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The structure of Indonesia’s health services and health coverage system
The Indonesian health system is characterised by amixture of public–private provision of services (see
Figure A1 in the Annex). Since the decentralisation in 2001, public health service delivery falls under
the restriction of district and provincial governments (which are under the Ministry of Home Affairs).
The central Ministry of Health remains responsible for the management of some tertiary and specialist
hospitals, provision of strategic direction, setting of standards, regulation, and ensuring availability of
financial and human resources.
Provincial governments own the provincial hospitals and organize the health services through the
provincial health offices (PHOs). The PHOs play a coordinating role for health issues within
the province and across districts. The district governments own district hospitals and organize health
services through district health offices (DHOs). DHOs also operate health services provided through
the primary health centres (Puskesmas) and their networks of village health posts (Poskesdes); village
birth facilities (Polindes) and monthly community health extension posts (posyandu) (WHO 2017).
Community and village-level health service delivery has always been a cornerstone of public health
care delivery in Indonesia (even during General Suharto’s regime). The relationship between Ministry
of Health, PHO and DHO is not a hierarchical one, but each level has its own mandates and areas of
authority.
The growing economy of Indonesia and the government’s aim of providing affordable universal
healthcare coverage (UHC) by 2019, led to an increase in the demand for health services in recent
years. To satisfy this demand and improve access to health services the government has opened the
health sector for investment, resulting in a growing number of private providers. Private sector
providers come from heterogeneous backgrounds including religious affiliated organizations,
companies and individuals/group of individuals. The public sector currently still takes the dominant
role, especially in rural areas and for primary basic health care provision. However, private health
service provision is increasing rapidly and based on official statistics more than 60 per cent of all
hospitals in Indonesia are private (World Bank 2014). Based on estimations of a stakeholder from the
Ministry of Health (Ministry of Health) around 60 per cent of outpatient visits in Indonesia occurred
at private facilities and the rest at public facilities, mostly at primary care level. Inpatient care occurs
mainly in public facilities except for the highest wealth quintile (i.e. the richest households) who
prefers private facilities for inpatient care. These findings are corroborated by a recent report from
the World Bank (World Bank 2014). Private sector health service delivery is regulated by the
government (central and local) through accreditation, licensing and registration (WHO 2017). Private
sector providers are actively encouraged by the government to enrol in the national UHC scheme
under the national social security management agency and improve access to health services (Badan
Penyelenggara Jaminan Sosial, BPJS).
Access to health services by the poor
Indonesia has made significant progress in many population health indicators in the last two and a half
decades. Life expectancy has steadily increased from 63 years in 1990 to 69 years in 2017, under-five
mortality dropped significantly from 84 per 1000 live births in 1990 to only 25 deaths per 1000 live
births in 2017 and so did infant mortality (from 62 to 23 per 1000 live birth). Huge progress was also
made in maternal mortality with a decrease from 446 death per 100 000 live birth in 1990 to 126
death 2015. Adolescent birth rates also remain far above the South Asian average of 33.8 compared to
50 in Indonesia.
However, progress in the decline of child undernutrition has been slow and stunting levels are still
high with 36 per cent of children under 5 years are being too short for their age (WHO, 2015a).
Furthermore, progress in combating infectious diseases has been slow with the incidence of Malaria
and Tuberculosis remaining high and far above the South Asian averages and the infection ratio for
HIV remaining unchanged. Additionally, the prevalence of risk factors for NCDs such as high blood