Author: I Nyoman Sutarsa, ANU, Luh Virsa Paradissa, Gadjah Mada University
In 2009, the Indonesian government implemented mandatory medical fees to establish a fair healthcare system and strengthen social security. The Health Law (Law No. 36 of 2009) requires the government to allocate at least 5 percent of the national budget and 10 percent of local government budgets to the health sector.
However, a new health law (Law No. 17 of 2023) was passed. August 2023, this mandatory health care fee has been abolished, but it has raised concerns about its potential to negatively impact health equity. The magnitude of these impacts will depend on the approach governments take in implementing new health spending mechanisms.
Before 2009, most healthcare costs in Indonesia were paid out-of-pocket (OOP), creating a wide disparity between the richest and poorest segments of society.only 26 percent In 2007, the proportion of Indonesians covered by government and private health insurance schemes was OOP. 48 percent This highlighted the need for government investment in the health sector to promote health equity across regions.
Mandatory minimum medical expenses This was the right policy direction to promote social security and health security in Indonesia. This move comes at a politically opportune time, in line with the implementation of health care decentralization since 2001 and the establishment of a national health insurance system under the provisions of the National Social Security Law (Law No. 40 of 2004). I got it.
Since 2009, mandatory health spending in Indonesia has had a positive impact on health spending, primary care functions, and overall population health outcomes.something important happened Reduce OOP spending — from 45.2 percent in 2000 to 31.8 percent in 2020 — which underlies the ability of mandatory health spending to reduce health disparities.Mandatory medical expenses also improved Maternal and child health outcomesincluding expanding the scope of coverage. Mandatory vaccinations.
Indonesia also witnessed Increase in community health centersincreased from 8234 in 2007 to 9601 in 2014; 10,205 people in 2020. Data shows that the implementation of mandatory health spending positively impacts the availability and access of essential health services and public health interventions.
Despite these improvements, revealed by evaluation Only 37.8% and 48% of local governments met mandatory health spending requirements in 2018 and 2020, respectively. This means that more than 50% of districts spend less than 10% of their mandated health spending due to limited local fiscal capacity and competing priorities.
Eliminating mandatory health spending would jeopardize the significant health advances achieved over the past decade and could further exacerbate Indonesia’s regional disparities. It can also increase OOP spending, impede access to health services, and reduce overall health outcomes.
Public health expenditure as a percentage of GDP Increased From 1.85 percent in 2000 to 3.41 percent in 2020, it remains below the World Health Organization’s standard of 5 percent. Careful planning is essential to prevent this rate from declining as mandatory health care fees are abolished.
Made by Indonesia big progress Much remains to be accomplished to improve health financing equity while expanding health insurance coverage. Increasing funding for primary care could enhance access to care for low-income people. The extent to which ending mandatory health spending will impact access and health equity will depend on the transition strategy of the Health Act of 2023.
of Health Act 2023 Mandates a performance-based budgeting system (PBBS) to replace mandatory health spending with the aim of increasing the efficiency of health spending. PBBS shifts the focus from allocating cash to achieving specific goals. Promote a proactive approach to health outcomes by prioritizing public health interventions, primary care and preventive medicine, and health promotion strategies to reduce costs.
PBBS also encourages health care providers to provide value-driven, efficient, and socially responsible care and requires integrated health information systems for spending tracking, performance evaluation, and outcomes evaluation. is.evidence from Burundi and Rwanda Although PBBS has been shown to strengthen health systems; zambia experience It shows that it strengthens accountability and autonomy in health care facilities.
Effective PBBS implementation has challenges — Prerequisites include: Robust performance information systems, well-prepared performance indicators, and effective management accounting and evaluation tools. Although the national government is ready to implement his PBSS, many local governments are not. PBBS requires a robust medical information system and accurate selection of performance indicators. Strengthening local health information systems requires significant investment.
Implementing PBBS may unintentionally disadvantage resource-limited, remote, and isolated health care facilities. Transitions to PBBS must be carefully planned to avoid disruption to health care services. One approach is to select districts with strong financial capacity, robust health systems and adequate health information systems as pilot areas for his PBBS implementation. These pilot projects can inform important strategies for implementing effective PBBS at all levels of government.
Improving the quality of healthcare spending is important, and the introduction of PBBS can promote effective healthcare.
The implementation of PBBS should start at the national level before expanding to the state and district levels. Under the Health Act of 2023, Over 100 regulations are in place. Such implementation should also include strategic alignment of health priorities from national to district levels, delineation of shared responsibilities, and fostering strong collaboration between sectors to address social determinants of health. There is.
I Nyoman Sutarsa is a Senior Lecturer in the Department of Medical Psychology, Faculty of Health and Medical Sciences, Australian National University, and a Senior Lecturer in the Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University.
Lou Virsa Paradisa holds a Master’s degree in Health Law from Gadjah Mada University Faculty of Law.
