MEASURING SUB NATIONAL & PROJECTING FISCAL SPACE. Pandu Harimurti World Bank Jakarta

Transkripsi

1 MEASURING SUB NATIONAL HEALTH SECTOR PERFORMANCE & PROJECTING FISCAL SPACE Pandu Harimurti World Bank Jakarta 1

2 Presentation Structure MEASURING SUBNATIONAL LEVEL PERFORMANCE THE CONCEPT Of FISCAL SPACE 2

3 The WHO Health System Framework System Building Blocks SERVICE DELIVERY HEALTH WORKFORCE INFORMATION MEDICAL PRODUCTS, VACCINES & TECHNOLOGIES FINANCING LEADERSHIP/GOVERNANCE ACCESS COVERAGE QUALITY SAFETY Overall Goals / Outcomes IMPROVED HEALTH (level and equity) RESPONSIVENESS SOCIAL & FINANCIAL RISK PROTECTION IMPROVED EFFICIENCY Source: Everybody s Business: Strengthening Health Systems to Improve Health Outcomes, WHO Framework for Action, WHO

4 Health System Performance Global comparison of Indonesian districts, DPT3 immuniza ation Kab. Tana Toraja Kab. Ciamis Kab. Morowali Kab. Subang Kab. Parigi Moutong Kab. Bombana DPT3 immunization Vietnam Turkey Kab. Madiun Uganda Pakistan Kota Ambon Kab. Lombok Indonesia Barat Kab. Asmat Japan Bangladesh Nepal Papua New Guinea Kota Singkawang India Timor-Leste Kab. Bangka Tengah Niger Somalia 100 Skilled birth attend dance Kota Padang Panjang Skilled birth attendance Kab. Kediri Kab. Bantul Kab. Barito Selatan Kab. Hulu Sungai Utara Kab. Nias Selatan Kota Kediri China Kab. Semarang Kab. Kuningan Kab. Barru Indonesia Ukraine Senegal Kab. Purbalingga Bhutan Tanzania Cambodia Kab. Wonosobo Burundi Pakistan 0 20 Kab. Pakpak Bharat Chad 0 20 Kab. Yahukimo Ethiopia Bangladesh Indonesia Other countries Indonesia Other countries Source: SUSENAS & WDI Often evidence of large differences in outcomes and outputs within countries. At least some of the differences are often due to differences in efficiency. 4

5 DISTRICT VARIATION OF LIFE EXPECTANCY WITHIN PROVINCE kabupaten kota provincial avg. National average Nusa Tenggara Barat Tengah Nusa Tenggara Timur Jawa Tenggara Jawa DI Selatan Tengah Kalimatan Timur Bali Sulawesi Utara DKI Jakartaa DI Yogyakartaa Kalimantan Selatan Bantenn Maluku Utaraa Sulawesi Gorontaloo Kalimantan Barat Barat Sulawesi Papuaa Bengkuluu Malukuu Bangka Belitung Sumatera Seltan Timur Sumatera Barat Lampung Jambi Sumatera Utaraa Aceh Riau Sulawesi Jawa Kalimantan Tengah Years There are significant differences in average life expectancy across provinces; 8 provinces exceed the Healthy Indonesia 2010 target of life expectancy of 67.9 Source: Indonesia : Sub National Health System Performance Assessment, NIHRD MOH, BPS, WHO,

6 District Variation in Catastrophic Health Payment within Province kabupaten kota provincial avg. National avg. 10% 8% 6% 4% 2% t0% Papua ku Utara n Tengah Banten Sulawesi Tenggara Bali Riau an Timur Selatanan an Barat Selatan Maluku D KI Jakarta Jambi Sumatera Utara Belitung Tengah gara Timu r % households 0% Malu Kalimantan Kalim at Sumatera Seltan Kalimantan Kalim ant Sulawesi Bangka Sulawesi N usa Teng Sumatera Barat Sulawesi Utara N usa Tenggara Barat Lampung Bengkulu DI Yogyakarta Jaw a Barat Jaw a Timur Jawa Tengah G orontalo Source: Indonesia : Sub National Health System Performance Assessment, NIHRD MOH, BPS, WHO,

7 Inputs vs. Outcomes: Measuring Efficiency Very Preliminary Findings Indonesia HSPA: Outcomes vs. inputs across districts INPUT INDEX Permanent Income Female Education 2 4 Kulon Progo (DI Yogyakarta) Magelang (Jawa Tengah) OUTPUT INDEX Complete Immunization Nurses per 100, Out-of-pocket expenditure Access to health facilities Output index 2 0 Skilled Birth Attendance Iodized Salt Content Catastrophic Expenditure Life Expectancy Input index Indonesia HSPA: Relating outcomes to inputs across districts. Some districts have achieve relatively high health system outcomes even with relatively l low input levels. l Useful for benchmarking. Source: Indonesia : Sub National Health System Performance Assessment, NIHRD MOH, BPS, WHO,

8 EFFICIENCY ANALYSIS Indonesia district-level efficiency analysis 4 Blitar (Jawa Timur) Madiun (Jawa Timur) Kulon Progo (DI Yogyakarta) 2 Wonogiri (Jawa Tengah) Output index 0 Soppeng (Sulawesi Selatan) Manokwari (Papua) -2 Jayawi Jaya (Papua) Input index Source: Indonesia : Sub National Health System Performance Assessment, NIHRD MOH, BPS, WHO,

9 Fiscal Space for Health Fiscal space for health (increase as % of government health spending) Conducive macroeconomic conditions Efficiency Reprioritization Other sector-specific resources Sector-specific foreign aid 9

10 Sources of Fiscal Space for Health Earmarked taxes Increasing currently low cigarette tax (37% of sales price) has potential to increase government revenues. A 10% increase could lower consumption by %, and increase revenues up to 9 %. Other countries: Thailand has employed sin taxes to fund health promotion Mandatingsocial health insurance The Government has committed to develop mandatory insurance to achieve universal coverage The challenge is with the large informal sector, two thirds of the workforce. 10

11 Fiscal Space for Health in Indonesia Taking into account Indonesia s context Demographic and epidemiological changes projected to increase demand for health care Universalcoverage throughmandatoryhealth health insurance Positive prognosis in economic growth Options to increase fiscal space for health in Indonesia: Use some proportion of resources raised from premium can be used to subsidize health care for the poor, Earmarked taxation, especiallyfromcigarettes cigarettes Reduction in fuel and energy subsidies Decentralization poses specific challenges hll such as; absorptive capacity constraints, capacity to raise local revenue, can hinder the actualization of fiscal space 11