East Asia and the Pacific Region Watching Brief 58101 GOVERNMENT HEALTH EXPENDITURES IN INDONESIA THROUGH DECEMBER 2000: AN UPDATE BY S. LIEBERMAN, M. JUWONO, AND P. MARZOEKI October 15, 2001, Issue 6 MAIN FINDINGS CONTENTS Ø During the recent economic crisis, government health spending in Indonesia fell in real per capita terms. Nevertheless, outlays were INTRODUCTION.....................................1 sustained at the mid 1990s level--cuts were less severe than those in the 1980s. OVERALL TRENDS.................................2 GREATER RELIANCE ON DONOR Ø A key crisis-period policy adjustment was increased reliance on ASSISTANCE..........................................2 international funding. These resources were used to fill gaps, and were not directed strategically, e.g., to increase the sustainability of INCREASED SPENDING ON PUBLIC health financing. HOSPITALS.......................................... 3 SPENDING IN SELECTED PROVINCES ... 4 Ø There were other crisis-responses of concern, e.g., rising per capita hospital outlays. And spending patterns overall appeared fragile DISCUSSION......................................... 4 and vulnerable as the country shifted to decentralized arrangements ANNEXES............................................. 8 in January 2001. INTRODUCTION 1. This Watching Brief reports on trends in centrally-directed health spending through January 1, 2001 when Indonesia moved to more decentralized funds channeling, decision making, and allocation arrangements. The note focuses on health spending during the economic crisis of the late 1990s, touching on overall trends and intra-sectoral and province-wise adjustments. 2. The main finding is that government health expenditures per capita were not sustained at the peak pre-crisis figure, but were protected at or above the mid 1990s level. Nevertheless, average per capita outlays remained very low overall and were especially low in provinces such as West Java. During the economic downturn, much greater use was made of donor assistance, but such support did not, it appears, contribute to the sustainability of health financing and spending. There also were shifts in the composition of expenditures, including reduced per capita public spending on primary health care and a rise in per capita hospital outlays. These trends in outlays ran counter to policy rhetoric and actual needs. In short, spending patterns exhibited significant weaknesses as the country shifted to new funding and allocation arrangements in 2001. OVERALL TRENDS 3. This Brief revises and extends an August 1999 overview of government health outlays up to and though the economic crisis.1 Updated information, augmented with expenditure figures for the country's autonomous family planning agency (BKKBN), generally confirmed previous findings. Per capita public outlays on health rose significantly in current and constant prices between the late 1980s and the early 1990s, with the share of health in overall public spending nearly doubling between 1987/88 and 1992/93 (Figure 1, Annex Tables 1 and 2). Per capita spending then remained roughly stable in real terms before rising sharply just before the onset of the crisis in 1997/98--per capita spending in 1996/97 was more than twice that a decade earlier.2 During the economic downturn itself, real per capita expenditures fell significantly, by 2.9% and 6.6% in successive years, then rebounded in 1999/2000. (The share of health in overall public spending followed the same pattern of decline and recovery.) Overall and per capita spending each fell in 2000 in real terms. Still, per capita outlays in constant prices remained somewhat higher than the average figure, Rp. 12,600, for 1992/93-1995/96. GREATER RELIANCE ON DONOR ASSISTANCE 4. While government health outlays were sustained at or above the level attained in the mid 1990s, the mix of public spending sources and elements changed. These compositional adjustments offer clues as to impacts of expenditure reductions and subsequent fluctuations during the crisis. Spending changes also have implications for health financing in the decentralized framework which Indonesia is establishing. 5. One crisis-period adjustment was increased reliance on foreign assistance in the health sector. The donor share of health spending accounted for less than 10% in the mid 1990s, compared to 13% for 1990/91-1992/93. It then rose to 24% of total government health spending during 1998/99-1999/2000 and to 25% during the curtailed 2000 fiscal year (Annex Tables 1 and 2). Donor spending per capita grew fourfold in real terms between 1995/96 and 1999/2000 (Figure 1, Annex Table 3). 6. The use made of stepped up donor assistance can be discerned in part through changes in reliance on other financing channels. Broadly, the 278% increase in real foreign assistance in health in 1998/99 compensated in effect for a 21% fall in Rupiah funding--the net result was a 5% decrease in overall outlays. Within the government total, the DIK (-38%) and SDO (-32%) components, which fund wages and operational activities, and salaries, fell most sharply in 1998/99 (Annex Table 2). Reductions in these routine spending categories indicate that the real incomes and operational needs of health staff may have absorbed some of the crisis-linked 1 F. Saadah, S. Lieberman, and M. Juwono, "Indonesian Health Expenditures during the Crisis: Have They Been Protected?" the World Bank, East Asia and Pacific Region, Watching Brief No. 5, August 1999. 2 Because information for relevant years was not available, this comparison excludes spending on family planning (see Annex Table 2). -2- spending decreases. On the other hand, donor financing probably contained some of these impacts. In particular, the ADB-assisted health safety net mechanism, JPS-BK, though treated as investment support, provided opportunities to fund not only some operational activities and but related expenses of health center staff and village midwives. 7. In 1999/2000, overall donor health assistance rose an additional 17% in real terms (Annex Table 2). Meanwhile, DIK and SDO spending, funded through budgeted Rupiah resources, rose at 32% and 20% in constant prices, while development outlays (DIP), which had increased by 9.7% in 1998/99, the first full crisis year, fell by 26% in 1999/2000. In contrast to the previous year, international support appears to have been used to offset reduced development allocations to health in the Rupiah budget. INCREASED SPENDING ON PUBLIC HOSPITALS 8. Along with greater use of donor resources, the crisis period brought adjustments in program content. One unexpected change was the rise in the share and level of hospital outlays in real per capita government spending (Annex Tables 4 and 5). Actually, this trend actually began before the crisis. Per capita hospital spending gains had lagged well behind those for primary level care through the mid 1990s. But in the 1995/96-1997/98 interval, real hospital outlays per capita grew by 13% while those for primary care rose by 10%. During the crisis (1997/98-1999/2000), real government hospital expenditures per person rose by 22%, while those for primary level services fell by 10%. 9. Within primary care, real spending on the health services and communicable disease components fell during 1998/99 but was then restored in 1999/2000 thanks to large flows through JPS-BK, the country's crisis-period health safety net scheme, introduced the previous year. Outlays on other primary care elements, including family planning and health education activities and program management, were not sustained in real terms (Annex Table 5). Funding for administration of hospital-related activities also fell in real terms during the crisis. But real spending on the main element, public hospital services, appears to have not only been protected but actually was raised in 1998/99 and 1999/2000 (Annex Table 5). 10. Donor assistance helped to sustain the financing of specific program components. Due in part to ADB backing for JPS-BK, support for primary care in the 1998/99-1999/2000 interval was twice as large in real terms as that in the 1996/97-1997/98 period. Within this heading, donor resources were directed mainly to health services and communicable disease support. In addition, a large allocation in 1998/99 only accounted for more than a third of spending on family planning (Annex Figure 1; Annex Table 6). 11. But even larger levels of donor funding went to government hospitals. Real donor financing of hospitals in 1998/99-1999/2000 was 3.6 times the 1996/7-1997/98 level. It appears that much of this financing came from Japan, Korea, Austria, and other bilateral donors and took the form of investment in hospital equipment. -3- SPENDING IN SELECTED PROVINCES 12. Province-level information throws further light on trends in health spending. Data for Lampung, North Sumatera, West Java, and Yogyakarta show that per capita public spending varied widely before the crisis. In 1996/97, per government health spending in West Java was 38% of that inYogyakarta and half of the national mean, while outlays in Lampung and North Sumatera were also well below the national figure before the economic downturn (Annex Tables 7 and 8). Real spending on the principal health components also varied substantially, with very low figures recorded for per capita outlays on primary care in West Java and hospital services in Lampung (Annex Table 8). Moreover, provincial spending was affected differentially during the crisis. Within the sample of provinces, per capita spending during the crisis fell by almost a third in Yogyakarta and North Sumatera , while West Java recorded a 26% reduction. At Rp, 4400 per person in 1999/2000, government health outlays in West Java comprised only 36% of average spending country-wide. During the crisis, real primary care spending in West Java, which was already far below the national figure, fell by 25%. Primary care spending was sustained more effectively in the other three provinces, while hospital services were generally protected in terms of real funding (Annex Table 8). 13. The four provinces drew on donor financing to differing extents during the crisis. For instance, the absolute amounts and budget share of donor aid more than doubled in Lampung and North Sumatera compared to the two pre-crisis years. Use of foreign financing rose less sharply in Yogyakarta and West Java. As regards allocations, In North Sumatera, international assistance funded primary care services for the most part, but in Lampung, West Java, and Yogyakarta, donor resources went largely to hospitals. DISCUSSION 14. How successful and what followed from GOI's health sector interventions during the economic crisis? A definitive view on crisis outcomes is not yet available as information on health and other impacts is still being collected and assessed. In the interim, the findings reported above can be interpreted in several ways. 15. In one perspective, GOI and the international community worked together effectively in crisis circumstances to protect government health spending. These efforts paid off. Facilities remained staffed and operational, and immunization, family planning, and other key services proceeded without major interruption. This is corroborated in national household survey findings which show that family planning use and coverage of BCG, measles, and DPT immunization in 1999 were at par with 1997.3 In short, Indonesia avoided the sort of catastrophic health setbacks seen in other countries undergoing economic shock and adjustment. This was accomplished through skillful use of donor assistance, which was available in substantial amounts when needed. 3 See Tables generated from different SUSENAS rounds in M. Pradhan, forthcoming. -4- 16. However, a closer look yields a less optimistic reading of events. It is known, for instance, that services in government health facilities were disrupted in the second half of 1997/98 and the first two quarters of 1998/99 due to shortages of drugs and operational funds. Stringent informal rationing and other controls were applied during this period. Not surprisingly, outpatient visits to government health services fell by a quarter in 1998. And there has been slippage in protecting the population against immunizable diseases. For example, 26 of 28 provinces recorded drops in measles vaccination in 1998 or 1999, and coverage rates in 2000 were below 1997 levels in 17 provinces.4 17. It would also not be surprising if crisis-related income reductions, rising poverty proportions, and reduced service utilization and coverage were associated with reversals in health outcomes. The mortality data needed to throw light on this point are not available. But suggestive evidence is found in trends in morbidity rates for illnesses considered to be "disruptive" by respondents. For example, the 1998 and 1999 SUSENAS rounds detected sizable increases over 1997 in acute morbidity, with sickness rates rising significantly amongst the poor, children and the elderly, and in particular provinces, e.g., West Java and Lampung. These increases eliminated morbidity gains achieved in the 1995-97 interval. 5 And these patterns are consistent with trend indications in malaria and several other deadly diseases, and in micro-nutrient deficiency diseases. 18. These outcomes are attributable, in this reading of events, to financing delays and reductions, and resource reallocations during the crisis. Donor resources arrived in a timely fashion, but it took much of 1998/99 for JPS-BK's distinctive funding and delivery instruments to become operational. Thanks in large measure to this program, funding and service delivery rebounded to an extent in 1999/2000. JPS-BK also seems to have introduced more effective provider incentives and accountability arrangements.6 Nevertheless, this scheme encountered numerous implementation problems, similar to those experienced in pre-crisis GOI health initiatives.7 And this program's start-up glitches may have contributed to the changing mix of 4 This point is based on figures supplied by the Directorate for Communicable Disease Control in MOHSW. See also Global Alliance for Vaccines and Immunization, "National Level Assessment of Immunization Services in the Republic of Indonesia," c/o UNICEF, Geneva, Switzerland, April 2001. 5 See F. Saadah, M.Pradhan, and S. Surbakti, "Health Care during Financial Crisis: What Can We Learn from the Indonesian National Socioeconomic Survey?" World Bank, HNP Notes, July 2000. 6 See S.Lieberman and P. Marzoeki, "Health Strategy in a Post-Crisis, Decentralizing Indonesia, "World Bank Report No.21318-IND, November, 2000. 7 Concerns, voiced by province and district-level staff and NGOs, have centered on "eligibility criteria and accountability checks relating to funds transferred through postal accounts; delays in funds received through conventional channels; an unfavorable public image in part due to inadequate dissemination of information on the program to intended beneficiaries, opinion leaders, and other constituencies; overly rigid guidelines; weak coordination between government units; cumbersome referral and reimbursement procedures for patients sent to hospitals; and weaknesses in targeting recipient of food supplements. Local health officials have also drawn attention to the inequities inherent in providing grants of identical amounts throughout the country. For example, the standard puskesmas allocation of Rp 10,000 per family per year was insensitive to variations in family size, disease prevalence, unit costs of delivering services, and visit rates. Lastly, health officials have been highly critical of the lack of performance findings which has made it difficult to develop remedial steps," (Lieberman and Marzoeki, 2000, p.22). -5- government health spending (see para.8). Specifically, increased real spending on hospitals may have responded to rising demand for outpatient care as customers bypassed primary care facilities which were barely operational starting in the second half of 1997/98. Of course, the ready availability of donor support for hospitals and government efforts to ensure that such facilities were supplied with drugs and medical consumables were contributory factors. 19. Adverse impacts on health sector financing also need to be included among the effects of Indonesia's recent economic crisis.. Health funding arrangements were a concern long before the economic downturn. Private services were paid for mainly in cash at the time of purchase as insurance coverage was very limited. Government spending depended on annual budget allocations and varied considerably from year to year. For various reasons, policy commitment was inadequate and resulted in per capita public outlays well below those in comparable countries, with expenditures in some provinces, including West Java, falling far short of inadequate national figures. 20. During the crisis, this flawed system was disrupted and weakened further by the ad hoc allocation of donor and domestic resources. International assistance was used opportunistically to fill current gaps in different spending categories. This probably diluted previous financial procedures and controls, and weakened implementation and accountability practices within the activities which received funding. And even less attention than before the crisis was given to introducing practical, experience-tested health financing reforms. 21. In this regard, MOH's decision to move ahead with its futuristic national health maintenance program, JPKM, was paradoxical and questionable. This approach combines the HMO model developed in the USA with other design elements. Using JPS-BK and other crisis resources, the government set up funds holding entities called Bapels in each district. Expected to eventually become the local anchors in the JPKM system, Bapels were given crisis period resource allocation assignments. The outcome was largely unfavorable from two perspectives. First, the Bapels do not seem to have improved JPS-BK performance in any respect. Second, it is doubtful whether these units, often staffed by active or ex-civil servants, gained experience in serving customers, assessing health risks, collecting and investing funds, setting rates, and working with providers to deliver services. 22. Finally, the above discussion points to various health risks as Indonesia implements and fine-tunes its decentralized government framework. Districts and provinces are inheriting health services which have been weakened and to an extent discredited by inadequate and unpredictable funding. In addition, the transfer of service responsibilities, staff, and facilities is taking place against a backdrop of disarray and lack of innovation in health financing. The old, crisis- compromised system of numerous centrally controlled channels is still in place though expected to transfer much lower funding flows. Meanwhile, only limited efforts have been made to foster insurance-based or other sustainable, prepaid arrangements. And compared to the imperfect mechanisms relied on until December 2000, there appear to be fewer instruments available now -6- to address the health funding inequities which are apparent in provincial and district data. For these and other reasons, the health status of Indonesians remains highly vulnerable as the country grapples with decentralization. Figure 1 Government Health Expenditures, Overall and by Major Component, Per Capita Constant Prices, 1993=100 16 14 12 10 (Rp. 000) 8 6 4 2 0 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 2000 (12mos) GOI Funding Per Capita Donor Assistance Per Capita Total Spending Per Capita Data Source: See Annex 9 -7- Annex Table 1 Public Sector Health Expenditures by Level of Government, 1984/85 - 2000 In Billions of Rupiah 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 MoH - DIP 101.7 94.7 58.3 27.7 79.6 76.7 149.3 229.6 314.3 376.2 411.1 420.0 485.2 592.9 1,210.1 1,041.9 - OPRS 49.0 49.0 53.9 50.8 52.7 50.9 - DIK 97.3 122.6 134.4 143.9 161.0 190.9 235.5 290.6 368.7 475.5 492.0 673.6 800.2 1,004.0 966.3 1,609.5 - DIK-S 3.1 15.9 66.8 84.1 106.7 116.7 171.1 215.6 -INPRES 98.5 94.4 109.1 76.3 -DIP DA I 26.7 31.2 41.9 48.1 59.2 74.4 72.1 97.8 116.5 104.7 66.5 297.7 -DIP DA II 42.4 65.5 111.6 149.3 199.1 220.1 196.9 219.1 258.4 316.8 268.2 270.6 Foreign exchange subsidy 559.0 199.0 for raw material for drugs BKKBN - DIP 101.8 134.3 159.2 207.6 220.4 215.0 225.1 309.6 236.0 109.7 171.1 - DIK 62.1 73.7 88.1 116.5 156.3 177.2 207.6 238.6 297.0 327.3 425.8 MoRA (DIP) 0.2 0.2 0.2 0.2 0.2 0.2 SDO 117.3 160.6 174.8 187.7 171.1 255.5 255.6 295.5 334.6 385.0 443.0 532.6 624.7 738.8 871.7 1,320.7 -DIK DA I 69.3 89.2 101.5 172.3 220.6 323.4 41.0 47.5 35.0 36.0 39.0 86.0 76.5 71.5 105.5 109.0 -DIK DA II 63.1 89.7 98.9 118.9 175.5 193.1 Total GOI 455.8 519.8 511.6 471.6 519.8 869.6 1,078.4 1,380.9 1,757.5 2,086.6 2,257.4 2,691.7 3,191.3 3,698.3 4,946.3 6,068.5 BLN-MoH 30.3 41.0 24.4 25.3 133.6 218.2 136.2 164.3 271.6 155.5 169.9 166.1 297.1 308.4 1,257.7 2,118.8 BLN-BKKBN 49.5 19.8 12.2 64.3 52.3 47.7 17.1 13.2 4.1 362.3 91.0 Total BLN 30.3 41.0 24.4 25.3 133.6 267.7 156.0 176.5 335.9 207.8 217.6 183.2 310.3 312.5 1,620.0 2,209.8 Total BLN in million $ 29.4 36.8 19.0 15.4 77.8 149.8 82.9 89.3 163.9 98.7 99.6 80.3 131.0 67.4 165.6 295.1 % Annual change 25.0% -48.3% -19.0% 405.3% 92.5% -44.7% 7.8% 83.5% -39.8% 1.0% -19.4% 63.2% -48.6% 145.7% 78.2% Total GOI+BLN w/o BKKBN 486.1 560.8 536.0 496.9 653.4 973.4 1,026.4 1,310.1 1,769.3 1,917.7 2,082.8 2,442.2 2,953.4 3,477.8 6,129.3 7,681.5 % Annual change 15.4% -4.4% -7.3% 31.5% 49.0% 5.4% 27.6% 35.1% 8.4% 8.6% 17.3% 20.9% 17.8% 76.2% 25.3% Total GOI+BLN 486.1 560.8 536.0 496.9 653.4 1,137.3 1,234.4 1,557.4 2,093.4 2,294.4 2,475.0 2,874.9 3,501.6 4,010.8 6,566.3 8,278.3 % Annual change 15.4% -4.4% -7.3% 31.5% 74.1% 8.5% 26.2% 34.4% 9.6% 7.9% 16.2% 21.8% 14.5% 63.7% 26.1% Population in million 161.6 164.0 166.5 169.2 172.0 175.6 179.3 181.6 183.9 186.2 188.6 191.0 193.4 195.9 198.4 200.9 Spend perCap in thousand 3.0 3.4 3.2 2.9 3.8 5.5 5.7 7.2 9.6 10.3 11.0 12.8 15.3 17.8 30.9 38.2 w/o BKKBN % Annual change 13.7% -5.9% -8.8% 29.4% 45.9% 3.3% 26.0% 33.4% 7.0% 7.2% 15.8% 19.4% 16.3% 74.0% 23.8% Spend perCap in thousand 3.0 3.4 3.2 2.9 3.8 6.5 6.9 8.6 11.4 12.3 13.1 15.1 18.1 20.5 33.1 41.2 % Annual change 13.7% -5.9% -8.8% 29.4% 70.5% 6.3% 24.6% 32.7% 8.2% 6.5% 14.7% 20.3% 13.1% 61.7% 24.5% Total GOI Expenditure 17,780.7 23,746.5 22,807.9 27,110.4 33,252.1 39,729.1 47,371.9 52,127.5 60,511.7 68,718.0 74,760.7 79,215.7 98,512.9 127,948.5 202,715.9 207,641.0 %Health/Total GOI 2.7% 2.4% 2.4% 1.8% 2.0% 2.9% 2.6% 3.0% 3.5% 3.3% 3.3% 3.6% 3.6% 3.1% 3.2% 4.0% -8- Data Source: See Annex 9 Annex Table 2 Public Sector Health Expenditures by Level of Government, 1984/85 - 2000 In Billions of Rupiah, Constant Prices 84/85 85/86 86/87 87/88 88/89 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 2000(9mos) 2000(12mos) GDP Deflators, 1993=100 Government Consumption 47.2 52.9 54.6 54.8 56.2 64.3 70.0 76.3 86.9 99.9 106.4 116.7 127.5 143.7 223.1 281.7 324.7 315.6 Gross fixed capital formation 58.5 60.6 64.8 71.7 74.8 80.9 85.9 87.1 92.1 100.7 108.4 115.1 123.3 150.6 280.3 328.3 356.3 352.8 MoH - DIP 173.8 156.2 89.9 38.7 106.4 94.8 173.9 263.6 341.2 373.4 379.4 364.8 393.6 393.6 431.7 317.4 194.6 262.1 - OPRS 56.3 53.2 53.5 46.8 45.8 41.3 - DIK 206.3 231.8 246.0 262.4 286.4 297.1 336.5 380.6 424.2 475.8 462.6 577.1 627.7 698.8 433.1 571.3 464.6 637.4 - DIK-S 3.6 15.9 62.8 72.1 83.7 81.2 76.7 76.5 52.6 72.2 -INPRES 168.4 155.7 168.3 106.5 97.1 130.7 -DIP DA I 35.6 38.5 48.8 55.2 64.2 73.8 66.5 84.9 94.5 69.5 23.7 90.7 -DIP DA II 56.7 80.9 130.0 171.4 216.1 218.4 181.7 190.3 209.6 210.3 95.7 82.4 Foreign exchange subsidy 199.4 60.6 for raw material for drugs BKKBN - DIP 125.8 156.4 182.8 225.4 218.8 198.4 195.5 251.1 156.7 39.1 52.1 38.5 51.9 - DIK 96.7 105.3 115.4 134.0 156.4 166.6 177.9 187.2 206.7 146.7 151.1 128.8 176.7 MoRA (DIP) 0.2 0.2 0.2 0.1 0.1 0.1 SDO 248.7 303.6 319.9 342.3 304.4 397.7 365.2 387.0 385.0 385.2 416.5 456.3 490.1 514.2 390.7 468.8 368.1 505.0 -DIK DA I 65.1 76.4 79.6 119.9 98.9 114.8 86.9 89.8 64.1 65.6 69.4 133.9 109.3 93.6 121.4 109.1 128.7 176.6 -DIK DA II 59.3 76.8 77.6 82.7 78.7 68.5 Total GOI 884.1 937.0 888.2 815.4 858.9 1,265.3 1,425.5 1,706.0 1,968.4 2,080.3 2,106.1 2,318.2 2,536.1 2,533.7 2,014.4 2,054.4 1,472.9 2,012.6 % Annual change 6.0% -5.2% -8.2% 5.3% 47.3% 12.7% 19.7% 15.4% 5.7% 1.2% 10.1% 9.4% -0.1% -20.5% 2.0% -2.0% Total GOI w/oBKKBN 884.1 937.0 888.2 815.4 858.9 1,042.8 1,163.8 1,407.8 1,609.0 1,705.1 1,741.1 1,944.8 2,097.8 2,170.4 1,828.6 1,851.1 1,305.7 1,784.0 BLN-MoH 51.8 67.6 37.6 35.3 178.6 269.7 158.6 188.7 294.9 154.3 156.8 144.3 241.0 204.7 448.7 645.4 479.9 646.2 BLN-BKKBN 61.2 23.1 14.0 69.8 51.9 44.0 14.9 10.7 2.7 129.3 27.7 27.9 37.5 Total BLN 51.8 67.6 37.6 35.3 178.6 330.9 181.7 202.7 364.7 206.3 200.8 159.1 251.7 207.5 577.9 673.1 507.8 683.7 % Annual change 30.6% -44.3% -6.2% 405.8% 85.3% -45.1% 11.6% 79.9% -43.4% -2.6% -20.7% 58.2% -17.6% 178.6% 16.5% 1.6% Total BKKBN-GOI 222.5 261.7 298.2 359.4 375.2 365.0 373.4 438.3 363.4 185.8 203.3 167.3 228.6 TotalBKKBN/Family Planning 283.7 284.8 312.2 429.2 427.1 409.0 388.3 449.0 366.1 315.1 231.0 195.2 266.1 Total GOI+BLN w/o BKKBN 935.9 1,004.6 925.9 850.7 1,037.5 1,312.5 1,322.4 1,596.5 1,903.8 1,859.5 1,897.8 2,089.1 2,338.8 2,375.1 2,277.3 2,496.5 1,785.5 2,430.2 % Annual change 7.3% -7.8% -8.1% 21.9% 26.5% 0.8% 20.7% 19.2% -2.3% 2.1% 10.1% 12.0% 1.6% -4.1% 9.6% -2.7% Total GOI+BLN 935.9 1,004.6 925.9 850.7 1,037.5 1,596.2 1,607.1 1,908.7 2,333.1 2,286.5 2,306.9 2,477.3 2,787.8 2,741.2 2,592.4 2,727.5 1,980.7 2,696.3 % Annual change 7.3% -7.8% -8.1% 21.9% 53.9% 0.7% 18.8% 22.2% -2.0% 0.9% 7.4% 12.5% -1.7% -5.4% 5.2% -1.1% Population in million 161.6 164.0 166.5 169.2 172.0 175.6 179.3 181.6 183.9 186.2 188.6 191.0 193.4 195.9 198.4 200.9 203.5 Spend perCap in thousand 5.8 6.1 5.6 5.0 6.0 7.5 7.4 8.8 10.4 10.0 10.1 10.9 12.1 12.1 11.5 12.4 11.9 w/o BKKBN % Annual change 5.8% -9.2% -9.6% 20.0% 23.9% -1.3% 19.2% 17.8% -3.6% 0.8% 8.7% 10.5% 0.3% -5.3% 8.3% -3.9% Spend perCap in thousand 5.8 6.1 5.6 5.0 6.0 9.1 9.0 10.5 12.7 12.3 12.2 13.0 14.4 14.0 13.1 13.6 13.3 % Annual change 5.8% -9.2% -9.6% 20.0% 50.7% -1.4% 17.3% 20.7% -3.2% -0.4% 6.0% 11.1% -2.9% -6.6% 3.9% -2.4% -9- Data Source: See Annex 9 Annex Table 3 Donor Health Assistance by Major Components, Overall and Per Capita (Rp. bn) Current Prices 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 2000 (12mos) Primary Care 127.2 97.3 84.9 312.7 143.6 174.9 134.8 188.4 171.1 838.9 857.9 1,544.5 Hospital 140.6 58.7 91.6 23.2 64.2 42.7 48.4 121.9 141.4 781.1 1,351.9 867.5 Total 267.8 156.0 176.5 335.9 207.8 217.6 183.2 310.3 312.5 1,620.0 2,209.8 2,412.0 Constant Prices Primary Care 157.2 113.3 97.4 339.5 142.5 161.4 117.1 152.8 113.6 299.3 261.3 437.8 Hospital 173.8 68.4 105.2 25.2 63.8 39.4 42.1 98.9 93.9 278.7 411.8 245.9 Total 331.0 181.7 202.7 364.7 206.3 200.8 159.1 251.7 207.5 577.9 673.1 683.7 Population (million) 175.6 179.3 181.6 183.9 186.2 188.6 191.0 193.4 195.9 198.4 200.9 203.5 (Rp.mn) Current Prices Primary Care/Cap 0.724 0.542 0.467 1.700 0.771 0.927 0.706 0.974 0.873 4.228 4.270 7.591 Hospital/Cap 0.801 0.328 0.505 0.126 0.345 0.226 0.254 0.630 0.722 3.938 6.729 4.264 Total perCap 1.525 0.870 0.972 1.826 1.116 1.154 0.959 1.604 1.595 8.166 10.999 11.855 Constant Prices Primary Care/Cap 0.895 0.632 0.537 1.846 0.765 0.856 0.613 0.790 0.580 1.509 1.301 2.152 Hospital/Cap 0.990 0.381 0.579 0.137 0.342 0.209 0.220 0.511 0.479 1.405 2.050 1.209 Total perCap 1.885 1.013 1.116 1.983 1.107 1.065 0.833 1.301 1.059 2.913 3.350 3.361 Data Source: See Annex 9 -10- Annex Figure 1 Donor-Funded Government Health Expenditures Per Capita, in Constant Prices (1993=100) 2.5 2 1.5 (Rp. 000) 1 0.5 0 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 2000 (12mos) Primary Hospitals Data Source: See Annex 9 -11- Annex Table 4 Trends in Public Sector Health Expenditures, by Program (Rp. Bn) Current Prices PROGRAM 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 Primary Care 757.9 873.8 1,046.6 1,555.3 1,596.2 1,780.2 2,055.6 2,494.0 2,759.9 4,256.4 IEC, Health Services, Nutrition 397.4 461.9 559.8 703.2 789.6 880.3 1,029.5 1,230.7 1,419.8 2,186.1 CDC, Clean Water, Environmental Health 59.0 73.7 83.5 224.2 119.0 145.1 141.7 189.6 168.5 204.2 Quarantine 3.3 3.7 4.9 6.2 7.7 9.6 12.1 15.7 19.0 17.3 Warehouse for drugs 0.6 1.2 1.7 2.1 3.3 4.4 4.3 5.1 6.2 5.7 Health Education 15.3 19.4 26.0 33.0 41.8 112.1 123.5 133.9 156.1 202.6 Family Planning (BKKBN) 213.4 227.8 259.5 388.4 429.0 439.9 449.8 561.4 537.1 799.3 Other Programs 3.8 6.1 9.6 38.9 14.0 17.4 19.8 27.9 34.6 425.3 Dir General (2) 3.2 3.7 4.6 5.1 6.5 7.4 9.9 9.8 14.2 13.8 Regional Office-Province&District 42.6 54.7 66.6 87.8 120.3 137.0 233.8 283.4 362.0 361.0 Central Management and Other 19.3 21.5 30.4 66.3 65.0 27.1 31.3 36.5 42.3 41.0 Hospital 379.5 360.9 510.7 538.1 698.4 694.8 819.3 1,007.7 1,250.9 2,310.1 Hospital 318.9 294.3 415.2 426.8 541.3 584.1 677.6 834.2 1,032.9 1,914.4 Eyes & Lung 2.5 3.3 3.4 4.5 5.6 5.8 8.1 9.6 11.2 10.3 Other Programs 9.7 14.2 19.0 23.3 25.4 23.5 26.5 33.3 45.0 220.7 Dir General 5.4 5.2 7.2 10.3 4.4 14.3 13.4 14.1 14.1 14.1 Regional Office-Province&District 10.6 13.7 16.7 22.0 30.1 34.2 58.4 70.8 90.5 90.3 Central Management and Other 32.4 30.2 49.3 51.3 91.6 32.9 35.2 45.7 57.3 60.4 TOTAL 1,137.4 1,234.6 1,557.4 2,093.4 2,294.6 2,475.1 2,874.9 3,501.6 4,010.8 6,566.5 Data Source: See Annex 9 -12- Annex Table 5 Trends in Public Sector Health Expenditures by Program (Rp. Bn) Constant Prices, 1993=100 2000 PROGRAM 89/90 90/91 91/92 92/93 93/94 94/95 95/96 96/97 97/98 98/99 99/00 2000 (12 months) Primary Care 1,060.7 1,128.0 1,282.0 1,727.5 1,590.3 1,657.6 1,772.8 1,988.9 1,882.3 1,677.3 1,656.2 1,312.0 1,785.0 IEC, Health Services, Nutrition 573.1 605.6 690.6 785.2 786.9 820.1 887.9 981.6 966.4 859.7 904.6 617.4 840.7 CDC, Clean Water, Environmental Health 72.9 85.8 95.9 243.4 118.1 133.9 123.1 153.8 111.9 72.8 164.4 245.9 331.1 Quarantine 5.1 5.3 6.4 7.1 7.7 9.0 10.4 12.3 13.2 7.8 10.6 6.2 8.5 Warehouse for drugs 0.9 1.7 2.2 2.4 3.3 4.1 3.7 4.0 4.3 2.6 3.5 2.6 3.6 Health Education 23.8 27.7 34.1 38.0 41.8 104.4 106.5 106.5 106.7 82.7 74.8 55.7 75.9 Family Planning (BKKBN) 283.7 284.8 312.2 429.2 427.1 409.0 388.3 449.0 366.1 315.1 231.0 195.2 266.1 Other Programs 5.3 7.7 11.6 42.5 13.9 16.1 17.1 22.4 23.3 152.7 57.7 9.0 12.2 Dir General (2) 5.0 5.3 6.0 5.9 6.5 7.0 8.5 7.7 9.9 6.2 9.2 5.0 6.8 Regional Office-Province&District 66.2 78.2 87.3 101.1 120.4 128.8 200.3 222.3 251.9 161.8 185.5 164.1 225.1 Central Management and Other 24.6 25.8 35.7 72.6 64.6 25.2 27.1 29.3 28.6 15.9 14.9 11.0 15.0 Hospital 535.6 479.4 626.8 605.6 696.4 649.4 704.6 798.9 858.9 915.2 1,071.3 668.7 911.4 Hospital 448.7 389.8 507.6 479.4 539.6 545.4 583.1 662.2 708.3 757.6 949.1 584.4 795.8 Eyes & Lung 3.9 4.7 4.5 5.2 5.6 5.5 6.9 7.5 7.8 4.6 5.8 4.9 6.8 Other Programs 14.5 19.2 23.7 26.2 25.3 22.0 22.7 26.4 30.8 81.3 40.3 15.2 20.8 Dir General 8.4 7.4 9.4 11.9 4.4 13.4 11.5 11.1 9.8 6.3 3.0 2.4 3.3 Regional Office-Province&District 16.6 19.5 21.8 25.3 30.1 32.2 50.1 55.6 63.0 40.5 46.4 41.0 56.3 Central Management and Other 43.5 38.6 59.8 57.7 91.3 30.8 30.3 36.2 39.3 24.9 26.7 20.8 28.4 TOTAL 1,596.3 1,607.4 1,908.7 2,333.1 2,286.7 2,306.9 2,477.3 2,787.8 2,741.2 2,592.5 2,727.5 1,980.7 2,696.3 Data Source: See Annex 9 -13- Annex Table 6 Donor Support by Program and Year, Constant Prices ( Rp. Bn) 2000 PROGRAM 96/97 97/98 98/99 99/00 2000 (12 months) Primary Care 152.8 113.6 299.3 261.3 325.1 437.8 IEC, Health Services, Nutrition 71.5 66.2 114.1 161.9 120.9 162.8 CDC, Clean Water, Environmental Health 47.2 21.5 32.5 57.8 159.7 215.1 Quarantine, Environmental Health Warehouse for drugs Health Education 13.4 10.4 15.8 7.9 11.6 15.6 Family Planning (BKKBN) 10.7 2.7 129.3 27.7 27.9 37.5 Other Programs 3.1 6.0 4.2 4.2 2.3 3.1 Dir General (2) Regional Office-Province&District Central Management and Other 7.0 6.7 3.4 1.7 2.7 3.7 Hospital 98.9 93.9 278.7 411.8 182.6 245.9 Hospital 91.9 83.1 266.2 401.4 179.5 241.7 Eyes & Lung Other Programs 2.1 5.1 6.8 7.4 1.4 1.9 Dir General Regional Office-Province&District Central Management and Other 4.9 5.7 5.6 3.0 1.7 2.3 TOTAL 251.7 207.5 577.9 673.1 507.8 683.7 Data Source: See Annex 9 -14- Annex Table 7 Real Public Expenditures on Health in Selected Provinces in the Late 1990s by Major Program 96/97 97/98 98/99 99/00 West Java Primary Care 221.9 254.4 353.0 398.3 Hospital 85.3 101.2 121.7 187.8 Total 307.3 355.6 474.7 586.1 N. Sumatra Primary Care 94.1 116.3 139.3 182.4 Hospital 39.2 49.4 52.9 70.9 Total 133.3 165.7 192.2 253.3 DI Yogyakarta Primary Care 32.2 43.9 48.3 61.4 Hospital 24.3 27.0 37.2 349.7 * Total 56.5 70.9 85.5 411.1 * Lampung Primary Care 44.7 53.8 83.0 85.7 Hospital 9.2 12.8 17.6 31.9 Total 54.0 66.5 100.6 117.6 Data Source: See Annex 9 * Apparently reflects a substantial Letter of Credit amount from the donor which was issued and processed in 1999/2000 and is thus counted as a realized expenditure. -15- Annex Table 8 Real Public Expenditures on Health in Selected Provinces in the Late 1990s by Major Program: Total and Per Capita (1993=100) 96/97 97/98 98/99 99/00 West Java Primary Care (Rp. Bn) 176.3 174.1 141.6 134.8 Hospital (Rp. Bn) 67.4 69.9 52.0 64.6 Total (Rp. Bn) 243.8 244.0 193.6 199.5 Population (million) 40.2 41.1 42.0 43.6 Primary Care/Cap (Rp.000) 4.4 4.2 3.4 3.1 Hospital/Cap (Rp.000) 1.7 1.7 1.2 1.5 Total/Cap (Rp.000) 6.1 5.9 4.6 4.6 N. Sumatra Primary Care (Rp. Bn) 74.5 79.8 57.5 61.8 Hospital (Rp. Bn) 31.1 34.0 22.2 24.3 Total (Rp. Bn) 105.6 113.8 79.7 86.2 Population (million) 11.2 11.3 11.4 11.5 Primary Care/Cap (Rp.000) 6.7 7.1 5.0 5.4 Hospital/Cap (Rp.000) 2.8 3.0 1.9 2.1 Total/Cap (Rp.000) 9.4 10.1 7.0 7.5 DI Yogyakarta Primary Care (Rp. Bn) 25.5 30.1 19.9 21.0 Hospital (Rp. Bn) 19.2 18.7 15.5 109.1 * Total (Rp. Bn) 44.7 48.7 35.4 130.1 * Population (million) 3.0 3.0 3.1 3.1 Primary Care/Cap (Rp.000) 8.5 10.0 6.4 6.8 Hospital/Cap (Rp.000) 6.4 6.2 5.0 35.2 * Total/Cap (Rp.000) 14.9 16.2 11.4 42.0 * Lampung Primary Care (Rp. Bn) 35.5 36.9 33.3 29.1 Hospital (Rp. Bn) 7.3 8.7 7.0 10.4 Total (Rp. Bn) 42.9 45.6 40.2 39.5 Population (million) 6.4 6.5 6.6 6.7 Primary Care/Cap (Rp.000) 5.5 5.7 5.0 4.3 Hospital/Cap (Rp.000) 1.1 1.3 1.1 1.5 Total/Cap (Rp.000) 6.7 7.0 6.1 5.9 National Primary Care (Rp. Bn) 1,988.9 1,882.3 1,677.3 1,656.2 Hospital (Rp. Bn) 798.9 858.9 915.2 1,071.3 Total (Rp. Bn) 2,787.8 2,741.2 2,592.5 2,727.5 Population (million) 193.4 195.9 198.4 200.9 Primary Care/Cap (Rp.000) 10.3 9.6 8.5 8.2 Hospital/Cap (Rp.000) 4.1 4.4 4.6 5.3 Total/Cap (Rp.000) 14.4 14.0 13.1 13.6 Data Source: See Annex 9 * See note to Annex Table 7 -16- Annex 9, Data Sources, Definitions, & Notes Source of data All data were from MOF except for the following: · The foreign exchange subsidy 98/99 was from Nota PAN. · The foreign exchange subsidy 99/00 was from Balai POM. · The SDO (Subsidi Daerah Otonomi) was estimated for 1999/2000. · DIPDA I and II for 1988/89-1993/94 were estimated as 67% and 85% respectively of their yearly totals within the overall Health and Social Welfare category (sector code 13). · DIKDA I and II for 1984/85-1993/94 were estimated. Definitions Nota PAN: A book published yearly by MOF and BPK which includes all GOI revenues and expenditures audited by BPK (Comptroller). Balai POM: Food and Drug Control Agency. Routine funds DIK: National level routine budget. Intended mainly for salaries, operation and maintenance, procurement of medicines and consumables, replacement equipment and expendable supplies. DIKDA I: Provincial routine budget (includes locally generated funds) DIKDA II: District routine budget (includes locally generated funds). DIK-S: Non taxable income from hospitals, which is returned to finance routine expenditures. Development funds BLN: Foreign assistance channeled through the development budget (Bantuan Luar Negeri). DIP: National level development budget. DIPDA I: Provincial development budget (includes locally generated funds). DIPDA II: District development budget (includes locally generated funds). INPRES: Grant financing for health center construction and some operating costs (drug purchases, clean water, and environmental health). OPRS: Hospital buildings renovation, equipment maintenance, and additional consumables of medicines for public hospitals. -17- Notes MORA: Includes spending to assist in communicable disease control. How the health budget was mapped to primary care (PC) and hospital-related spending (Annex Table 4): 1. PC includes IEC, Health Services, CDC, Nutrition, Environmental Health, Water, Health Education, Family Planning. 2. Hospital Spending includes Improvement of Medical Services; Expansion of Hospitals; Referral Services; Operation and Maintenance for Hospitals; and Laboratory Services. 3. Other programs and outlays were distributed proportionately between PC and hospitals. Two Types of Deflators: Government Consumption: used for DIK, DIK-S, SDO, DIKDA I and II. Gross Fixed Capital Formation: for DIP, BLN, INPRES, DIPDA I and II. -18- Annex Figure 2 Flow of Funds to Health Before and After Decentralization Before 2001 Health Share from APBN: DIK, Locally Generated SDO: SBO-RSD APBN: DIP- INPRES DIP, and Revenues & Shared & SALARY MORA BLN - MOH Revenues DIP DA II DIK DA II Local Hospitals, Puskesmas, MOH Health Programs, Kanwil, Kandep and Kantor Dinas 2001 APBN: DIK, APBN: Health Share from Locally Generated Revenues & DAU DIP, and DIP- Shared Revenues BLN - MOH MORA DIP DA II & DIK DA II Local Hospitals, Puskesmas, MOH Health Programs, and Kantor Dinas -19-