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Health Policy Plan. 2017 Feb;32(1):91-101. doi: 10.1093/heapol/czw101. Epub 2016 Aug 6.

Sub-national health care financing reforms in Indonesia.

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Development Economics Group, Wageningen University, Hollandseweg 1, 6706 KN Wageningen, The Netherlands
International Institute of Social Studies, Erasmus University Rotterdam, Kortenaerkade 12, 2518 AX The Hague, The Netherlands.
Crawford School of Public Policy, Australian National University, HC Coombs Building No. 9, Fellows Road, Canberra, ACT, 2601, Australia.
SMERU Research Institute, Jl. Cikini Raya No. 10A, Jakarta 10330, Indonesia.


Indonesia has seen an emergence of local health care financing schemes over the last decade, implemented and operated by district governments. Often motivated by the local political context and characterized by a large degree of heterogeneity in scope and design, the common objective of the district schemes is to address the coverage gaps for the informal sector left by national social health insurance programs. This paper investigates the effect of these local health care financing schemes on access to health care and financial protection. Using data from a unique survey among District Health Offices, combined with data from the annual National Socioeconomic Surveys, the study is based on a fixed effects analysis for a panel of 262 districts over the period 2004-10, exploiting variation in local health financing reforms across districts in terms of type of reform and timing of implementation. Although the schemes had a modest impact on average, they do seem to have provided some contribution to closing the coverage gap, by increasing outpatient utilization for households in the middle quintiles that tend to fall just outside the target population of the national subsidized programs. However, there seems to be little effect on hospitalization or financial protection, indicating the limitations of local health care financing policies. In addition, we see effect heterogeneity across districts due to differences in design features.


Decentralization; Indonesia; health care utilization; health financing; health insurance; local government

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