Country Overview Indonesia has made significant progress in health outcomes over the last decades. For instance, infant mortality dropped from 118 deaths per thousand births in 1970 to 35 in 2003, and life expectancy increased from 48 years to 66 years over the same period. This progress owed much to the expansion of public health provision in the 1970s and 1980s, and programs in family planning. However, new challenges have emerged as a result of social and economic changes. First, disease patterns have become more complex. Indonesia, in fact, is in the midst of an epidemiological transition in which non-communicable diseases are increasingly important while infectious diseases remain a significant part of the disease burden. Second, there are important regional and socioeconomic inequities in the health system. For instance, in many provinces, the infant and child mortality rates compare unfavorably with some of the poorest countries in Asia. Third, performance and utilization of public health services is declining and the private sector is now the major source of health care. In most areas of Indonesia, in fact, the private sector now accounts for more than two-thirds of ambulatory care, more than half of hospital contacts and 30-50 percent of all deliveries (compared with only approximately 10 percent a decade ago). Fourth, health financing is low and inequitable. Health financing is overwhelmingly private, with individuals providing 75-80 percent of all health outlays, and most of this out-of-pocket, i.e. at the time they receive health services. Fifth, decentralization poses new challenges but also presents new opportunities. Local governments have become the focal point for health care provision: their share in total public health spending increased from 10 percent prior to decentralization, to 50 percent in 2001. Finally, HIV/AIDS transmission rates are increasing (an estimated 120,000 Indonesians are now infected with HIV/AIDS) - the epidemic is most intense in some urban areas and groups with high risk behavior. Back to top
Ongoing Projects Project: P073772 - Health Workforce & Services (Provincial Health Project III)Approval Date: 12 June 2003, Closing Date: 31 Dec 2008 Estimated Project Cost: US$429.37 Million The Health Workforce and Services Project will support health sector decentralization in four provinces, focusing on sustainable financing, and client-centered delivery of health services. Specifically, the project aims at enhancing access to care, quality of care, and, health outcomes at the district level, while strengthening health work-force policy, management, and development in a decentralized context. A corollary development objective is to empower the Ministry of Health, the Ministry of National Education, and the Indonesian Medical Association, the three key stakeholders in the sector, through assistance to redefine their roles and responsibilities, vis-à-vis health work-force policy, planning, and management; and, by building their institutional capacity towards fulfilling policy making, legislation, regulation, quality assurance/control, and technical assistance. The project will have three components, each applicable to all three levels of governance: (a) improved health system stewardship, including policy and planning, management and system regulation; (b) sustained and expanded health services financing and delivery; and (c) strengthened health workforce policy, management and training, including enhanced quality of medical education. Project: P049539 – Provincial Health Project II Approval Date: 26 June 2001, Closing Date: 30 June 2007 Estimated Project Cost: US$896.44 Million The two objectives of the Second Provincial Health Project are to 1) bring about effective health sector decentralization, in the provinces of North Sumatra, West Java, and Banten; and to initiate key sector reforms and put health financing on a firm footing, while protecting health services essential for the poor and the public at large during a period of government restructuring; and 2) to help the Ministry of Health carry out its roles in a decentralized system. These responsibilities encompass providing sectoral vision and leadership, analysis and policy follow-up of the health needs of the poor and risks to the public at-large, advocacy of best practices and standards, and support for local initiative. This project has two components. One addresses health needs and issues in specific districts and provinces through the use of block grants. The second component focuses on strengthening communicable disease surveillance, assuring equity in service provision through a national health grant program, and strengthening the newly established Food and Drug Control Agency. Project: P049545 - Provincial Health Project IApproval Date: 15 June 2000, Closing Date: 30 June 2006 Estimated Project Cost: US$79.07 Million The Provincial Health Project for Indonesia aims to bring about effective health sector decentralization in two provinces; and to help the central ministry carry out its new role in a decentralized system. The project will proceed in two phases and consist of two main components. The first component sets the stage for decentralization and health reform, while helping to sustain health social safety net services introduced during the economic crisis. Task forces are established to address institutional and health sector issues and to assist in building district implementation capacity. The second component helps the central health ministry become an effective, analytical, advisory, and advocacy agency; and provides grants to provinces and districts. The project midterm review was conducted in May 2004. Project resources have contributed to 20 percent increase of funds for health annually at the district level and doubled the discretionary fund for health. The project also supports provinces/districts in conducting reform initiatives particularly in the areas of human resource development, regulatory framework, public accountability, health information system and resource mobilization.
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Closed Projects Project: P036956 - Safe Motherhood Project Indonesia Team Leader: Ms Puti Marzoeki Approval Date: 1 July 1997, Closing Date: 31 Dec 2004 The Safe Motherhood Project aimed at assisting the Government of Indonesia to improve maternal health status, reduce mortality and morbidity, through a partnership and family approach, in selected districts in two provinces (East and Central Java). The project was designed as to achieve these objectives by: (i) improving quality and utilization of maternal health services; (ii) strengthening the sustainability of maternal health services at the village level; (iii) improving quality of family planning services; and (iv) preparing adolescents to lead a healthy reproductive life. The project contributed to increased coverage of ante natal care, the strengthening of the referral system of maternal and neonatal complications, the piloting of demand side interventions for improving access of the poor to maternal care, the piloting of efforts to improve quality of family planning services, and establishing networks for adolescent reproductive health services.  Implementation Completion Report Project: P003967 - Health Project (05)Approval Date: 14 July 1998, Closing Date: 31 July 2004 The key objectives of the project were to achieve greater efficiency of utilization and equity of distribution of health personnel, increase the skills of health professionals, and improve the quality of health professional practices. To achieve these goals, the project was designed (i) to strengthen the decentralization of planning, deployment and management of personnel, (ii) to strengthen the role of the private sector, (iii) to strengthen the licensing of health personnel, (iv) to support professional associations, (v) to support quality assurance, (vi) to improve the quality of pre-service and in-service training, and (vii) to strengthen the accreditation of training institutions. Implementation Completion Report Project: P042540 - Iodine Deficiency Control Project Approval Date: 17 Dec. 1996, Closing Date: 31 Dec 2003 The goal of the Intensified Iodine Deficiency Control Project was to lower the prevalence of Iodine Deficiency Disorder in Indonesia. During the project, it was estimated that the percent of households consuming fully iodized salt increased from 58% to 73% between 1996 and 2003. In this same period, Indonesia witnessed a 35% decline in the Total Goiter Rate in severely and moderately endemic areas, as well as actively trained hundreds of small scale salt producers in salt iodization methods. Implementation Completion Report Project: P039643 - HIV/AIDS and STD Prevention and Management ProjectApproval Date: 27 Feb. 1996, Closing Date: 30 June 1999 The HIV/AIDS and Sexually Transmitted Diseases (STDs) Prevention and Management Project was intended to help implement the AIDS strategy presented in the 1994 Presidential and Ministerial decrees. These policy pronouncements were aimed at achieving lower STD and HIV incidence and fewer deaths from AIDS in Indonesia. Project activities were revised after the economic crisis in Indonesia. Implementation Completion Report
Back to top Project: P003965 - Fourth Health Project: Improving Equity and Quality of Care Project Approval Date: 15 June 1995, Closing Date: 30 March 2001 The Fourth Health Project aimed at improving health outcomes in Indonesia by supporting directly districts and health centers to enhance health care quality and equity. A wide range of upgrading work, from small improvements (e.g., installation of tiles floors, replacement of roofs, improved water supply and sanitation etc.) to total replacement of facilities were carried out in over 3,700 health centers and sub-centers, 26 District Drugstores, 11 District Hospitals, and a number of other facilities such as Provincial Training Centers, administrative buildings and nursing schools. The Project also financed 119 international fellowships (12 to 24 months) and 82 domestic fellowships in a wide range of disciplines, including quality assurance, health care financing - related areas, management and public health. Implementation Completion Report Project: P003914 - Third Community Health and Nutrition ProjectApproval Date: 22 Dec. 1992, Closing Date: 31 March 2001 The goal of the project was to elevate infant, child and maternal health status by improving the effectiveness of community health and nutrition interventions in five provinces (West Java, Central Java, Maluku, East Nusa Tenggara and Irian Jaya). The project focused on supporting local capacity building and a “learning by doing” approach. The components focused on (a) building provincial and district capacity to plan, implement and evaluate safe motherhood, child survival and nutrition interventions; and (b) strengthening the capacity of the central Ministry of Health. Project objectives were embodied in a design in which health and nutritional status was addressed through interrelated activities at the province, district, and central levels. Implementation Completion Report Project: P003924 - Fifth Population ProjectApproval Date: 5 March 1991, Closing Date: 30 Sept. 1996 The project had two main objectives. The first was to assist BKKBN (Family Planning Coordinating Board) in carrying out its tasks and responsibilities in a setting defined by a maturing family planning movement. The second objective was to help the Government of Indonesia (GOI) expand access to maternal health services by training and deploying village midwives. Quality improvements in contraceptive services were brought about through expanded method choice (via procurement of contraceptives), and by upgrading through training the clinical and counseling skills of providers. Training capacity was enhanced through training of trainers and procurement of teaching equipment and materials and about 16,000 village midwives were trained and deployed. Implementation Completion Report Project: P003874 - Health Project (03)Approval Date: 25 Apr. 1989, Closing Date: 31 March 1996 The objectives of the project were to raise the health status of the population in Kaltim and Nusa Tenggara Barat (NTB) by improving service coverage and quality in the project provinces, increasing efficiency in the use of available resources, encouraging greater resource mobilization at the province level, and strengthening institutional capabilities for management and service delivery at the provincial and central levels. The number of posyandus (community health centers), the health center contact rates, immunization rates, and bed occupancy rates, increased markedly over the project's life. For example, the number of posyandus increased by 50 percent in NTB and 100 percent in Kaltim, the immunization rates (measured as the proportion of target population immunized) increased by about 125 percent in both provinces and the percent of pregnant women receiving antenatal care increased from 50 to 80 percent in Kaltim and from 30 to 92 percent in NTB. The project had also one major study, the Resource Mobilization Study, which was meant to provide information that could be used to assess the demand response to incremental health service fees that were instituted as part of the cost recovery encouraged by the project, and to estimate the effect of the fees on equity objectives.
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Analytical and Advisory Activities Project: P091820 - Health and Nutrition, Economic and Sector Work (in progress)
This task has two main goals: 1. to inform the conduct of nutrition policy in the new decentralized service delivery setting, and 2. to assist health finance reform during the process of decentralization. For nutrition, policy support and dialog is undertaken on an ongoing basis; however, some specific components concern: a) the determination of the cost of service delivery for existing nutrition programs, b) evaluations of the effectiveness of existing nutrition programs, c) an analysis of the institutional setting of nutrition delivery in the new decentralized service delivery environment, and d) an assessment of the heterogeneity of district level nutritional status as well as district capacity for implementing nutrition policy.
Project: P075179 - Health and decentralization, Economic and Sector Work
The aims of the task are to characterize and assess features and trends in health policy following two years of decentralization, to suggest possible central government responses and to highlight implications for the Bank. The analysis is aimed at updating aspects of the November 2000 Bank health strategy note, drawing on new information on health spending and the government health work force. Other inputs include lessons and observations stemming from implementation of the three Provincial Health Projects, consultant reports from the Fifth Health and the Health Workforce and Services Projects, official decisions and statements, and interviews with policy makers. Present day de facto policy structures are reviewed with respect to poverty-focus, assurance of technical quality, attention to public health functions, financing sustainability and implications for the private health sector.
Project: P052543 - Indonesia - Health strategy in a post-crisis, decentralizing Indonesia (2000), Sector Report
The study reviews the strategy for a prospective health development, and the health benefits associated with decentralization, in a challenging period in Indonesia. It addresses the major government reorganization, which consists of decentralization of spending authority, enhanced access to resources at local government levels, and civil service reform. The study argues that the potential health system benefits, associated with decentralization, will enable citizens to become involved systematically in decisions regarding health policy, design, and financing, as well as influencing service provision. The report describes the health system performance, and costs in the country, namely an adaptation of health for all, aimed at a wide coverage, featuring integrated service provision at the primary health level.
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