Indonesia’s Journey to UHC:

Five Important Challenges

Prof. Peter Berman
School of Population and Public Health
The University of British Columbia
And
Harvard T.H. Chan School of Public Health
Jakarta, April 22, 2019
What is UHC?
• A state where the health needs of all the population are met without
undue financial hardship -- WHO (2005)
• A state where all the essential health needs of all the population are
met without undue financial hardship – WHO (2015)

Both concepts include improving health and financial risk protection

with equity – fundamental goals of a health system

“Coverage” in UHC includes both service coverage (actual use related

to need) and financial coverage (entitlement/enrollment in benefits)
Indonesia’s Journey to UHC
• Indonesia has emphasized the more “comprehensive” UHC
• It is a major leader in the SDG-period global movement towards UHC,
given its size, rapid income growth, earlier progress in health
improvement and fertility reduction, growing health systems capacity.
• How Indonesia meets the challenges of advancing towards UHC will
be an important example to the world
4

A Framework for Analyzing Health System Performance and Developing

Strategies to Advance Towards UHC
Epidemiological
Demographic Political

Level
And Legal /
Ecological
Distri- Regulatory
bution

Technological Economic
Socio-Cultural

Source: Roberts, et al 2008

Some high-level observations on positive progress to date
Since establishing JKN in 2014
Creation of a unified national health insurance system
Significant increase in government health expenditure
Dramatic increase in enrollment – moving towards universal –
focus on the those defined legally as “poor”
Some reduction in out-of-pocket spending, with very recent
results suggesting even larger reductions
Continued investment in government delivery system and parallel
growth in private sector
Increased access to clinical services and hospitals
But, there is evidence of some major challenges – let me
emphasize five.
Challenge 1: Large and increasing financial deficits
in JKN
Diagnosis of causes
• Funds available to finance UHC/JKN insufficient to support
“comprehensive” UHC
• Backlog of needs and rising demand will place increasing pressure on
available funds
Possible actions
• Increase financial allocations from existing and new sources
• Reconsider the “comprehensiveness” of the current promised benefit
package, phasing in expanding benefits as resources become available
• Increase contributions from defined populations
Challenge 2: Stalling progress in meeting
population health priorities
Diagnosis of causes
• JKN’s development has emphasized providing financial risk protection (FRP)
through clinical services.
• In practice, this has created both supply- and demand-side disincentives at
the margin for maintaining/expanding priority population health programs,
e.g. immunization, disease control, MCH, NCDs
Possible actions
• Reconsider the balance in goals between population health and FRP, with
evidence
• Align the politics with intended goals – listening to and shaping citizens’
expectations and satisfaction
• Strengthen investments and incentives to protect population health
interventions
Challenge 3: Significant (increasing?) inequalities
in UHC benefit
Diagnosis of causes
• Disparities in health system supply and realized access across
Indonesia’s difficult geography
• JKN funding sends money at the margin to where that supply and
demand are realized
Possible actions
• Develop benchmarks for a core UHC package of benefits, possibly
different for different areas, and channel investments and service
funds to assure that those are met
• Design region/area-specific plans for government and JKN spending
to reduce specific inequalities
Challenge 4: Insufficient use of the power of financing
(e.g. incentives) to improve system performance
Diagnosis of causes
• Overly complex financing flows to fund different types of investments and
services
• Limited legal and weak governance mechanisms to strategically direct
financing and purchasing in highly decentralized system
• JKN as the most flexible purchaser still relatively small part of total financing
Possible actions…this is the hardest one!
• Simplify government budget flows for health
• Strengthen government role/direction in funding, governance, management
for population health priorities and/or strengthen JKN role in incentives
through purchasing for population health priorities
• Strengthen district-level capacity and incentives to use financing more
effectively for UHC goals
Challenge 5: Getting more, and more use, of data and
evidence for policy and program improvement
Diagnosis of causes
• Ample national technical competence for analytics needed for health system
improvement but not well aligned with ability of government to use analytics
• Fragmented governance for strategic direction in government health efforts: MoH, JKN,
other govt actors
• Over-reliance on external partners
• Gaps in evidence needed, e.g. causes of faltering population health initiatives;
determinants and distribution of health-related impoverishment; financial and actuarial
projections; evidence to set health and FRP priorities
Possible actions
• Govt financing for increased analytical work on specific topics
• Creation of high-level independent health systems analysis policy and research think-
tank
• Align partner support to develop and sustain this capacity
Some concluding thoughts
• There are many things that need to be done, but it will be important
to have a manageable set of strategic priorities on which to focus
• Setting these priorities should be justified in terms of the ultimate
outcomes to be improved (health, FRP, equity) and the intermediate
outcomes that will move in that direction.
• The journey to UHC is longer than a five-year plan – there needs to be
national investment in the capacities to get there

THANK YOU/ TERIMA KASIH

FOR THE OPPORTUNITY TO SHARE MY IDEAS
WITH YOU TODAY