Transitioning Externally-funded Health
Programs in Indonesia : Critical Areas to
Ensure Program Sustainability
The World Bank
Presentation outline
2
Background on the demand for programmatic
sustainability and transition planning
The roles of external funding in Indonesia’s health
sector
Critical Areas of transition planning
Country context
Financial sustainability
Critical areas
LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLEINCOME HIGH INCOME
Total health spending per capita (left axis)
OOP spending share (right axis)
External spending share (right axis)
0 1 0 2 0 3 0 4 0 5 0 6 0 S h ar e o f t o ta l h e al th e xp en di tu re ( % ) 5 2 5 1 00 5 00 2 50 0 1 00 00 T ot al h ea lth e xp en di tu re p er c ap ita , U S
250 500 1000 2500 10000 35000 100000 GNI per capita, US$
Source: World Development Indicators database
Health financing transition
4
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Changes in eligibility for accessing donor funds
5
• Indonesia re-gained its lower middle-income status in 2003
• With sustained economic growth, it is likely to transition to upper middle-income
status within the next few years
• DAH initiatives have explicit eligibility and graduation clauses using recipient country incomes status
• GFATM determines eligibility based on a series of factors that include country income and disease burden
GNI per capita and poverty trends in Indonesia, 1995-2013
LOWER MIDDLE INCOME LOW INCOME LOWER MIDDLE INCOME IBRD
$1-a-day poverty (right axis) $2-a-day poverty (right axis)
Blend IBRD 0 20 40 60 80 10 0 S ha re o f po pu la tio n (% ) 15 00 20 00 25 00 30 00 35 00 G D P p e r ca pi ta , U S $
1993 1996 1999 2002 2005 2008 2011 2015
Year
Indonesia’s low dependence on EXTERNAL
FUNDING….
6
9/23/17
The share of external financing to total health spending has been consistently low for the past decade or so.
External funding for health for Indonesia External source as share of THE, 2014
Cambodia India Lao PDR Ghana Nigeria Philippines Vietnam Solomon Islands Papua New Guinea
Sri Lanka South Africa
Indonesia LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE
INCOME HIGH INCOME
Thailand China Rusia Malaysia Brazil 1 2 5 10 20 50 10 0 S ha re o f to ta l h ea lth e xp en di tu re ( % )
250 500 1000 2500 10000 35000 100000 GNI per capita, US$
Source: World Development Indicators database
0 5 10 15 S ha re o f to ta l h ea lth e xp en di tu re ( % )
1995 2000 2005 2010 2014
Year
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Rising program costs and resource gaps with new
commitment to access targets and growing
demand
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TB
- Continues to be one of the main
causes of premature deaths
- Current low coverage and multi
drug resistance are expected to increase future costs
HIV
- HIV epidemic is projected to
continue to grow
- The GoI has committed to
expand test and treat coverage by strengthening the continuum of care model (Layanan
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• The share of external funds varied across these programs but ranged
from 40-60% except for immunization program
• The share of domestic financing has been increasing for the past few
years
What are the roles of external financing
9
•
Not only financial support but also provide technical
assistance;
•
Filling in the gap for activities Gov’t budget has less
flexibility;
•
Pushing agenda forward: Accountability and good
governance, Health System Strengthening, QA
However, it could cause
•
Fragmentation of planning, financing flows, reporting,
monitoring, management of services and HR;
•
Unpredictability: disbursement is irregular and future
financial flows is uncertain
•
Conflict in prioritization
Context
Title of Presentation 10
China Malaysia Russia Thailand Philippines Ghana India Cambodia Lao PDR Vietnam Brazil South Africa
Sri LankaIndonesia
LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE
INCOME HIGH INCOME
1 2 5 1 0 1 5 2 0 S h ar e o f G D P ( % )
250 500 1000 2500 10000 35000 100000
GNI per capita, US$
Total health expenditure
Indonesia is
one of the lowest
levels
of health expenditure globally (3.6%
of GDP); An
outlier
compare to LMIC
(5.6% of GDP) and for East Asia &
Pacific region (5.1% of GDP)
Indonesia has started implementing
Jaminan Kesehatan Nasional
, JKN, a
Context
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However, health is financed by a combination of sources:
OOP
,
central
and
sub-national
government budgetary health
expenditures, and
SHI
.
Over half
of national government expenditures on health
now occur at the district level, up from less than an average
of less than 10% pre-decentralization
Intergovernmental fiscal
transfers
are large,
fragmented, and complex,
these transfers not to
Financial Sustainability
• Program funding needs are projected to increase due to epidemic growth as well as, new GoI commitments to reach global targets, such as
expansion of HIV test and treat, improve case finding and notification rate, introduction of new vaccines, etc.
• Mobilization of domestic resources, especially at sub national level,
continues to be challenging; sub national level expenditure information is scarce
• Fiscal Space for health: the requirement for
5% and 10% budget allocation for health sector, SDGs and other global commitment, rooms for improving efficiency in service delivery, and JKN
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…..but also service delivery preparedness, ensuring,
public health functions, organizational arrangement..
Integrating HIV services into JKN Basic
Programmatic sustainability
•
Supply side availability and readiness in general is weak and varied widely
and not necessarily link with epidemic profile; information at private sector
is limited
•
The involvement of Non-state providers is key to reach target population
groups (Key Affected Population in HIV, outreach in remote areas for
Malaria, TB),
•
Pharmaceuticals and Supply Chain Management : access to global price,
and distribution costs esp. to remote areas
•
Public Financial Management : planning and budgeting capacity, program
expenditure tracking
•
Monitoring & Evaluation : on the one hand improved capacity for disease
surveillance, but parallel reporting requirements complicate HMIS
Health Services Puskesmas
Private Clinics
Public Hospitals
Private Hospitals
HIV & AIDS Poor * Fair *
TB Fair Poor Poor Poor
Malaria Fair * Fair Fair
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Transition Challenges:
Financing and Programmatic Functions
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Lessons from the Avahan Transition
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Early planning and allocation of funds for transition
Continued alignments with government at each stage of
transition, including signing formal MoUs
Provision of technical and managerial support to build domestic
capacity, and institutionalization of support mechanisms
A phased approach to provide space for course correction
Provision of post-transitional support to maintain quality
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Lessons from USAID family planning transition
17
Systematic phase-out approach required
Need to work on NGO sustainability for a long time
Need technical criteria for phasing-out financing: income not
enough
Need institutionalization of policies
Need to build capacity in public sector for a long time
Until there is high use/prevalence/diffusion of an intervention
difficult to be sustainable
Don’t necessarily need to sustain what you have today
Behavior change at population level through diffusion (use of
products, avoiding risks, or health seeking behavior) may be
enough
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Lessons for Indonesia: Sustainability and
Transitioning of Key Health Programs
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Understanding underlying health needs of the population (course
of epidemic)
Estimating resource needs (funding gap) and fiscal space for
sustaining core health programs
Integration of external funded programs into a well functioning
health system to ensure sustainability and enhance health
outcomes
Understanding institutional capacity of the country to deliver
services
Develop a clear transition strategy or plan to ensure smooth
transition from external funded programs to domestically
