SUB NATIONAL HEALTH SYSTEM PERFORMANCE ASSESSMENT (Indonesia Experience) National Institute of Health Research and Development In Collaboration with World Health Organization BPS Statistics Indonesia ___________________________________________________________________________________ Health System Metrics.
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SUB NATIONAL HEALTH SYSTEM PERFORMANCE ASSESSMENT (Indonesia Experience) National Institute of Health Research and Development In Collaboration with World Health Organization BPS Statistics Indonesia ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Why Assess District Health System Performance in Indonesia? Decentralization in 2001 redefined role of central MoH and districts: created new challenges vis-à-vis district-centre information flows. National health goals, similar to those identified by WHO HSPA. Variety of reforms in last 10 years: to improve staff distribution, insurance coverage, provider performance (quality), etc. Interest in what existing data can say about district performance and what the implications would be for district benchmarking. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. WHO HSPA Framework Goals and functions of the health system GOALS / OUTCOMES FUNCTIONS Stewardship (Oversight) Resources Generation Financing (Collecting, Pooling and Purchasing) Responsiveness Service Proviision HEALTH Fair Financial Contribution ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Adaptation of WHO HSPA for Indonesia WHO HSPA 2000 Framework Indonesia Application Scope International/National District-level Goals/Outcomes HALE Fairness in Financial contribution Responsiveness Life expectancy Catastrophic expenditure Risk Factors Responsiveness Smoking Access to safe water Intermediate Outputs Coverage indicators Provider performance Coverage indicators Utilization Inputs Health expenditure Education Human resources Facilities Income Female education ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Health Information System: Indonesian Data Sources Population based: CENSUS 2000. Household surveys (Susenas and other household surveys). Health service based: MoH inventories: human resources; facilities. National health accounts. Public health expenditure review. Studies: Indonesia Human Development Report 2001,04 ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Indonesia Sub-National HSPA Report Part I: Intro/Background II: Health and Health System Goal • Health conditions • Financial protection • Responsiveness of the health system 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 ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. DISTRICT VARIATIONS IN LIFE EXPECTANCY AT BIRTH National Estimate: 66.2 Range: 57.5 – 73.7 Below National Estimate Above National Estimate ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. DISTRICT VARIATION OF LIFE EXPECTANCY WITHIN PROVINCE kabupaten kota provincial avg. National average 80 70 65 60 55 50 Nusa Tenggara Barat Kalimantan Selatan Banten Maluku Utara Sulawesi Tengah Nusa Tenggara Timur Gorontalo Kalimantan Barat Jawa Barat Sulawesi Tenggara Papua Bengkulu Maluku Bangka Belitung Sumatera Seltan Jawa Timur Sumatera Barat Lampung Jambi Sumatera Utara DI Aceh Riau Sulawesi Selatan Jawa Tengah Kalimantan Tengah Kalimatan Timur Bali Sulawesi Utara DKI Jakarta DI Yogyakarta Years 75 There are significant differences in average life expectancy across provinces; 8 provinces exceed the Healthy Indonesia 2010 target of life expectancy of 67.9 ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Catastrophic health payments and impoverishment Percentage of Households with catastrophic health payments by province Percentage of Households impoverished due to out-pocket payments by province Gorontalo Jawa Tengah Jawa Timur Jawa Barat DI Yogyakarta Bengkulu Lampung Goront alo Lampung Jawa Tengah Nusa Tenggara Timur Bengkulu Jawa Timur DI Yogyakart a Nusa Tenggara Barat Nusa Tenggara Barat Sulawesi Utara Sumatera Barat Nusa Tenggara Timur Sulawesi Tengah Bangka Belitung Sumatera Utara Jambi DKI Jakarta M aluku Sulawesi Selatan Kalimantan Barat Kalimantan Selatanan Sumatera Seltan Kalimatan Timur Sulawesi Tengah Jawa Barat Sulawesi Tenggara Kalimant an Barat M aluku Jambi Sumat era Ut ara Sulawesi Selat an Sumat era Selt an Sumat era Barat Kalimant an Tengah Kalimant an Selat anan Sulawesi Ut ara Papua National Average Riau Bali Sulawesi Tenggara Banten Kalimantan Tengah M aluku Utara Papua National Average Bant en Riau Bangka Belit ung Kalimat an Timur Bali DKI Jakart a M aluku Ut ara 0% 2% 4% 6% 8% 10% 0% 2% 4% 6% 8% 10% ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. 0% ___________________________________________________________________________________ Papua Maluku Utara Kalimantan Tengah Banten Sulawesi Tenggara Bali Riau Kalimatan Timur Sumatera Seltan Kalimantan Selatanan Kalimantan Barat Sulawesi Selatan Maluku DKI Jakarta Jambi Sumatera Utara Bangka Belitung Sulawesi Tengah Nusa Tenggara Timur Sumatera Barat Sulawesi Utara Nusa Tenggara Barat Lampung Bengkulu DI Yogyakarta Jawa Barat Jawa Timur Jawa Tengah Gorontalo % households District Variationin Catastropic Health Payment within Province kabupaten kota provincial avg. National avg. 10% 8% 6% 4% 2% Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Responsiveness Percentage of respondents rating a responsiveness domain to be most important Health system responsiveness by domain and type o care ambulatory inpatient 5 40 2 1 3 30 Prompt Attention 12 Dignity 20 Communication 60 16 10 Autonomy Confidentiality Choice Basic Amenities access to support quality of basic ammenities choice confidenciality autonomy dignity communication Social Support 0 prompt attention % of users rating domain as "poor" 2 ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Nusa Tenggara Timur Sulawesi Tenggara Nusa Tenggara Barat Maluku Utara Kalimantan Barat Gorontalo Jawa Barat Sulawesi Tengah Sulawesi Selatan Papua Maluku Banten Jambi Kalimantan Selatan Lampung Jawa Tengah Kalimantan Tengah Bangka Belitung Jawa Timur Bengkulu Sumatera Seltan Riau Kalimatan Timur Sumatera Barat DI Yogyakarta Sumatera Utara Sulawesi Utara Bali DKI Jakarta % of births attended by trained personnel DISTRICT VARIATION IN BIRTHS ATTENDED BY TRAINED PERSONEEL WITHIN PROVINCE kabupaten kota provincial avg. National avg. 100% 80% 60% 40% 20% 0% ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Human Resources and Coverage Skilled Birth Attendance and Physicians, Nurses and Midwives Source: MOH Inventory 2001, Susenas 2001 Skilled Birth Attendance and Midwives Source: MOH Inventory 2001, Susenas 2001 80 60 50 Below 80% Coverage 40 Above 80% Coverage 30 20 10 0 Less than 18 18 - 30 31 - 51 Midw ives per 100,000 population 52+ Number of Districts Number of Districts 70 90 80 70 60 50 Below 80% Coverage Above 80% Coverage 40 30 20 10 0 Less than 58 58 - 96 97 - 179 180+ Physicians, Nurses, and Midw ives per 100,000 • 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. 0% ___________________________________________________________________________________ Maluku Sulawesi Tengah Sulawesi Tenggara Riau Kalimantan Selatan Sulawesi Selatan Kalimantan Barat Kalimatan Timur Jambi Lampung Sumatera Seltan Kalimantan Tengah Sulawesi Utara Banten Gorontalo Maluku Utara Jawa Barat DKI Jakarta Bengkulu Sumatera Utara Jawa Timur Nusa Tenggara Timur Jawa Tengah Sumatera Barat Nusa Tenggara Barat Papua Bangka Belitung DI Yogyakarta Bali % of ambulatory care DISTRICT VARIATION IN UTILIZATION OF AMBULATORY CARE WITHIN PROVINCE kabupaten kota province avg. national avg. 100% 80% 60% 40% 20% Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. EFFICIENCY ANALYSIS 4 Indonesia district-level efficiency analysis Madiun (Jawa Timur) Blitar (Jawa Timur) 2 Kulon Progo (DI Yogyakarta) W onogiri (Jawa Tengah) 0 Soppeng (Sulawesi Selatan) -2 Manokwari (Papua) -4 Jayawi Jaya (Papua) -4 -2 0 2 Input index 4 6 ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Key Messages HSPA framework can be applied at subnational & can be used for setting benchmarks. Benchmarks may include input, output, outcome, non health-related aspects of health system, quality of care Input vs Output: Measure Efficiency Indicators selection and target setting Problems related to data availability and quality (HIS) ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Next steps HIS assessment (HMN tool). Advocacy: Common understanding on principles of HIS for all parties concerned Strengthen data sources both population based and service based Population based: Surveys: strengthen the integration Vital registration: Initiate IMRSSP ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. NATIONAL HEALTH SURVEY (SURKESNAS) TOWARDS HEALTHY INDONESIA 2010 Integrated Approach Round 2001 Community based Other surveys IDHS NHHS/ NSES SURKESNAS Facility/service based HFS BHR Baseline 2004 2007 2010 Monitoring Monitoring Evaluation (Process (Outcome (Outcome (Process & process indicators) indicators) & process indicators) indicators) Focus of survey 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 IMRSSP: Flow of COD reporting (Generic) DEATH EVENT HOME Death Report Health Facility CERT, 2 DOA CERT, 1 POLICE CENTRAL RT/RW Death Report CERT, 1 VA CERT, 1 Death Report COD Stat VILLAGE HEALTH CENTER CERT, 2 Death Report COD Stat SUB-DISTRICT Death Report District Health Office COD Stat POP ADMN COD Stat PROV INCE Vital Stat ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. COD Notification (Health Center DHO) Glion surSystem Montreaux, Switzerland. THANK YOU ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland.