SP4PHC in Indonesia
SP4PHC is focused on improving purchasing through the national health insurance program in Indonesia, Jaminan Kesehatan Nasional (JKN), which covers over 80% of the population. Due to its escalating costs, there are growing concerns about the scheme’s long-term financial sustainability. Additionally, Indonesia has a high maternal mortality rate and family planning progress has stagnated. SP4PHC’s goal is to improve how JKN uses purchasing as a lever to increase access to and quality of family planning and maternal, neonatal, and child health services through the full range of public and private health providers. For more information, view our Indonesia overview presentation and one pager. To see how our SP4PHC team in Indonesia has helped its government respond to Covid-19, view our Covid-19 response page.
SP4PHC has four key strategies to strengthen primary health care access and quality in Indonesia.
Strategy 1: Strengthening the purchasing of maternal, newborn, and child health (MNCH) services
Indonesia suffers from stubbornly high maternal mortality. One contributing factor is that private midwives, a crucial source for delivering reproductive and MNCH services, largely operate outside of the country’s national health insurance (JKN) system. SP4PHC is collaborating with the Ministry of Health, Social Insurance Administering Body for Health (BPJS-K), and USAID Health Financing Activity to test policies that improve how quality MNCH services are purchased and to influence ongoing JKN reform decisions.
Strategy 2: Strengthening how district health offices purchase services from primary health care providers
Indonesia currently has multiple, fragmented channels for funding health services. Although decentralization gave districts greater autonomy over health programming and budgeting, they lack the capacity and guidance to manage these funds to maximize allocative efficiency. SP4PHC is collaborating with District Health Offices to understand the types of funds given to districts, what purchasing signals they are sending to facilities, and policy options needed to strengthen the public financial management capacity of District Health Offices.
Strategy 3: Improving how family planning services are purchased
Progress on increasing the modern contraceptive prevalence rate and total demand satisfied has stagnated in Indonesia. Specific challenges include both low utilization of family planning services throughout JKN and limited access to family planning commodities by private providers. SP4PHC is collaborating with Universitas Gadjah Mada to map the family planning funding flows and to develop policy recommendations for government stakeholders on increasing access to family planning through the private sector.
Strategy 4: Aligning purchasing in the time of Covid-19
The national government’s response to Covid-19 has implications for service delivery. Issues include how funding for routine essential services (family planning, MNCH, nutrition, and immunization) was impacted and how a lack of public financial management capacity at District Health Offices affected their ability to utilize health funds effectively. SP4PHC is collaborating with the Vice President’s Office, the Ministry of Health, and District Health Offices to identify opportunities to improve purchasing mechanisms, which will help the government respond to the current pandemic and prepare for future crises.
These three factsheets below serve as a reference and aim to visualize the latest data and trends on purchasing family planning, maternal & newborn health services, and a broader overview of purchasing in Indonesia. Each factsheet also highlights some of the activities the SP4PHC country team is working on with local stakeholders within that topic area. These factsheets are updated annually (latest in May 2021). Health Purchasing Factsheet Maternal, Newborn, and Child Health Factsheet Family Planning Factsheet
Upcoming & Latest Events
From September 21-24, 2021, the SP4PHC team in Indonesia will present four abstracts at the Indonesian Health Economics Association (InaHEA)’s seventh biennial scientific meeting in Bandung, Indonesia. This year’s meeting is entitled “Protecting People: Indonesia’s Lessons from the COVID-19 Pandemic, Health Economic Point of Views.” The abstracts include:
- How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia; presented by Nirwan Maulana, Senior Analyst at ThinkWell Indonesia.
- How is the disease that JKN “purchased” compatible with the Doctor’s Clinical Practice Guide at Primary Health Care; presented by Halimah Mardani, Senior Analyst at ThinkWell Indonesia.
- Assessing the readiness of Puskesmas in the completion of disease management; presented by ThinkWell partner Harimat Hendrawan, Researcher at the National Institute of Health Research and Development within the Ministry of Health.
- The effect of JKN coverage on paying OOP for family planning services in Indonesia; presented by Nadhila Adani, Data Analyst at ThinkWell Indonesia.
Stay tuned to learn more about the key takeaways.
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Indonesian maternal and neonatal mortality rates remain some of the highest in Southeast Asia. In a decentralized system, local government plays an important role in decreasing maternal and neonatal mortality. We aim to assess and compare district-level innovations that address maternal and neonatal mortality. This was a qualitative study conducted via four focus group discussions in eight selected districts in November 2021. Data obtained were analyzed using the WHO health system building blocks framework. We found high variation in districts’ innovations ranging from expansion of service for maternity waiting homes to periodical obstetrician visits at public primary health care centers. A majority of districts use a local approach as the basis for innovation. Some innovations are modifications of the national program or initiated purely by District Health Offices, public primary health care centers, and the community. Many interventions are based on multisectoral commitment, community participation, and targeting to strengthen health service delivery. Leadership and health financing also have an influence on the implementation of these innovations. The multitude of innovations reflects a high variation in barriers to reducing maternal and neonatal mortality that need to be addressed at the district level. A routine forum to share districts’ best practices is warranted. Additionally, family-based surveillance for neonatal danger signs, monitoring for pregnant women and neonates via WhatsApp, and zoning systems for referrals to health care facilities in larger districts are innovations identified in this study that have potential to be replicated in other districts or expanded nationally.
Minding the gap between utilization and coverage of maternal and newborn services in Indonesia
Indonesia’s Jaminan Kesehatan Nasional (JKN) aims to cover the entire population and prevent financial hardship in accessing healthcare. Including access to maternal and newborn health (MNH) services and family planning services at public and private primary health care and higher-level facilities. This brief, published in August 2022, examines the gap between utilization and coverage of MNH services in Indonesia, highlights the reasons for this gap, and provides recommendations for reducing the gap and improving coverage.
The Implementation of Family Planning Services in The Jaminan Kesehatan Nasional (JKN) Program
Family planning (FP) has been a part of the benefits package of the Indonesian national health insurance scheme (JKN) since its inception in 2014. Yet, it has not resulted in a significant increase in the modern contraceptive prevalence rate (mCPR), which has stagnated at around 57%. The team collaborated with the National Population and Family Planning Board (BKKBN) and the Ministry of Health to analyze JKN’s role in FP utilization across 12 districts. The resulting learning brief unearthed a series of challenges and provides recommendations at the national, district, and community levels across the domains of financing, regulation, socialization, and human resources. These recommendations are being used to inform ongoing government policy discussions on revising the JKN benefits package and engaging more private providers, who are popular sources of FP in Indonesia.
How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia
While the Government of Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out-of-pocket (OOP) for their health care. This journal article published in July 2022 in PLOS Global analyzes how JKN is influencing OOP payments, especially among the poor and rural, at the range of public and private PHC providers and hospitals across the country. While the results show that JKN has a protective effect, especially for the poor, it still needs better engage the private sector and increase investment in its supply-side readiness (especially in the East) to further reduce OOP payments and ensure effective, quality coverage.
The effect of national health insurance on out-of-pocket payments for family planning services in Indonesia
Although family planning (FP) services are included in the benefits package provided by the national health insurance, Jaminan Kesehatan Nasional (JKN), many Indonesian women still go to private providers who are often not contracted by JKN and charge them out-of-pocket to access FP services. A recent pre-print study aims to understand how JKN influences out-of-pocket payments for long- and short-acting contraceptives—especially those used among subsidized and unsubsidized JKN member groups—across all types of public and private providers. These findings hope to extend universal access to FP benefits in the country.
How JKN Coverage and Supply-side Readiness Influences Out-of-Pocket Payments Across Indonesia
This brief, published in January 2022, summarizes findings from a study on how Indonesia’s national health insurance coverage and the supply-side readiness of providers influence out-of-pocket payments, as well as how that relationship changes across the different provinces of Indonesia. In addition to reviewing the study findings, this brief also offers policy recommendations for how the Government of Indonesia can improve both its demand-side and supply-side financing to expand affordable access to high-quality health care across all its islands.
What can Bangladesh and Indonesia’s COVID-19 response teach us about the importance of public financial management?
In a new blog for P4H Global, ThinkWell’s teams in Bangladesh and Indonesia shine a spotlight on how upstream public financial management (PFM) obstacles restricted how front-line responders could respond to COVID-19. These insights draw from the experience of Bangladesh and Indonesia, where the authors have been working closely with their respective governments to identify and address some of these challenges.
Maintaining Essential Services During the Covid-19 Pandemic in Indonesia
Bringing Private Midwives into Indonesia’s National Health Insurance Scheme
ThinkWell and Universitas Gadjah Mada’s Center for Reproductive Health conducted a landscaping assessment to better understand why private midwives are not joining JKN. This report, published in July 2020, also has policy recommendations for JKN administrators to incentive private midwives to enroll in the scheme. Strategic purchasing techniques can then be used to improve quality of care, increase access of affordable services, and strengthen coordination within the service delivery system.
Brief describes five different models of technical assistance (TA) that ThinkWell Indonesia has provided to the country's government, provides real-world examples from ThinkWell's experience, and offers lessons from these models that can inform TA for other partners.