Let’s Put It Into Context!

In order to understand the extent of the double burden in Indonesia, there needs to be some kind of context and background information of the country and its demographics right? Let’s gain more insight into the country Indonesia, with its 258,316,051 inhabitants! We reposted all the blogs, so it’s ordered in such a way that you can just scroll down to learn all about the wonderful country Indonesia!

But first, get into the Indonesian atmosphere by looking at the video ; )

Written by: Jessica


In this this blog we will talk about the number of people living in Indonesia, where they are living (since Indonesia is kind of different geographically, compared to other countries) and the age structure. Getting curious already?

Let’s find out!

Map of Indonesia (very useful for a country like Indonesia!)



Population distribution
Indonesia is a country that consists of about 17,500 islands, many is it? However, “only” 6,000 of them that are inhabited. The five main islands are Sumatra, Java, Kalimantan (Borneo), Sulawesi, and New Guina, and two major archipelagos; Nusa Tenggara and the Maluku Islands. Indonesia is the world’s fourth most populated country, but there are very large differences between the population of the different islands. About 60% of the country’s population lives on Java and it is one of the most densely populated areas in the world. Let’s see how the population was distributed in 2013…

[Source: Indonesia Health Profile 2013, Ministry of Health]

So what did you noticed? Did you compared the number of people living in certain areas/islands and looked at the map to have an idea of the sizes of these areas/islands? Many people live in areas which are actually far smaller than the areas where less people live is it?! For example, West Papua where the minority of Indonesian inhabitants live is much bigger than West Java where the majority of inhabitants live.

So let’s integrated this information into one map, to see the population density. The population density shows the average number of the population per 1 square kilometer.

blog-2[Source: Indonesia Health Profile 2013, Ministry of Health]

Now we can see it even more clear: in the larger areas the population density is less than 35 per square kilometer. In the smaller areas the population density can be even more than 250 per square kilometer. We now know that this is not only due to the fact that these areas are smaller, but more due to the fact that many more people live in these areas.

Age structure
Wondering how old the 258,316,051 inhabitants are on average?
Well, the majority of the Indonesians (42,35%) are between 25 and 54 years old, about a quarter between 0 and 14 years and the minority of the population (6,79%) is 65 years and older, followed by the group Indonesians between 55-65 years old with 8.4% of the population. And last, but not least, we have the group between 15 to 24 years old, which is about 17,03% of the Indonesian population. So, now you can do the calculation of the average yourself ; )
But we can also visualize it, by making a population pyramid…

[Source: CIA, 2016]

The pyramid and the percentages showed us that Indonesia has quite high number of young inhabitants. The body of the pyramid is wide, which reflects an increase of life expectancy and an increase of wealth and health condition.

Written by: Jessica


Skolnik, R (2016). Global Health 101 (3rd edition). Burlington: Jones & Barlett learning.

Indonesia Health Profile 2013. Ministry of Health, Republic of Indonesia. Retrieved 15 November. Retrieved from: http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Indonesia%20Health%20Profile%202013%20-%20v2%20untuk%20web.pdf

Cia.gov [internet]. The World Factbook. East & Southeast Asia: Indonesia. Retrieved 15 November. Retrieved from: https://www.cia.gov/library/publications/the-world-factbook/geos/id.html

The Economy

In terms of the economic context: did you know that Indonesia is classified as a lower-middle-income country?

So what does that actually mean?

The categorization “lower-middle-income country” is made by the Organization for Cooperation and Development (OECD) and it means that these countries have a gross national income per person between 1,036 and 4,085 dollar. However, the country continues to grow economically despite its status as a lower-middle income country.

Indonesia is the largest economy in Southeast Asia, but since 2012 the economic growth slowed down. This is due to the fact that the export boom  of the commodities had come to an end. Did you know that during the global financial crisis, Indonesia together with India and China were the only G20 members that were still growing? Furthermore, the Government of Indonesia managed to lower its debt-to-GDP ratio from 100% in 1999 (which was shortly after the financial crisis of Asia) to less than 25% today.
Do you know what the agriculture products of Indonesia are? No? Let’s list them…
  • tapping latex from the rubber treeRubber and similar products
  • Palm oil
  • Poultry
  • Beef
  • Forest products
  • Shrimp
  • Cocoa
  • Coffee
  • Medicinal herbs
  • Essential oil
  • Fish and its similar products
  • Spices

What about the industry products? Very varied: petroleum and natural gas, textiles, automotive, electrical appliances, apparel, plywood, handicrafts, footwear, rubber, cement, mining, medical instruments and appliances, chemical fertilizers, processed food, jewelry and not to mention tourism! And indeed, Indonesia is worth traveling to  ; )


So how is Indonesia now doing financially?

Poverty and unemployment is still a big issue in Indonesia and affects a big population of people, however, it has been greatly reduced over the last few decades. About 32 million people still live in poverty and about half of all households still remain around the national poverty line of about US$22 a month. So where precisely live the highest percentages of poor people in Indonesia? Papua Island had the highest percentage of poor population in 2013. And in Java Island, the province with the highest percentage of poor population (15 – 20%) was DI Yogyakarta in 2013. The map below gives a good overview.


However, it’s important to point out that  the depth and severity levels of poverty differs. And if we take  malnutrition into account, than we know that malnutrition undermines economic growth. Furthermore, it perpetuates poverty! People who are malnourished are more prone to develop diseases, but are also weak to fully participate in the “working life”. Hence, their income will reduce, which drives them even more in poverty. Not to mention, this also means less income to feed the children in poor households. Therefore,  it was one of the most important constraints to achieving many of the Millennium Development Goals (MDGs). So what does this mean if we look at inequalities? And what is the perception of the Indonesians themselves? Look at the video below to find out.

Employment rates have also increased and have contributed to fall in poverty rates. Other factors that remain a challenge are corruption, an inadequate infrastructure, and unequal distribution of resources between regions and a regulatory environment which is quite complex. The good news is that the subsidies for fuels is reduced significantly since 2015, which resulted in the Government redirecting its spending to development priorities.

So what about the health expenditures? Most important thing to know in our case. Well, only 3.0% of GDP in Indonesia  was spend on health in 2012. This was three times less than the OECD average of 9.3%. Furthermore, if we look at the health expenditure per capita, Indonesia ranks well below the OECD average (USD 3484), spending of only USD 150 in 2012.  However, we do know that health spending tends to rise with incomes and that in general countries with higher GDP per capita also tend to spend more on health. So in this case is not that surprising that Indonesia is still lacking behind compared with the high income countries. Do you want to see this comparison? Look at the figure below!


Did you know that the main source of health funding in nearly all OECD countries is the public sector? This again was lower in Indonesia, where 40% of health spending was funded by public sources in 2012.

In 2014 the total expenditure on health was 2.9 % of GDP. And the total expenditure on health per capita 299 (Intl $).

Written by: Jessica


Cia.gov [internet]. The World Factbook. East & Southeast Asia: Indonesia. Retrieved 15 November. Retrieved from: https://www.cia.gov/library/publications/the-world-factbook/geos/id.html

Skolnik, R (2016). Global Health 101 (3rd edition). Burlington: Jones & Barlett learning.

OECD Health Statistics 2014 How does Indonesia compare? OECD. Retrieved 15 November. Retrieved from: http://www.oecd.org/els/health-systems/Briefing-Note-INDONESIA-2014.pdf

Who.int [internet]. Countries. Indonesia. World Health Organization. Geneva. Zwitserland.[c 2016] Retrieved 15 November. Retrieved from: http://www.who.int/countries/idn/en/

Asian Development Bank (ADB). Social Protection Project Briefs. Investing in Children in Indonesia:  A Step Toward Poverty Reduction. Retrieved 16 November. Retrieved from: https://www.adb.org/sites/default/files/publication/28488/ino-nutrition.pdf

A Health System is like a car…

How is health care organized in Indonesia? To find out, we will have to dive into the health system of Indonesia. Again, let’s get that context more in sight! This blog wil give you more information on the definition of a Health system. You can scroll down for the other blogs that are specific on the Health System in Indonesia.

Do you know what a health system is and what it encompass?

A health system includes all the people, institutions and resources that are, in one way or the other, needed to improve the health of people.

Do you want a more precise definition?

Ok, the WHO describes a health system as the following: “All the activities whose primary purpose is to promote, restore, improve or maintain health, protect people against the impoverishing effects of illness, and ensure that those who need care are treated with dignity and respect

Or a more descriptive definition?

Roemer: “A combination of resources, organization, financing and management that culminate in the delivery of health services to the population” The last definition is quite comparable with a car. A car with all its different components! Yet, if the motor isn’t working, or the driver is missing, or there isn’t a steer or some wheels. Than how are you going to drive that care? We need them all right? Moreover, the car will drive at its best if all of these components work together in harmony! The same counts for a health system.

So we know some important components of a car, but what are the important components of a heath system?
Well, this is what a health system definitely needs in order to meet the health needs of people:journal-pmed-1000397-g001

  1. Finance
  2. Stewardship, which is leadership and governance (it’s the boy in the picture, responsible for the car to work. If not, than he will try to fix it).
  3. Health workforce
  4. Medical products, vaccines & technologies
  5. Service delivery (i.e. Clinics and hospitals)
  6. Information and research


So who would be the boy in the picture that is fixing the car in Indonesia?  That wil be the ministry of Health! Wondering who’s in charge there? It’s Prof. Dr. dr. Nila Farid Moeloek.

Prof. Dr. dr. Nila Farid Moeloek

Written by: Jessica


Murray, C.J.L. Frenk, J. A WHO Framework for Health System Performance Assessment. Evidence and Information for Policy World Health Organization. World Health Organization. Retrieved 01 December. Retrieved from: http://www.who.int/healthinfo/paper06.pdf

Wpro.who.int [internet]. Health Services Development. The WHO Health Systems Framework. Retrieved 19 November. Retrieved from: http://www.wpro.who.int/health_services/health_systems_framework/en/

Human Resources: the workforce of a health system.

There were 1765 hospitals  and 9.133 community health centers in Indonesia in 2010. The MOH planned to increase the number of community health centers with approximately 12.514 units by year 2019 and 14,826 units by year 2025. Furthermore, the development of hospitals is targeted to achieve the ratio of 1,5 beds per 1000 population by 2019 and 2  beds per 1000 population by year 2025.

But what is a health system without a strong workforce right? Even more important, is the number of health workers meaningful if the quality is poor? Let’s find out what the status of health workforce is in Indonesia.

We know from our previous blog that the population density throughout the country is quite divers due to geographic diversity. This also makes the provision of equitable health care services more difficult. Especially in the remote areas acces to health care services in puskemas (government-mandated community health clinics) is a big issue. The same counts for  the provision of the sufficient numbers of competent health workers in those areas. Furthermore, it poses a serious challenge for achieving the goals of JKN (scroll down for the blog on JKN ; ) ) and health development.

Luckily, the ratio of health workers to the overall population increased in Indonesia, which rapidly increased the overall number of health workers. Moreover, it’s more than the minimum number recommended by the WHO, which is 2.3 doctors, nurses and midwives per 1,000 population. So where did the increase came from? Well, much of the increase came from the private sector. You know how? They invest in medical schools. About 60 per cent of the 72 medical schools in Indonesia are private!

Does this means that Indonesia is there yet? No, there is always space for improvements.

37dc53c6-3b25-4715-adea-acdab8a125b5_maternity%20health%20care%20indonesia_61fa44aa_490x330Although the number of health workers increased, the achieved numbers are still insufficient to meet population growth and therefor the growing demand for health care.

Do you know on which level the shortfall is especially?

It’s at the primary health care level (puskesmas). Also, the shortfalls of midwives and nurses  in hospitals are a concern, since Indonesia needs to respond to the growing burden of Non Communicable Diseases (NCD)  and injuries. And thus, the double burden of disease, such as the double burden of malnutrition! And alongside, should try to reduce maternal and infant mortality. Furthermore, there is also a shortage  of other key health workers for public health and health promotion.

So what are the targets the Government wants to achieve in the future? You can find them in the tabel underneath which present the ratio per 100.000 population.

[ Source: The Indonesia Human Resources for Health Development Plan Year 2011 – 2025]

Than there is the distribution problem. Remember from our first blog within the Indonesian context section, that the country is quite different geographically, with all its Island. So imagine how you would distribute health care is such a way that it’s provided in an equal manner? Well the geographical distribution of health workers has been a longstanding challenge in Indonesia. And as of today, 30 of the 33 provinces do not have the WHO recommended standard of 1 physician per 1,000 population yet.

So what are the contributing factors of this impaired geographical distribution of health care? Well, Indonesia has a dual practice system, which means that health personnel is allowed to work in both public and private facilities. This is allowed in order to relieve budgetary pressure on government. However, it is also a contributing factor to mal-distribution of health personnel, particularly among specialist doctors.

So does the Government put effort to solve this problem? 

Yes, the Government of Indonesia both central and local level implemented a range of programs and policies to improve distribution and impact of health workers, but more work is needed. Additionally, mal-distribution of health workers in underserved and remote areas is of special concern and needs more attention. However, there are no specific policies for human resources in these areas currently. And next to that, a distribution policy has not considered the need of these specific regions.


So, what about the quality of the workforce?

The competency of health workers  is very important, since a lack of it will decrease people’s trust in the health care system and moreover, decrease the performance of the health system. Currently, the competency of the health workers in Indonesia is insufficient to respond to the challenges of service provision. Furthermore, because Indonesia does not have enough health workers, maximum benefit is needed from current health workers (and this will increase workload and pressure really). So what is important to improve this competence in health workers? Well, it starts with the quality of training facilities! At this moment there is much variability whiting these facilities and  only half of the schools are accredited.

What are the plans to improve the HRH situation in Indonesia?

According to the HRH plan (with the vision that “all people have access to qualified health workers”), beter and sufficient amount of workforce should be achieved with the following four missions:

1. Strengthening regulation and planning for HRH development.
2. Improving the production/ HRH education.
3. Assuring the equitable distribution, well utilized and well developed of HRH.
4. Improving supervision and quality control of HRH  in health services.

So time to come in action!

Written by: Jessica


Health sector review. Policy briefs 2015 – 2019. Australia Indonesia Partnership for Health Systems Strengthening (AIPHSS). Retrieved 05 December 2016. Retrieved from: http://aiphss.org/wp-content/uploads/2014/12/Kumpulan-Policy-Brief_English_Bagian-I-23Nov2014.pdf

The Indonesia Human Resources for Health Development Plan Year 2011 – 2025 , summary. The World Health Organization. Retrieved 05 December 2016. Retrieved from: http://www.who.int/workforcealliance/countries/indonesia_hrhplan_summary_en.pdf


On the way to Universal Health Care!

By 2019 Indonesia wants to achieve universal health coverage for its citizens! A wonderful goal, but also challenging. Around 60% of the population isn’t covered yet and the out-of-pocket payments remains high even for those that are covered. Furthermore, many Indonesians that aren’t covered are in the informal sector. Another challenge is to ensure acces to quality health services in the remote areas of the country, which are the rural areas in particular. But, Indonesia isn’t afraid for some challenges!

So first an overview in the development of achieving universal heath coverage in Indonesia. A very promising goal to help all the citizens of Indonesia, especially as the rising double burden of disease (due to the rise in NCDs and CDs) and the double burden of malnutrition means more demand on health care.

So in 2005, the “Asuransi Kesehatan untuk Yang Miskin” or “Askeskin” was launched. At the time, this was a new Social Health Insurance for the Poor program. Let’s continue to 2008. In that year “Askeskin” evolved into an even broader program of health insurance, with  wider coverage and the lessons Askeskin were incorporated as well! The program was  also known as Jamkesmas. So in 2010, yet another new program was added. Why? It was needed to reduce maternal and child mortality. And the program provided coverage for all pregnant women. The program was a very good initiative don’t you think? Because a healthy mother increase the changes of a healthy baby! The program was called “Jaminan Persalinan” or “Jampersal”.


So how is going with the universal health coverage goal as of today?

In the final years the preparations of the launch of the new Jaminan Kesehatan Nasional (JKN) was up and running.  And the Government is now trying to design the JKN in such a way that the multiple programs (mentioned above) will consolidate under one national administrative, management and service system. At the same time the Government will try to identify the gabs that are there and “fill those gaps” in coverage. The JKN was launched in 2014.

What will universal health coverage bring?
It will improve equity and raise the quality of services. Something that is very much needed as you will realize when reading trough all our blogs. So a “road map” for continuing expansion of JKN will be made  to the eventually try to achieve universal health coverage by 2019.

The development of JKN was based on five core principles:

  1. The spirit and practice of gotong royong, meaning mutual support.
  2. Mandatory membership for all Indonesians by 2019.
  3. “Portability” of the right to service: members of JKN are entitled to service anywhere in Indonesia.
  4. Principles and best practice of social health insurance to guide the management of JKN.
  5. Medical service is equal for all JKN members; however, members paying all or a portion of their own membership can choose to pay for a higher level of in-patient service

So in order to achieve this the following key challenges of building and implementing JKN need to be tackled according to the the Ministry of Health:

  • Regulatory infrastructure for both service delivery and management
  • Finance, transformation, and integration of programs and institutions (from former programs)
  • Health facilities, referral, and infrastructure
  • Human resources and capacity building
  • Pharmaceutical and medical devices
  • Socialization and advocacy

So big challenges indeed! And you know what I think? That in this case very close collaboration between other ministries is needed. This is not only a job for the Ministry of Health, since it encompasses areas that fall under other ministries.

Written by Jessica


Mboi, N. Indonesia: On the Way to Universal Health Care.Minister of Health of the Republic of Indonesia, (2012–2014). Health Systems & Reform. Retrieved 08 December. Retrieved from: http://www.tandfonline.com/doi/pdf/10.1080/23288604.2015.1020642?needAccess=true

Pandu Harimurti, Eko Pambudi, Anna Pigazzini, and Ajay Tandon. UNICO Studies Series 8 The Nuts & Bolts of Jamkesmas, Indonesia’s Government-Financed Health Coverage Program for the Poor and Near-Poor. The World Bank, Washington DC, January 2013.