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transportation costs to reach secondary and tertiary health care centres in Papua, for example, are
often higher than the direct medical cost – thus making access for many poor households unaffordable.
Realizing the potential detrimental effects of indirect health cost on the use of maternal and child
health services for poor households the government launched the DAK Jampersal programme in 2016,
which covers all non-medical cost related to maternal and child health such as transportation and
accommodation cost for pregnant mothers who want to deliver in a health facility.
Additionally, poor acceptability of some health care services, lack of trust in the quality of the services
and lack of information are other important access barriers. Several stakeholders pointed out that poor
JKN beneficiaries were often unaware of the benefits the health insurance scheme entitled them to. In
some cases, the JKN membership cards were kept at the house of village heads as poor households did
not know how and for what they should use the card. Poor acceptability could pose a barrier to access
to health services, especially to maternal and reproductive health services.
The provision of high quality services remains a challenge because the demand for services is far
greater than the supply, especially with regards to maternal, newborn and child services (WHO, 2017).
People usually expressed lower levels of trust in primary local health care providers and higher levels
of trust in hospital and specialist care. Related, the Ministry of Health struggles to attract skilled health
workers to rural and remote postings across the countries which further exuberates regional and
rural/urban disparities. To counteract this the Ministry of Health has started to offer shorter contracts
and higher enumeration for health workers in remote posts (WHO, 2017), and introduced various
policies to encourage health workers to take up positions in rural and remote parts of Indonesia. For
example, the Healthy Archipelago programme (Nusantara Sehat) deploys health workers to
underserved rural and remote locations for a two-year assignment. The Presidential Regulation
No.4/2017 on Compulsory Service of Specialist Doctor (WKDS), requires all specialist doctors to first
undertake 1-year long service in remote district hospitals, regional referral hospitals, and provincial
referral hospitals. The Ministry of Health pays for their salaries while local governments provide
additional incentives through their regional budget. As of 2017, 870 specialists have been deployed –
short of the target of 2,000 specialists.
Dual practice (i.e. health personnel works for both the public and the private sector) is very common
in Indonesia and frequently leads to maldistribution of health workers (and in particular specialized
doctors) away from public health facilities and towards more lucrative private practice (WHO, 2017).
Actors in Indonesia’s health system
Health service in Indonesia is mainly delivered by the public and private sector. All major
developments and improvements in the health system in the last decades have mainly been driven by
domestic political actors and initiatives (Pisani, Olivier Kok et al., 2017). However, there are a large
number of international and national NGOs that support community-based service delivery, in
particular preventive healthcare and promotion through the Posyandu system. At national level, NGOs
raise awareness for various health issues, do advocacy work, raise funds and work in partnership with
the government on the monitoring and evaluation of health programmes. To increase their visibility,
cooperation and sustainability NGOs have created a joined platform called the Collaboration Forum
for Indonesia Community Health Development (Forum Kerjasama Pengembangan Kesehatan
Masyarakat Indonesia/FKPKMI). All NGO activities in Indonesia are regulated and monitored by the
Law (WHO, 2017).
A number of bi-lateral donors and international agencies including AusAID, USAID, GIZ, IDB, ADB, the
World Bank, the Global Fund, WHO and UNICEF support the health systemdevelopment and operation.
Support varies and usually includes activities and substantial grants to improve specific aspects of the
health sector. For example, infectious disease control initiatives (e.g. malaria, TB, leprosy) have long
been supported by donors (in addition to government support and with high-level coordination by the