1. ___________________________________________________________________________________ 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 Organization BPS Statistics Indonesia

2. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Decentralization in 2001 redefined role of central MoH and districts: created new challenges vis-à-vis district-centre information flows. 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. 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. 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. Interest in what existing data can say about district performance and what the implications would be for district benchmarking. Why Assess District Health System Performance in Indonesia?

3. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. FUNCTIONS GOALS / OUTCOMES WHO HSPA Framework Goals and functions of the health system HEALTH Responsive- ness Fair Financial Contribution Service Proviision Resources Generation Stewardship (Oversight) Financing (Collecting, Pooling and Purchasing)

4. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. WHO HSPA 2000 Framework Indonesia Application Scope International/NationalDistrict-level Goals/Outcomes HALE Life expectancy Fairness in Financial Catastrophic expenditure contribution ResponsivenessResponsiveness Risk FactorsSmoking Access to safe water Intermediate Coverage indicatorsCoverage indicators Outputs Provider performanceUtilization Inputs Health expenditureHuman resources EducationFacilities Income Female education Adaptation of WHO HSPA for Indonesia

5. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Population based: CENSUS 2000. CENSUS 2000. Household surveys (Susenas and other household surveys). Household surveys (Susenas and other household surveys). 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: Indonesia Human Development Report 2001,04 Indonesia Human Development Report 2001,04 Health Information System: Indonesian Data Sources

6. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Indonesia Sub-National HSPA Report Part 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

7. ___________________________________________________________________________________ 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

8. ___________________________________________________________________________________ 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

9. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. National Average Catastrophic health payments and impoverishment

10. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. District Variationin Catastropic Health Payment within Province

11. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Responsiveness Health system responsiveness by domain and type o care Percentage of respondents rating a responsiveness domain to be most important

12. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. DISTRICT VARIATION IN BIRTHS ATTENDED BY TRAINED PERSONEEL WITHIN PROVINCE

13. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Human Resources and 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

14. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. DISTRICT VARIATION IN UTILIZATION OF AMBULATORY CARE WITHIN PROVINCE

15. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. EFFICIENCY ANALYSIS

16. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. Key Messages HSPA framework can be applied at sub- national & can be used for setting benchmarks. HSPA framework can be applied at sub- national & can be used for setting benchmarks. Benchmarks may include input, output, outcome, non health-related aspects of health system, quality of care Benchmarks may include input, output, outcome, non health-related aspects of health system, quality of care Input vs Output: Measure Efficiency Input vs Output: Measure Efficiency Indicators selection and target setting Indicators selection and target setting Problems related to data availability and quality (HIS) Problems related to data availability and quality (HIS)

17. ___________________________________________________________________________________ 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 principles of HIS for all parties concerned Advocacy: Common understanding on principles of HIS for all parties concerned Strengthen data sources both population based and service based Strengthen data sources both population based and service based Population based: Population based: Surveys: strengthen the integration Surveys: strengthen the integration Vital registration: Initiate IMRSSP Vital registration: Initiate IMRSSP

18. NATIONAL HEALTH SURVEY (SURKESNAS) TOWARDS HEALTHY INDONESIA 2010 Other surveys Other surveys IDHS NSES NHHS/ BHR NHHS/ BHR 2001 2004 2007 2010 Baseline Monitoring Evaluation Monitoring (Outcome & process indicators) (Process indicators) (Process indicators) (Outcome & process indicators) Facility/service based Community based Round Integrated Approach Focus of survey HFS SURKESNAS 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

19. ___________________________________________________________________________________ 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/RW HEALTH CENTER VILLAGE SUB-DISTRICT POP ADMN District Health Office District Health Office PROV INCE CERT, 2 CERT, 1 VA Death Report DOA Death Report COD Stat Vital Stat COD Stat CERT, 1 POLICE CENTRAL Death Report COD Notification System (Health Center DHO)

20. ___________________________________________________________________________________ Health System Metrics Technical Meeting, September 28-29, 2006. Glion sur Montreaux, Switzerland. THANK YOU