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___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
SUB NATIONAL HEALTH SYSTEM PERFORMANCE
ASSESSMENT (Indonesia Experience)
National Institute of Health Research and Development
In Collaboration with
World Health OrganizationBPS Statistics Indonesia
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
DecentralizationDecentralization in 2001 redefined role of central in 2001 redefined role of central MoH and districts: created new challenges vis-à-vis MoH and districts: created new challenges vis-à-vis district-centre information flowsdistrict-centre information flows..
National health goalsNational health goals, similar to those identified by , similar to those identified by WHO HSPA.WHO HSPA.
Variety of Variety of reformsreforms in last 10 years: to improve staff in last 10 years: to improve staff distribution, insurance coverage, provider distribution, insurance coverage, provider performance (quality), etc.performance (quality), etc.
Interest 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..
Why Assess District Health System Performance in Indonesia?
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
FUNCTIONS GOALS / OUTCOMES
WHO HSPA FrameworkGoals and functions of the health system
HEALTHHEALTH
Responsive-ness
Responsive-ness
Fair Financial
Contribution
Fair Financial
Contribution
Service Proviision
Service Proviision
Resources Generatio
n
Resources Generatio
n
Stewardship
(Oversight)
Stewardship
(Oversight)
Financing (Collecting, Pooling and Purchasing)
Financing (Collecting, Pooling and Purchasing)
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
WHO HSPA 2000 Framework Indonesia Application
Scope International/National District-level
Goals/Outcomes HALE Life expectancy Fairness in Financial Catastrophic expenditure
contribution Responsiveness Responsiveness
Risk Factors SmokingAccess to safe water
Intermediate Coverage indicators Coverage indicatorsOutputs Provider performance Utilization
Inputs Health expenditure Human resources Education Facilities
IncomeFemale education
Adaptation of WHO HSPA for Indonesia
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Population based:Population based: CENSUS 2000.CENSUS 2000. Household surveys (Susenas and other Household surveys (Susenas and other
household surveys).household surveys).Health service based:Health service based: MoH inventories: human resources; facilities.MoH inventories: human resources; facilities. National health accounts.National health accounts. Public health expenditure review.Public health expenditure review.Studies:Studies: Indonesia Human Development Report 2001,04 Indonesia Human Development Report 2001,04
Health Information System: Indonesian Data Sources
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Indonesia Sub-National HSPA ReportPart I: Intro/Background
III: Risk Factors and Health Services Provision
• Risk Factors• Coverage and health services utilization
IV: Health system resources• Human resources• Health facilities
V: Health system performance• Health system efficiency
VI: Conclusions
II: Health and Health System Goal• Health conditions• Financial protection• Responsiveness of the health system
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Below National Estimate
Above National Estimate
National Estimate: 66.2
Range: 57.5 – 73.7
DISTRICT VARIATIONS IN LIFE EXPECTANCY AT BIRTH
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
There are significant differences in average life expectancy across provinces; 8 provinces exceed the Healthy Indonesia 2010 target of life expectancy of 67.9
DISTRICT VARIATION OF LIFE EXPECTANCY WITHIN PROVINCE
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Percentage of Households with catastrophic health payments by province
0% 2% 4% 6% 8% 10%
Papua
M aluku Utara
Kalimantan Tengah
Banten
Sulawesi Tenggara
Bali
Riau
Kalimatan Timur
Sumatera Seltan
Kalimantan Selatanan
Kalimantan Barat
Sulawesi Selatan
M aluku
DKI J akarta
J ambi
Sumatera Utara
Bangka Belitung
Sulawesi Tengah
Nusa Tenggara Timur
Sumatera Barat
Sulawesi Utara
Nusa Tenggara Barat
Lampung
Bengkulu
DI Y ogyakarta
J awa Barat
J awa Timur
J awa Tengah
Gorontalo
National Average
Percentage of Households impoverished due to out-pocket payments by province
0% 2% 4% 6% 8% 10%
M aluku Utara
DKI J akarta
Bali
Kalimatan Timur
Bangka Belitung
Riau
Banten
Papua
Sulawesi Utara
Kalimantan Selatanan
Kalimantan Tengah
Sumatera Barat
Sumatera Seltan
Sulawesi Selatan
Sumatera Utara
J ambi
M aluku
Kalimantan Barat
Sulawesi Tenggara
J awa Barat
Sulawesi Tengah
Nusa Tenggara Barat
DI Y ogyakarta
J awa Timur
Bengkulu
Nusa Tenggara Timur
J awa Tengah
Lampung
Gorontalo
National Average
Catastrophic health payments and impoverishment
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
District Variationin Catastropic Health Payment within Province
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Responsiveness
0
10
20
30
40
pro
mp
t a
tte
ntio
n
dig
nity
co
mm
un
ica
tion
au
ton
om
y
co
nfid
en
cia
lity
ch
oic
e
qu
alit
y o
f b
as
ic
am
me
niti
es
ac
ce
ss
to
su
pp
ort
% o
f u
se
rs r
ati
ng
do
ma
in a
s "
po
or"
ambulatory inpatient 1
60
12
16
3
25 2
Prompt Attention
Dignity
Communication
Autonomy
Conf identiality
Choice
Basic Amenities
Social Support
Health system responsiveness by domain
and type o care
Percentage of respondents rating a responsiveness
domain to be most important
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Nu
sa
Te
ng
ga
ra T
imu
r
Su
law
esi T
en
gg
ara
Nu
sa
Te
ng
ga
ra B
ara
t
Ma
luku
Uta
ra
Ka
lim
an
tan
Ba
rat
Go
ron
talo
Ja
wa
Ba
rat
Su
law
esi T
en
ga
h
Su
law
esi S
ela
tan
Pa
pu
a
Ma
luku
Ba
nte
n
Ja
mb
i
Ka
lim
an
tan
Se
lata
n
La
mp
un
g
Ja
wa
Te
ng
ah
Ka
lim
an
tan
Te
ng
ah
Ba
ng
ka
Be
litu
ng
Ja
wa
Tim
ur
Be
ng
ku
lu
Su
ma
tera
Se
lta
n
Ria
u
Ka
lim
ata
n T
imu
r
Su
ma
tera
Ba
rat
DI Y
og
ya
ka
rta
Su
ma
tera
Uta
ra
Su
law
esi U
tara
Ba
li
DK
I Ja
ka
rta
0%
20%
40%
60%
80%
100%
% o
f b
irth
s a
tte
nd
ed
by
tra
ine
d p
ers
on
ne
l
kabupaten kota provincial avg. National avg.
DISTRICT VARIATION IN BIRTHS ATTENDED BY TRAINED PERSONEEL WITHIN PROVINCE
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Human Resources and Coverage
Skilled Birth Attendance and MidwivesSource: MOH Inventory 2001, Susenas 2001
0
10
20
30
40
50
60
70
80
Less than 18 18 - 30 31 - 51 52+
Midwives per 100,000 population
Num
ber o
f Dis
tric
ts
Below 80% Coverage
Above 80% Coverage
Skilled Birth Attendance and Physicians, Nurses and
Midwives Source: MOH Inventory 2001, Susenas 2001
0
10
20
30
40
50
60
70
80
90
Less than 58 58 - 96 97 - 179 180+
Physicians, Nurses, and Midwives per 100,000
Num
ber o
f Dis
tric
ts
Below 80% Coverage
Above 80% Coverage
• A higher concentration of midwives increases the likelihood for a district to achieve greater than 80% skilled birth 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
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
DISTRICT VARIATION IN UTILIZATION OF AMBULATORY CARE WITHIN PROVINCE
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
-4-2
02
4O
utp
ut in
de
x
-4 -2 0 2 4 6Input index
Indonesia district-level efficiency analysis
Wonogiri (Jawa Tengah)
Kulon Progo (DI Yogyakarta)
Soppeng (Sulawesi Selatan)
Jayawi Jaya (Papua)
Madiun (Jawa Timur)
Manokwari (Papua)
Blitar (Jawa Timur)
EFFICIENCY ANALYSIS
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Key Messages HSPA framework can be applied at sub-HSPA framework can be applied at sub-
national & can be used for setting benchmarks.national & can be used for setting benchmarks. Benchmarks may include input, output, Benchmarks may include input, output,
outcome, non health-related aspects of health outcome, non health-related aspects of health system, quality of caresystem, quality of care
Input vs Output: Measure EfficiencyInput vs Output: Measure Efficiency Indicators selection and target settingIndicators selection and target setting Problems related to data availability and quality Problems related to data availability and quality
(HIS)(HIS)
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
Next steps
HIS assessment (HMN tool).HIS assessment (HMN tool). Advocacy: Common understanding on Advocacy: Common understanding on
principles of HIS for all parties principles of HIS for all parties concernedconcerned
Strengthen data sources both Strengthen data sources both population based and service basedpopulation based and service based
Population based:Population based: Surveys: strengthen the integrationSurveys: strengthen the integration Vital registration: Initiate IMRSSPVital registration: Initiate IMRSSP
NATIONAL HEALTH SURVEY (SURKESNAS)TOWARDS HEALTHY INDONESIA 2010
Other surveys
Other surveys
IDHSIDHS
NSESNSES
NHHS/BHR
NHHS/BHR
2001 2004 2007 2010
Baseline Monitoring EvaluationMonitoring
(Outcome& processindicators)
(Process indicators)
(Processindicators)
(Outcome& processindicators)
Facility/servicebased
Community based
RoundIntegratedApproach
Focus of surveyHFSHFS
SURKESNASSURKESNAS
Notes: NHHS/BHR: National Household Health Survey/Baseline Health Research; NSES (SUSENAS): National Social Economic Survey; IDHS (SDKI): Indonesia Demographic and Health Survey; HFS: Health Facilities Survey
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
IMRSSP: Flow of COD reporting (Generic)
DEATH EVENT
HOME Health Facility
RT/RWRT/RW
HEALTH CENTER
HEALTH CENTER
VILLAGEVILLAGE
SUB-DISTRICT
SUB-DISTRICT
POP ADMNPOP ADMN
DistrictHealth Office
DistrictHealth Office PROV
INCE
CERT, 2
CERT, 2
CERT, 1
CERT, 1
VA
DeathReport
Death Report
DOA
Death Report
COD Stat
COD Stat
Vital Stat
CODStat
COD Stat
CERT, 1
POLICEPOLICECENTRA
L
Death Report
Death Report
COD Notification System (Health Center DHO)
___________________________________________________________________________________Health System Metrics Technical Meeting, September 28-29, 2006.
Glion sur Montreaux, Switzerland.
THANK YOU
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