VZCZCXYZ0001
PP RUEHWEB

DE RUEHJA #1498/01 2200233
ZNR UUUUU ZZH
P 070233Z AUG 08
FM AMEMBASSY JAKARTA
TO RUEHC/SECSTATE WASDC PRIORITY 9722
INFO RUEAUSA/DEPT OF HHS WASHINTON DCQ

UNCLAS JAKARTA 001498 
 
SIPDIS 
SENSITIVE 
 
USAID FOR KHILL/GH, JBORRAZZO/GHIDN, SSOLAT/ASIA/EAA 
FA FOR DDIJKERMAN, GAC FOR MDYBUL 
SENSITIVE BUT UNCLASSIFIED 
 
E.O. 12958: N/A 
TAGS: SENVCASCEAIDID
SUBJECT: 2008 HEALTH PUBLIC EXPENDITURE REVIEW: 
POOR PERFORMANCE 
 
¶1. (SBU) Summary. The World Bank has completed a Health 
Public Expenditure Review (HPER) for Indonesia. 
 
The review confirms preliminary 2007 DHS results: no 
improvement in child death rates over the past five years, 
compared to a 53% decline from 1994 to 2002; a drastic 
erosion of breastfeeding best practices; effective 
treatment for diarrhea diminishing; the highest maternal 
mortality rate in East Asia, fertility rates remaining 
unchanged; slight increases in immunization and skilled 
birth attendance, and a continued high maternal mortality 
ratio with 420 maternal deaths per 100,000 live births. 
These findings corroborate the poor performance of the 
GOIQs recently-decentralized health system.  End Summary. 
 
- Challenges 
 
¶2. The HPER highlights the challenges of overall adequacy 
of funding, the roles of public versus private expenditures 
in the health sector, the roles of central and regional 
budgets, appropriate mechanisms for mobilizing resources 
and purchasing services, and the proportion of public 
expenditure that should be devoted to public health as 
opposed to individual medical care. 
 
- Looking forward 
 
¶3. Close collaboration with the Ministry of Health and 
National Bureau of Planning is important to ensure optimal 
use of limited resources available for health and to 
improve health outcomes and financial protection for the 
poor by increasing the coverage of health insurance for the 
poor (ASKESKIN). This is particularly essential in a time 
of escalating fuel and food prices. 
 
- Some better ideas 
 
¶4. The report provides nine ideas for making the health 
sector more efficient: 
 
1) make better use of the existing resources available for 
health, while also making more resources available in the 
medium term. 
 
2) in particular, make more resources available for 
reproductive health and allocate resources for referral and 
institutional deliveries. 
 
3) improve the allocation of resources for preventive care 
and allow sufficient resources for operations and 
maintenance to ensure quality of basic care. 
 
4) devote additional resources and attention to all major 
public goods that determine health outcomes. 
 
5) adjust the general allocation fund (DAU) to provide 
incentives for local civil service reform and allow 
operational use of deconcentrated funding. 
 
6) improved health outcomes and financial protection for 
the poor may be possible by increasing the coverage of the 
GOIQs health insurance for the poor program (ASKESKIN). 
 
7) ensure better financial sustainability of ASKESKIN by 
introducing cost-containment options. 
 
8) increase efficiency of service provision for publicly 
insured enrollees by allowing program beneficiaries to also 
use private providers. 
 
9) improve reporting systems and data availability. 
 
- Preliminary DHS data 
 
¶5. (SBU) Summary HPER findings complement the preliminary 
2007 Demographic Health Survey (DHS) results which provided 
evidence of poor performance of the recently Decentralized 
Health System in Indonesia and slowed progress toward 
Millennium Development Goals (MDGs). 
 
1) Indonesia has the highest maternal mortality ratios in 
East Asia, at 420 maternal deaths per 100,000 live births, 
about double the Philippines, three times that of Viet Nam, 
and four times that of Thailand. 
 
2) Child malnutrition rates have stagnated since 2000 and 
are increasing in some provinces such as Maluku and Papua 
 
(eastern Indonesia). 
 
3) Female literacy and access to clean water and sanitation 
are low among the poorest population. 
 
4) Geographical disparities and inequities persist for 
health-related MDGs. Health indicators perform better in 
Java and Bali, while eastern Indonesia lags behind. 
 
¶6. Medium Term Concerns: 
 
1) Indonesia still has considerable demographic momentum, 
with total population expected to hit 271 million by 2025, 
and to increase to almost 300 million by 2050.  This will 
substantially increase need and demand for health services. 
 
2) Migration and urbanization are accelerating. 
Urbanization will be accompanied by greater demand for 
health care. 
 
3) Substantial efforts are needed to address the continuing 
high maternal mortality ratio, this will represent a large 
cost item for the health sector. 
 
4) Emerging diseases, such as Avian Influenza and HIV/AIDS, 
have placed additional burdens on the health budget. 
 
5) Major changes in the method of financing health care, 
such as the expansion of effective health insurance 
coverage, will increase demand for services. 
 
¶7. Comment (SBU).  One unfortunate consequence of 
decentralization appears to be poor performance by the 
health sector with worrying outcomes, especially for 
IndonesiaQs poor, about 120 million people.  Recently, this 
disturbing trend has been aggravated by incompetent 
political leadership at the Ministry of Health and the 
knock on effect of budget subsidies for fuel and food which 
have disadvantaged investments in people.  Despite these 
challenges the Mission continues to actively engage with 
key players to work to turn the situation around, a task 
helped by recent steps that promise new resources for AI 
and HIV/AIDS, but hurt by cuts in funding for other health 
issues.  End comment 
 
HUME