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most indicators, inequality was pro-rich, i.e. wealthier households had better outcomes than poorer
households. These socio-economic inequalities are particularly pronounced with regards to maternal,
newborn and child health services.
Access to and use of health services are severely challenged by inadequate human resources in the
health sector, restrictions to physical accessibility, and high direct and indirect costs of healthcare,
which affect the poor disproportionately. Although human resources for health have increased rapidly
in the last 3 decades, ratios are still lower than the internationally recommended figures and strong
geographical disparities persist across the provinces and between rural and urban areas.
Similarly, there have been improvements in the physical health infrastructure such as the number of
primary health care facilities and inpatient beds over the last two decades; however, Indonesia still
lags behind compared to other East Asian countries (WHO, 2017) and considerable disparities with
regards to rural and urban areas and across provinces are also seen here. Physical accessibility to
health services too remains a critical challenge, particularly in many rural areas. Weak transport
infrastructure, especially in rural and remote areas, was highlighted by several stakeholders and
exemplified in a recent survey, where more than 85 per cent of rural households described access to
hospital care as “very challenging” or “difficult” compared to 46 per cent of urban households
(Riskedas, 2018). Rajan et al. (2018) estimates the median distance to the nearest health facility in
Indonesia to be five kilometres; but in the Eastern provinces including Papua and Maluku, the median
distance is 30 kilometres. Women from poorer households were considerably more likely to cite
“Distance to the nearest health facilities” as a barrier to access than women from richer households
(21.8 per cent vs 5.8 per cent) (Badan Pusat Statistik 2012).8 In combination with logistical challenges,
other factors such as long waiting times (especially in public facilities) and short opening hours limit
physical access to primary health care (Ekawati, Claramita et al., 2017).
Private expenditures for health – mainly out of pocket expenditures9 which increases the risk for
catastrophic expenditures of already poor and vulnerable households – remain consistently high in
Indonesia (above 60 per cent of total health expenditure). In 2016, 0.8 per cent of the Indonesian
population, equivalent to 2million people, were pushed into poverty because of out of pocket spending
on health services (WHO, 2016; WHO, 2018). Based on DHS data ‘gettingmoney’ formedical treatment’
was the most commonly cited barrier to access to health care among women from the lowest wealth
quintile and women with no education (Badan Pusat Statistik, 2012). Worries about financial
affordability were also primary barriers for divorced and widowed women and for women with more
than 5 children.
Pro-poor initiatives for access to health services
In order to improve the level of access to health services by the poor, e.g. through reducing the financial
risks of out of pocket health spending, the government took various measures (WHO, 2017; WHO,
2018).
An early effort was the decentralization of health service delivery in 2001, where the government
transferred most of the authority for decision-making, planning and management of the public health
service from the central national level to subnational provincial and district level. Most of the authority
for health service delivery was given to local district governments, making them de facto responsible
for the delivery of health services and responsive to local health needs (WHO, 2017). Furthermore,
since 2009, a number of social protection programmes, rolled out to reduce poverty are implemented
with coordinated efforts among ministries. For example, the Family Hope Program (or PKH) – a
conditional-cash-transfer social assistance program first piloted in 2007 – has close links with health
8 Similar differences were found with regards to education (24.4 per cent of women with no education vs 6.0 per cent of women with
secondary education or more).
9 48 per cent of total health expenditure in 2014