctors: Public vs. PrivateDoctors: Public vs. Private
Distribution of doctors by sectorS MOH I t 2001
Doctors per 100,000 populationBy Sector and Province
Public (Government + Military) Private & State Owned Corp.
Source: MOH Inventory 2001
27%
Government
Military40
50
60
70
80
Doctors per 100,00(S
ource: MO
H Inve
69%
4%
Military
Private & State Owned Corp.
0
10
20
30
00 populationentory, 2001)
• 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
3333
• 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.
Midwives: Variation by ProvinceMidwives: Variation by ProvinceMidwives per 100,000 populationBy Province �
2010 National Target
60
80
100
120 Midw
ives per 10(Source: M
OH
2010 National Target
Province Jawa Tengah
0
20
40
60
00,000 population Inventory, 2001)
Below National Average
Above National Average
• National average: 32.3 midwives per 100,000 population• Provincial variation: 17.5 (Maluku) - 102.6 (DI Aceh)• Midwives form 13% of the total health workforce and 28% of all health professionals in Indonesia
3434
p
Midwives: Variation by Province and Districts
Kabupaten Kota
Variation across districts and provincesINDONESIA: Midwives per 100000 population
2010 National Target
200
250
popu
latio
n
Provincial Average
2010 Tar get
100
150
2pe
r 100
000
p
N ati onal Average
050
Mid
wive
s
uku
nten arat
talo
mur
arat
arta
ung
atan ara
gah
arta
ung
arat
Ria
uat
an mur Bali
mbi
gara
mur ara
ara
arat
pua
gah
atan gah
kulu
ceh
Mal
uBa
nJa
wa
BaG
oron
tJa
wa
Tim
Teng
gara
Ba
DKI
Jak
aLa
mpu
Sula
wes
i Sel
aSu
law
esi U
tJa
wa
Ten g
DI Y
ogya
kaBa
ngka
Bel
ituKa
liman
tan
Ba R
umat
era
Sela
Teng
gara
Tim B
Jam
law
esi T
engg
Kalim
anta
n Ti
mSu
mat
era
Ut
Mal
uku
Ut
Sum
ater
a B a Pa
pim
anta
n Te
ngim
anta
n Se
laSu
law
esi T
eng
Beng
kD
I Ac
3535
Nus
a S K Su
Nus
a Sul K S
Kali
Kal S
Source: MOH Inventory 2001
DISTRICT VARIATION IN MIDWIVES PER 100,000 POPULATION
Source MOH Inventory 2001Source MOH Inventory 2001
National Average: 32 2National Average: 32.2
Range: 2.1 – 233
Below National Average (32 2) Missing Data
3636
Below National Average (32.2)
Above National Average (32.2)
Missing Data
Human Resources and Coverage
Skilled Birth Attendance and MidwivesSource: MOH Inventory 2001, Susenas 2001
Skilled Birth Attendance and Physicians, Nurses and Midwives Source: MOH Inventory 2001, Susenas 2001
40
5060
7080
Dis
tric
ts
Below 80% Coverage 5060708090
Dis
tric
ts
Below 80% Coverage
010
203040
Less than 18 18 - 30 31 - 51 52+
Num
ber o
f
Above 80% Coverage
010203040
Less than 58 58 - 96 97 - 179 180+
Num
ber o
f
Above 80% Coverage
Less than 18 18 30 31 51 52
Midwives per 100,000 population Physicians, Nurses, and Midwives per 100,000
• A higher concentration of midwives increases the likelihood for a district to achieve greater than 80% skilled birth attendance (MDG target)attendance (MDG target)
• However, the relationship is not very clear for the highest category of midwives – the number of districts achieving more than 80% coverage is less for the highest category (52+) than for the second highest (31 – 51)
• Though when we include physicians and nurses together with midwives the relationship between higher coverage and higher concentration of human resources is stronger
3737
g g
MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
3838MoH, BPS, World Health Organization
Hospital Beds: Variation by Province
Hospital Beds per 100,000 populationBy Province
Ho
Province Kalimantan Timur
6080100120140160180
ospital Beds per 100
(Source: M
OH
Inve
0204060 ,000 population
ntory, 2001)
Below National Average
Above National Average
• National average: 62 hospital beds per 100,000 population• Provincial variation: 26 (Lampung) to 166 (DKI Jakarta)
3939
Provincial variation: 26 (Lampung) to 166 (DKI Jakarta)
MoH, BPS, World Health Organization
DISTRICT VARIATION IN HOSPITAL BEDS PER 100,000 POPULATION
Source MOH Inventory 2001Source MOH Inventory 2001
National Average: 62 6National Average: 62.6
Range: 0 - 1046
Below National Average (62 6) Missing Data
4040
Below National Average (62.6)
Above National Average (62.6)
Missing Data
Hospital Beds: Public vs. Private
Distribution of hospital beds by sector
Hospital Beds per 100,000 populationOwnership by Province
180 (S
Public (Including Military) Private & Corporate
Distribution of hospital beds by sectorSource: MOH Inventory 2001
37%
54%
Government
Military 60
80
100
120
140
160
Hospital B
eds per S
ource: MO
H Invento
9%
Military
Private & State Owned Corp.
0
20
40
60 100,000ory, 2001)
• 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
4141
the private sector
MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 FrameworkWHO HSPA 2000 Framework Indonesia ApplicationIndonesia Application
ScopeScope International/NationalInternational/National DistrictDistrict--levellevel
OutcomesOutcomes HALEHALE Life expectancyLife expectancyFinancial risk protectionFinancial risk protection Catastrophic expenditureCatastrophic expenditureResponsivenessResponsiveness [Responsiveness][Responsiveness]ResponsivenessResponsiveness [Responsiveness][Responsiveness]
InputsInputs Health expenditureHealth expenditure Human resourcesHuman resourcesEducationEducation FacilitiesFacilities
IncomeIncomeF l d tiF l d tiFemale educationFemale educationAccessAccessOOP expenditure
Intermediate Outcomes Intermediate Outcomes Coverage indicatorsCoverage indicators Coverage indicatorsgg gProvider performanceProvider performance UtilizationUtilization
Risk FactorsRisk Factors SmokingSmoking
4242MoH, BPS, World Health Organization
Coverage: Iodized Salt
(%) Kabupaten Kota
Provincial Average
Variation across districts and provincesINDONESIA: Iodized salt content (%)
N ati onal Average
080
100
ate
iodi
ne in
sal
t Provincial Average
020
4060
lds
with
ade
qua
0H
ouse
hol
ggar
a Ba
rat
ggar
a Ti
mur Bali
wes
i Sel
atan
Bant
enD
KI J
akar
taaw
a Te
ngah
Jaw
a Ba
rat
si Te
ngga
raJa
wa
Tim
urYo
gyak
arta
anta
n Ba
rat
Lam
pung
Ria
uat
era
Uta
raw
esi T
enga
her
a Se
lata
nat
era
Bara
tPa
pua
gka
Belitu
ngJa
mbi
tan
Sela
tan
anta
n Ti
mur
Gor
onta
lota
n Te
ngah
awes
i Uta
raBe
ngku
lu
Nus
a Te
ngN
usa
Teng
Sula
w DJa
Sula
wes J
DI Y
Kalim
a
Sum
aSu
law
Sum
ate
Sum
Ban g
Kalim
anKa
lima
Kalim
an Sul
a
Source: Iodized Salt Survey 2001
4343MoH, BPS, World Health Organization
DISTRICT VARIATION IN ADEQUATE IODIZED SALT CONTENT
Source Iodized Salt Survey 2001
National Average: 64.3%National Average: 64.3%
Range: 8.5 – 100%
Below National Average Missing Data
4444
Above National Average
Coverage: Skilled Birth Attendance
Kabupaten KotaProvincial Average
Variation across districts and provincesINDONESIA: Skilled birth attendance
N ati onal Average
2010 T ar get
8010
0nd
ance
(%)
Provincial Average
N ati onal Average
2040
60Sk
illed
birth
atte
nS
gara
Tim
ursi
Teng
gara
ggar
a B
arat
aluk
u U
tara
anta
n Ba
rat
Gor
onta
loJa
wa
Bara
tw
esi T
enga
hw
esi S
elat
anPa
pua
Mal
uku
Bant
enJa
mbi
tan
Sela
tan
Lam
pung
wa
Teng
ahta
n Te
ngah
ka B
elitu
ngJa
wa
Tim
urBe
ngku
luer
a Se
lata
nR
iau
anta
n Ti
mur
ater
a Ba
rat
Yogy
akar
taat
era
Uta
raaw
esi U
tara Bali
DKI
Jak
arta
Nus
a Te
ngSu
law
esN
usa
Teng M
aKa
lima J
Sula
wSu
law
Kal
iman
t
Jaw
Kalim
ant
Bang
J
Sum
ate
Kalim
aSu
ma
DI Y
Sum
aSu
la D
Source: Susenas 2001
4545MoH, BPS, World Health Organization
Source: Susenas 2001
DISTRICT VARIATION IN SKILLED BIRTH ATTENDANCEATTENDANCESource Susenas 2001
National Average: 65.8%
Range: 16.5 – 100%
4646
Below National Average
Above National Average
Missing Data
Coverage: Immunization
Kabupaten KotaProvincial Average
Variation across districts and provincesINDONESIA: Complete immunization
2010 Tar get
6080
100
niza
tion
(%)
g
N ati onal Average
020
406
Com
plet
e im
mun
0C
ater
a U
tara
DI A
ceh
ggar
a Ba
rat
Jaw
a Ba
rat
Jam
bi
ater
a Ba
rat
Ria
uan
tan
Bara
tw
esi S
elat
anta
n Se
lata
nD
KI J
akar
ta
Papu
aM
aluk
uer
a Se
lata
nBe
ngku
luta
n Te
ngah
Lam
pung
Jaw
a Ti
mur
si T
engg
ara
awa
Teng
ahw
esi T
enga
hgg
ara
Tim
uran
tan
Tim
ur
awes
i Uta
ra Bali
Yogy
akar
ta
Sum
a
Nus
a Te
ngJ
Sum
Kalim
aSu
law
Kalim
ant D
Sum
ate
Kalim
anat J
Sula
wes Ja
Sula
wN
usa
Teng
Kalim
a
Sula
DI Y
Source: Susenas 1999
4747MoH, BPS, World Health Organization
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccessOOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsg gProvider performance Utilization
Risk Factors Smoking
4848MoH, BPS, World Health Organization
Ambulatory Utilization Based On NeedINDONESIA: Ambulatory care utilization (%)
ed (%
) Kabupaten KotaProvincial Average
Variation across districts and provincesINDONESIA: Ambulatory care utilization (%)
N ati onal Average
4060
80on
bas
ed o
n ne
e0
20bu
lato
ry u
tiliza
tio
u h a u n n at at bi g n h a n o a at a u a r ur h at at a g a li
Amb
Mal
uku
Sula
wes
i Ten
gah
law
esi T
engg
ara
Ria
uim
anta
n Se
lata
nSu
law
esi S
elat
anKa
liman
tan
Bara
Kalim
anta
n Ba
raJa
mb
Lam
pung
umat
era
Sela
tan
iman
tan
Teng
ahSu
law
esi U
tara
Ban
ten
Gor
onta
loM
aluk
u U
tara
Jaw
a Ba
raD
KI J
akar
taBe
ngku
luSu
mat
era
Uta
raJa
wa
Tim
uTe
ngga
ra T
imu
Jaw
a Te
ngah
Sum
ater
a Ba
raTe
ngga
ra B
ara
Papu
aBa
ngka
Bel
itung
DI Y
ogya
karta Ba
SSu
l
Kal S K K Su Kal S
Nus
a
Nus
a B
Source: Susenas 2001
4949
From the analysis of SUSENAS 2001, Bali province has the highest ambulatory utilization, 65.8%. Maluku has the lowest with 20.4% of visits. There are 12 provinces out of 29 provinces above the national average, 50.3%.
DISTRICT VARIATION IN AMBULATORY UTILIZATIONSource: Susenas 2001
National Average: 50.3%
Range: 16.5 – 100%
5050
Below National Average
Above National Average
Missing Data
Adaptation of WHO HSPA for Indonesia
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Outcomes HALE Life expectancyFinancial risk protection Catastrophic expenditureResponsiveness [Responsiveness]Responsiveness [Responsiveness]
Inputs Health expenditure Human resourcesEducation Facilities
IncomeF l d tiFemale educationAccess OOP expenditure
Intermediate Outcomes Coverage indicators Coverage indicatorsProvider performance Utilization
Risk Factors Smoking
5151MoH, BPS, World Health Organization
Risk Factor: Smokingve
ry d
ay Kabupaten KotaProvincial Estimate
INDONESIA: Smoking Prevalence 2003
National estimate
2030
who
sm
oke
ev10
2op
ulat
ion
10+
0ro
porti
on o
f Po
Tim
ur Bali
Mal
uku
Uta
raPa
pua
elat
anak
arta
Ace
hon
talo
Tim
urel
atan
akar
taU
tara
ggar
aen
gah
enga
hBa
rat
Uta
rael
atan
Jam
bien
gah
Tim
urBa
nten
Bara
tm
pung
elitu
ngBa
rat
Bara
tR
iau
ngku
lu
Pr
usa
Teng
gara
MM
aluk
u PKa
liman
tan
SeD
I Yog
ya DI
Gor
oK
alim
anta
n Su
law
esi S
eD
KI J
aSu
mat
era
Sula
wes
i Ten
gKa
liman
tan
TeJa
wa
TeK
alim
anta
n Su
law
esi
Sum
ater
a S e J
Sula
wes
i Te
Jaw
a Bus
a Te
ngga
ra
Lam
Bang
ka B
eSu
mat
era
Jaw
a
Ben
5252
Nu Nu
Source: Susenas 2003
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking ((work in progresswork in progress).).
5353
oss b e uses o be c a g (( o p og esso p og ess))
MoH, BPS, World Health Organization
Inputs vs. Outcomes: Measuring Efficiency
2
WHO HSPA: Outcomes vs. inputs across countries
Inputs vs. Outcomes: Measuring Efficiency
01
dex
BahamasOman
-2-1
Out
put i
nd-3
-
-2 0 2 4Input index
WHO HSPA: Relating outcomes to inputs across countries. Some countries achieve relatively high health outcomes even
ith l ti l l i t l l ( O B h )
p
5454
with relatively low input levels (e.g., Oman vs. Bahamas).
MoH, BPS, World Health Organization
Inputs vs. Outcomes: Measuring EfficiencyVery Preliminary Findings
Indonesia HSPA: Outcomes vs. inputs across districts
Very Preliminary Findings
24
Magelang (Jawa Tengah)Kulon Progo (DI Yogyakarta)
INPUT INDEX• Permanent Income
• Female Education
OUTPUT INDEX• Complete Immunization
• Skilled Birth Attendance
20
Out
put i
ndex
• Female Education
• Nurses per 100,000
• Out-of-pocket expenditure
• Access to health facilities
• Skilled Birth Attendance
• Iodized Salt Content
• Catastrophic Expenditure
• Life Expectancy
-4-
-4 -2 0 2 4 6
Indonesia HSPA: Relating outcomes to inputs across districts. Some districts have achieve relatively high health system outcomes
ith l ti l l i t l l U f l f b h ki
4 2 0 2 4 6Input index
5555
even with relatively low input levels. Useful for benchmarking.
MoH, BPS, World Health Organization
Inputs vs. Outcomes: Measuring EfficiencyVery Preliminary Findings
4
Indonesia HSPA: Outcomes vs. inputs across districts
Madiun (Jawa Timur)
Very Preliminary Findings
2de
x
W onogiri (Jawa Tengah)
Kulon Progo (DI Yogyakarta)
Soppeng (Sulawesi Selatan)
Madiun (Jawa Timur)Blitar (Jawa Timur)
-20
Out
put i
n d
J i J (P )
Manokwari (Papua)
-4
-4 -2 0 2 4 6
Jayawi Jaya (Papua)
Input index
Indonesia HSPA: This shows one way to characterize the “frontier”. The frontier reflects the maximum achievable outcomes for given input l l Di tri t n r l t th fr nti r r r l ti l high p rf rm r
5656
levels. Districts on – or close to – the frontier are relatively high performers.
MoH, BPS, World Health Organization
Inputs vs. Outcomes: Measuring EfficiencyVery Preliminary Findings
4
Deciles of input index
Very Preliminary Findings
2pu
t ind
ex-2
0D
istri
butio
n of
out
p-4
1 2 3 4 5 6 7 8 9 10
Indonesia HSPA: This is another way to see the relationship between inputand outputs: the x-axis shows deciles of inputs; the y-axis shows the distributionof outputs within each input decile. As can be seen, there is a positive gradientwith diminishing returns
5757
with diminishing returns.
MoH, BPS, World Health Organization
DISTRICT HEALTH SYSTEM PERFORMANCE S C S S O CASSESSMENT IN INDONESIA:
results and future use for benchmarking
Why assess district health system performance Indonesia?
WHO Health System Performance Assessment (HSPA) framework as template.
Adaptation of WHO HSPA framework to Indonesia.
Results for Indonesia HSPA.
Relating inputs to outcomes: measuring efficiency.
Possible uses for benchmarking (work in progress).
5858
oss b e uses o be c a g ( o p og ess)
MoH, BPS, World Health Organization
Implications for BenchmarkingImplications for Benchmarking
HSPA framework can be used for setting benchmarks.HSPA framework can be used for setting benchmarks.
Benchmarks for input indicators could be in terms of targets for Benchmarks for input indicators could be in terms of targets for h lth k h lth f iliti d ti l tt i t th lth k h lth f iliti d ti l tt i t thealth workers, health facilities, educational attainment, etc.health workers, health facilities, educational attainment, etc.
Benchmarks may be defined in terms of attainment of health Benchmarks may be defined in terms of attainment of health system outcomes (e g attainment of life expectancy ofsystem outcomes (e g attainment of life expectancy of xxsystem outcomes (e.g., attainment of life expectancy of system outcomes (e.g., attainment of life expectancy of xxyears).years).
Benchmarks for outcomes could be based on attainment of Benchmarks for outcomes could be based on attainment of b tb t f i di t i t t diff t i t l lf i di t i t t diff t i t l lbestbest--performing districts at different input levels.performing districts at different input levels.
5959MoH, BPS, World Health Organization
Implications for BenchmarkingOther examples of benchmarking frameworks.Other examples of benchmarking frameworks.
Implications for Benchmarking
UN Millennium Development Goals (MDGs)UN Millennium Development Goals (MDGs)::TargetTarget IndicatorsIndicators
Reduce byReduce by twotwo--thirdsthirds UnderUnder--5 mortality rate5 mortality rateReduce by Reduce by twotwo thirdsthirds UnderUnder 5 mortality rate5 mortality rateunderunder--5 mortality rate 5 mortality rate Infant mortality rateInfant mortality rate(1990(1990--2015)2015) Proportion of 1Proportion of 1--year old year old
children immunized against children immunized against measlesmeasles
Reduce by Reduce by threethree--quartersquarters Maternal mortality ratioMaternal mortality ratiothe maternalthe maternal--mortality ratiomortality ratio Proportion of birthsProportion of births(1990(1990--2015)2015) attended by skilled attended by skilled
personnelpersonnel
UNDP Human Development Index (HDI)UNDP Human Development Index (HDI): Composite : Composite index of health, education, and income. No specific index of health, education, and income. No specific targets; can be used to monitor improvements over targets; can be used to monitor improvements over time.time.
6060
time.time.
MoH, BPS, World Health Organization
Implications for Benchmarking
Other examples of benchmarking frameworks.Other examples of benchmarking frameworks.
Implications for Benchmarking
gg
Healthy Indonesia 2010 and Minimum Service StandardsHealthy Indonesia 2010 and Minimum Service Standards::IndicatorsIndicators TargetTarget
Percent coverage of births attended Percent coverage of births attended by trained staffby trained staff 90%90%Percent of contraceptive usersPercent of contraceptive users 70%70%P t f ill ith i l hildP t f ill ith i l hildPercent of villages with universal child Percent of villages with universal child immunizationimmunization 100%100%Percent coverage for Percent coverage for puskesmaspuskesmas visits (HI2010) /visits (HI2010) /
Percent coverage of outpatient visitsPercent coverage of outpatient visits (MSS)(MSS) 15%15%g pg p ( )( )Percent of subPercent of sub--districts free of severe districts free of severe malnutritionmalnutrition 80%80%
6161MoH, BPS, World Health Organization
Panel Discussion:Panel Discussion: How to Choose Benchmarks?
What indicators should be chosen?What indicators should be chosen?
How should targets be set for the chosenHow should targets be set for the chosenHow should targets be set for the chosen How should targets be set for the chosen indicators?indicators?
Is measurement of chosen indicator feasible? Is Is measurement of chosen indicator feasible? Is it valid and reliable?it valid and reliable?
Can the indicator be measured reliably over Can the indicator be measured reliably over time?time?time?time?
6262MoH, BPS, World Health Organization
Panel Discussion:Panel Discussion: How to Choose Benchmarks?
A h i di liA h i di li i ?i ?Are the indicators policyAre the indicators policy--reactive?reactive?
Should benchmarks be chosen for input as well Should benchmarks be chosen for input as well as outcome indicators?as outcome indicators?as outcome indicators?as outcome indicators?
Are districtAre district--representative data available for the representative data available for the chosen indicators?chosen indicators?chosen indicators?chosen indicators?
What are the implications for future survey What are the implications for future survey design?design?
Are resources available for data collection? Are resources available for data collection? Statistical capacity for analysis?Statistical capacity for analysis?
6363MoH, BPS, World Health Organization
Panel Discussion:Panel Discussion: How to Choose Benchmarks?
How to deal with problems relating to data How to deal with problems relating to data quality and measurement error?quality and measurement error?
Sh ld th b b h k fSh ld th b b h k f h lthh lthShould there be benchmarks for nonShould there be benchmarks for non--health health related aspects of health system, e.g., related aspects of health system, e.g., responsiveness, patient satisfaction, waiting responsiveness, patient satisfaction, waiting time etc ?time etc ?time, etc.?time, etc.?
Benchmarks related to quality of care? Medical Benchmarks related to quality of care? Medical error rates? Compliance with protocols?error rates? Compliance with protocols?error rates? Compliance with protocols?error rates? Compliance with protocols?
How many indicators? What is the marginal How many indicators? What is the marginal information content of an indicator?information content of an indicator?
6464MoH, BPS, World Health Organization
Key MessagesKey Messages
Various frameworks for benchmarking, including Various frameworks for benchmarking, including WHO HSPAWHO HSPA
Benchmarks may include input, output, Benchmarks may include input, output, outcome non healthoutcome non health related aspects of healthrelated aspects of healthoutcome, non healthoutcome, non health--related aspects of health related aspects of health system, quality of caresystem, quality of care
Input vs Output: Measure EfficiencyInput vs Output: Measure EfficiencyInput vs Output: Measure EfficiencyInput vs Output: Measure Efficiency
Indicators selection and target settingIndicators selection and target setting
Problems related to data availability and qualityProblems related to data availability and qualityProblems related to data availability and quality Problems related to data availability and quality (HIS)(HIS)
6565MoH, BPS, World Health Organization
THANK YOUTHANK YOU
6666
Top Related