dynamic estimation model

DYNAMIC ESTIMATION MODEL: GAP BETWEEN NEEDS AND AVAILABILITY OF HEALTH SERVICES TO 2020

By: James P. Thompson, Ufara Zuwasti, Halimah, Fretta Raymanel, Finza Nurfrimadini

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DYNAMIC ESTIMATION MODEL: GAP BETWEEN NEEDS AND AVAILABILITY OF HEALTH SERVICES TO 2020 Compiled and published by: Working Group on Social Health Assistance Policy for Poor Families The Secretariat of the National Team for the Acceleration of Poverty Reduction (TNP2K) All rights reserved. © 2015 The Secretariat of the Vice President of the Republic of Indonesia You are welcome to copy, distribute and submit reports for non-commercial purposes. To request a copy of this report or more details about this report, please contact TNP2K Communication & Management Unit Knowledge ([email protected]) This report is also available in Indonesian bahasa on the TNP2K website (www.tnp2k.go.id) NATIONAL TEAM OF ACCELERATION OF POVERTY REDUCTION Secretariat of the Vice President of the Republic of Indonesia Jl. Kebon Sirih No. 14 Central Jakarta 10110 Phone: (021) 3912812 | Facsimile: (021) 3912511 E-mail: [email protected] Website: www.tnp2k.go.id

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ACKNOWLEDGEMENTS This study was prepared by the Working Group on Social Assistance Policy Health for Poor Families, National Acceleration Team Secretariat Poverty Reduction (TNP2K). The core team of researchers includes Prof. James P. Thompson, PhD (System Dynamics Consultant, principal research designer); Dr. Ufara Zuwasti, MSc (Health Programs Officer); and Halimah, BSc (Data Analyst), and supported by Dwi Oktiana Irawati, Fretta Ray Manel, and Finza Nurfrimadini. This study received valuable input from numerous parties and institutions: Minister of Health of the Republic of Indonesia, Prof. Dr. dr. Nila Juwita F. Moeloek, SpM (K) and Ministry of Health officials; Expert Staff of the Ministry Finance of the Republic of Indonesia, Isa Rachmatawarta; Director of Service BPJS-Health, Drg. Fajriadinur, MM, and staff; Former Chairman of the Council Medical Indonesia, Prof. Dr. Raising Rasmin, SpP (K); Chairman of the Center Economic Review and Health Policy of UI Medical Faculty, Prof. Dr. Hasbullah Thabrany, MPH, Dr.PH; AIPHSS Consultant, Prof. Dr. Ascobat Gani, MPH, Dr.PH; and Country Manager of IMS Health Indonesia, Anand Srinivasan. This study involves the ranks of Local Government, Health Facilities First Level Government-Owned and Private, and Health Facilities Advanced Government and Private. The project supervisors were Prastuti Soewondo, PhD (Chairperson of the Working Group on Health Insurance Policy TNP2K) and John Langenbrunner, PhD (Consultant TNP2K). Full project oversight was provided by Bambang Widianto, PhD, Executive Secretary of TNP2K.

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CONTENTS ACKNOWLEDGEMENTS .......................................................................................................................... iii LIST OF FIGURES .................................................................................................................................... vii LIST OF TABLES .....................................................................................................................................xvii ACRONYMS AND GLOSSARY ................................................................................................................ xxii EXECUTIVE SUMMARY ............................................................................................................................ 1 BACKGROUND ......................................................................................................................................... 7 DATA SOURCE ......................................................................................................................................... 9 METHODOLOGY .................................................................................................................................... 10 System dynamics modeling............................................................................................................... 10 Population, Demand, and Supply ..................................................................................................... 11 1.

Population ............................................................................................................................. 11

2.

Demand ................................................................................................................................. 13

3.

Supply .................................................................................................................................... 16

Results Interpretation ....................................................................................................................... 21 1.

Hospital bed, physician, and nurse ....................................................................................... 21

2.

Midwife ................................................................................................................................. 22

RESULTS ................................................................................................................................................ 23 Projected supply and demand at national level ............................................................................... 23 1.

Background ........................................................................................................................... 23

2.

Key Findings .......................................................................................................................... 23

3.

Summary of projection ......................................................................................................... 24

Projected supply and demand at provincial level ............................................................................. 35 1.

Aceh ...................................................................................................................................... 38

2.

North Sumatera .................................................................................................................... 45

3.

West Sumatera...................................................................................................................... 52

4.

Riau ....................................................................................................................................... 60

5.

Jambi ..................................................................................................................................... 67

6.

South Sumatera .................................................................................................................... 74

7.

Bengkulu ............................................................................................................................... 81

8.

Lampung................................................................................................................................ 88

9.

Bangka Belitung Islands ........................................................................................................ 95

10.

Kep. Riau ......................................................................................................................... 102

11.

DKI Jakarta....................................................................................................................... 109

12.

West Java ........................................................................................................................ 116 v

13.

Central Java ..................................................................................................................... 123

14.

DI Yogyakarta .................................................................................................................. 130

15.

East Java .......................................................................................................................... 138

16.

Banten ............................................................................................................................. 145

17.

Bali................................................................................................................................... 152

18.

West Nusa Tenggara ....................................................................................................... 159

19.

East Nusa Tenggara ......................................................................................................... 166

20.

West Kalimantan ............................................................................................................. 173

21.

Central Kalimantan.......................................................................................................... 180

22.

South Kalimantan ............................................................................................................ 187

23.

East Kalimantan............................................................................................................... 194

24.

North Kalimantan ............................................................................................................ 201

25.

North Sulawesi ................................................................................................................ 208

26.

Central Sulawesi .............................................................................................................. 215

27.

South Sulawesi ................................................................................................................ 222

28.

South-East Sulawesi ........................................................................................................ 229

29.

Gorontalo ........................................................................................................................ 236

30.

West Sulawesi ................................................................................................................. 243

31.

Maluku ............................................................................................................................ 250

32.

North Maluku .................................................................................................................. 257

33.

West Papua ..................................................................................................................... 264

34.

Papua .............................................................................................................................. 271

STRENGTHS AND LIMITATIONS ........................................................................................................... 278 REFERENCES ........................................................................................................................................ 279

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LIST OF FIGURES Figure 1. Fundamental dynamics in Indonesia’s healthcare system .................................................... 10 Figure 2. How supply (healthcare capacities) affect demand .............................................................. 11 Figure 3. Population Data, 2010 ........................................................................................................... 12 Figure 4. Population projection to 2020 ............................................................................................... 12 Figure 5. Population projection based on age group and gender ........................................................ 13 Figure 6. General practitioner: registered vs practicing, 2013 ............................................................. 17 Figure 7. Specialist: registered vs practicing, 2013 ............................................................................... 17 Figure 8. Number of hospitals, 2013 ..................................................................................................... 18 Figure 9. Number of hospital beds, 2013.............................................................................................. 19 Figure 10. Nurse Practicing, 2013 ......................................................................................................... 20 Figure 11. Midwife Practicing, 2013 ..................................................................................................... 21 Figure 12: Sample graph: hospital bed ................................................................................................. 22 Figure 13: Sample graph: Midwife attended hospital births ................................................................ 22 Figure 14. Change in insurance status .................................................................................................. 25 Figure 15. Gaps summary ..................................................................................................................... 25 Figure 16. National total desired physicians ......................................................................................... 26 Figure 17. National desired physicians in hospital................................................................................ 27 Figure 18. National desired physicians in primary care ........................................................................ 27 Figure 19. National physicians providing hospital inpatient care ......................................................... 28 Figure 20. National number of physician visits per month at hospital and primary care outpatient .. 28 Figure 21. National physicians providing outpatient care in hospital and primary care ...................... 29 Figure 22. National total desired nurses ............................................................................................... 30 Figure 23. National total desired nurses in hospital ............................................................................. 30 Figure 24. National total desired nurses in primary care ..................................................................... 30 Figure 25. National nurses providing outpatient care in hospital and primary care ............................ 31 Figure 26. National nurses providing hospital inpatient care ............................................................... 31 Figure 27. National total desired midwives .......................................................................................... 32 Figure 28. National births per month in primary care .......................................................................... 32 Figure 29. National births per month in hospital .................................................................................. 33 Figure 30. National hospital inpatient admission per month ............................................................... 33 Figure 31. National hospital beds ......................................................................................................... 34 Figure 32. Summary projection 2019.................................................................................................... 35 Figure 33. Physician capacity distribution ............................................................................................ 36 Figure 34. Nurse capacity distribution .................................................................................................. 36 Figure 35. Midwife capacity distribution .............................................................................................. 37 Figure 36. Hospital bed capacity distribution ....................................................................................... 37 Figure 37. Aceh population projection to 2020 .................................................................................... 39 Figure 38. Aceh population projection by age group and gender ........................................................ 39 Figure 39. Changed in insurance status in Aceh ................................................................................... 40 Figure 40. Gaps summary ..................................................................................................................... 40 Figure 41. Aceh total desired physician ................................................................................................ 41 Figure 42. Aceh total desired physician in hospital .............................................................................. 41 Figure 43. Aceh total desired physician in primary care....................................................................... 41 Figure 44. Aceh total desired nurse ...................................................................................................... 42 Figure 45. Aceh total desired nurse in hospital .................................................................................... 42 Figure 46. Aceh total desired nurse in primary care............................................................................. 43 vii

Figure 47. Aceh total desired midwife .................................................................................................. 43 Figure 48. Aceh total hospital bed ........................................................................................................ 44 Figure 49. North Sumatera Population projection to 2020 .................................................................. 46 Figure 50. North Sumatera Population Projection by age group and gender ...................................... 46 Figure 51. Changed in insurance status in North Sumatera ................................................................. 47 Figure 52. North Sumatera gaps summary ........................................................................................... 47 Figure 53. North Sumatera Total Desired Physician ............................................................................. 48 Figure 54. North Sumatera total desired physician in hospital ............................................................ 48 Figure 55. North Sumatera total desired physician in primary care ..................................................... 48 Figure 56. North Sumatera total desired nurse .................................................................................... 49 Figure 57. North Sumatera total desired nurse in hospital .................................................................. 49 Figure 58. North Sumatera total desired nurse in primary care ........................................................... 50 Figure 59. North Sumatera total desired midwife ................................................................................ 50 Figure 60. North Sumatera total hospital bed ...................................................................................... 51 Figure 61. West Sumatera Population projection to 2020 ................................................................... 53 Figure 62. West Sumatera Population Projection by age group and gender ....................................... 53 Figure 63. Changed in insurance status in West Sumatera .................................................................. 54 Figure 64. West Sumatera gaps summary ............................................................................................ 54 Figure 65. West Sumatera Total Desired Physician .............................................................................. 55 Figure 66. West Sumatera total desired physician in hospital ............................................................. 55 Figure 67. West Sumatera total desired physician in primary care ...................................................... 56 Figure 68. West Sumatera total desired nurse ..................................................................................... 56 Figure 69. West Sumatera total desired nurse in hospital ................................................................... 57 Figure 66. West Sumatera total desired nurse in primary care ............................................................ 57 Figure 71. West Sumatera total desired midwife ................................................................................. 58 Figure 72. West Sumatera total hospital bed ....................................................................................... 58 Figure 73. Riau Population projection to 2020 ..................................................................................... 61 Figure 74. Riau Population Projection by age group and gender ......................................................... 61 Figure 75. Changed in insurance status in Riau .................................................................................... 62 Figure 76. Riau gaps summary .............................................................................................................. 62 Figure 77. Riau Total Desired Physician ................................................................................................ 63 Figure 78. Riau total desired physician in hospital ............................................................................... 63 Figure 79. Riau total desired physician in primary care........................................................................ 63 Figure 80. Riau total desired nurse ....................................................................................................... 64 Figure 81. Riau total desired nurse in hospital ..................................................................................... 64 Figure 82. Riau total desired nurse in primary care.............................................................................. 65 Figure 83. Riau total desired midwife ................................................................................................... 65 Figure 84. Riau total hospital bed ......................................................................................................... 66 Figure 85. Jambi Population projection to 2020 ................................................................................... 68 Figure 86. Jambi Population Projection by age group and gender ....................................................... 68 Figure 87. Changed in insurance status in Jambi .................................................................................. 69 Figure 88. Jambi gaps summary ............................................................................................................ 69 Figure 89. Jambi Total Desired Physician .............................................................................................. 70 Figure 90. Jambi total desired physician in hospital ............................................................................. 70 Figure 91. Jambi total desired physician in primary care ..................................................................... 70 Figure 92. Jambi total desired nurse ..................................................................................................... 71 Figure 93. Jambi total desired nurse in hospital ................................................................................... 71 Figure 94. Jambi total desired nurse in primary care ........................................................................... 72 viii

Figure 95. Jambi total desired midwife ................................................................................................. 72 Figure 96. Jambi total hospital bed ....................................................................................................... 73 Figure 97. South Sumatera Population projection to 2020 .................................................................. 75 Figure 98. South Sumatera Population Projection by age group and gender ...................................... 75 Figure 99. Changed in insurance status in South Sumatera ................................................................. 76 Figure 100. South Sumatera gaps summary ......................................................................................... 76 Figure 101. South Sumatera Total Desired Physician ........................................................................... 77 Figure 102. South Sumatera total desired physician in hospital .......................................................... 77 Figure 103. South Sumatera total desired physician in primary care ................................................... 77 Figure 104. South Sumatera total desired nurse .................................................................................. 78 Figure 105. South Sumatera total desired nurse in hospital ................................................................ 78 Figure 106. South Sumatera total desired nurse in primary care ......................................................... 79 Figure 107. South Sumatera total desired midwife .............................................................................. 79 Figure 108. South Sumatera total hospital bed .................................................................................... 80 Figure 109. Bengkulu population projection to 2020 ........................................................................... 82 Figure 110. Bengkulu Population Projection by age group and gender ............................................... 82 Figure 111. Changed in insurance status in Bengkulu .......................................................................... 83 Figure 112. Bengkulu gaps summary .................................................................................................... 83 Figure 113. Bengkulu Total Desired Physician ...................................................................................... 84 Figure 114. Bengkulu total desired physician in hospital ..................................................................... 84 Figure 115. Bengkulu total desired physician in primary care .............................................................. 84 Figure 116. Bengkulu total desired nurse ............................................................................................. 85 Figure 117. Bengkulu total desired nurse in hospital ........................................................................... 85 Figure 118. Bengkulu total desired nurse in primary care .................................................................... 86 Figure 119. Bengkulu total desired midwife ......................................................................................... 86 Figure 120. Bengkulu total hospital bed ............................................................................................... 87 Figure 121. Lampung Population projection to 2020 ........................................................................... 89 Figure 122. Lampung Population Projection by age group and gender ............................................... 89 Figure 123. Changed in insurance status in Lampung .......................................................................... 90 Figure 14. Lampung gaps summary ...................................................................................................... 90 Figure 125. Lampung Total Desired Physician ...................................................................................... 91 Figure 126. Lampung total desired physician in hospital ..................................................................... 91 Figure 127. Lampung total desired physician in primary care .............................................................. 91 Figure 128. Lampung total desired nurse ............................................................................................. 92 Figure 129. Lampung total desired nurse in hospital ........................................................................... 92 Figure 130. Lampung total desired nurse in primary care .................................................................... 93 Figure 131. Lampung total desired midwife ......................................................................................... 93 Figure 132. Lampung total hospital bed ............................................................................................... 94 Figure 133. Bangka Belitung Islands Population projection to 2020 .................................................... 96 Figure 134. Bangka Belitung Islands Population Projection by age group and gender ........................ 96 Figure 135. Changed in insurance status in Bangka Belitung Islands ................................................... 97 Figure 136. Bangka Belitung Islands gaps summary ............................................................................. 97 Figure 137. Bangka Belitung Islands Total Desired Physician ............................................................... 98 Figure 138. Bangka Belitung Islands total desired physician in hospital .............................................. 98 Figure 139. Bangka Belitung Islands total desired physician in primary care ....................................... 98 Figure 140. Bangka Belitung Islands total desired nurse ...................................................................... 99 Figure 141. Bangka Belitung Islands total desired nurse in hospital .................................................... 99 Figure 142. Bangka Belitung Islands total desired nurse in primary care........................................... 100 ix

Figure 143. Bangka Belitung Islands total desired midwife ................................................................ 100 Figure 144. Bangka Belitung Islands total hospital bed ...................................................................... 101 Figure 145. Riau Islands Population projection to 2020 ..................................................................... 103 Figure 146. Riau Islands Population Projection by age group and gender ......................................... 103 Figure 147. Changed in insurance status in Riau Islands .................................................................... 104 Figure 148. Riau Islands gaps summary .............................................................................................. 104 Figure 149. Riau Islands Total Desired Physician ................................................................................ 105 Figure 150. Riau Islands total desired physician in hospital ............................................................... 105 Figure 151. Riau Islands total desired physician in primary care........................................................ 105 Figure 152. Riau Islands total desired nurse ....................................................................................... 106 Figure 153. Riau Islands total desired nurse in hospital ..................................................................... 106 Figure 154. Riau Islands total desired nurse in primary care.............................................................. 107 Figure 155. Riau Islands total desired midwife ................................................................................... 107 Figure 156. Riau Islands total hospital bed ......................................................................................... 108 Figure 157. DKI Jakarta Population projection to 2020 ...................................................................... 110 Figure 158. DKI Jakarta Population Projection by age group and gender .......................................... 110 Figure 159. Changed in insurance status in DKI Jakarta ..................................................................... 111 Figure 160. DKI Jakarta gaps summary ............................................................................................... 111 Figure 161. DKI Jakarta Total Desired Physician ................................................................................. 112 Figure 162. DKI Jakarta total desired physician in hospital ................................................................ 112 Figure 163. DKI Jakarta total desired physician in primary care ......................................................... 112 Figure 164. DKI Jakarta total desired nurse ........................................................................................ 113 Figure 165. DKI Jakarta total desired nurse in hospital ...................................................................... 113 Figure 166. DKI Jakarta total desired nurse in primary care ............................................................... 114 Figure 167. DKI Jakarta total desired midwife .................................................................................... 114 Figure 168. DKI Jakarta total hospital bed .......................................................................................... 115 Figure 169. West Java Currently Available Data ................................................................................. 116 Figure 170. West Java Population projection to 2020 ........................................................................ 117 Figure 171. West Java Population Projection by age group and gender ............................................ 117 Figure 172. Changed in insurance status in West Java ....................................................................... 118 Figure 173. West Java gaps summary ................................................................................................. 118 Figure 174. West Java Total Desired Physician ................................................................................... 119 Figure 175. West Java total desired physician in hospital .................................................................. 119 Figure 176. West Java total desired physician in primary care........................................................... 119 Figure 177. West Java total desired nurse .......................................................................................... 120 Figure 178. West Java total desired nurse in hospital ........................................................................ 120 Figure 179. West Java total desired nurse in primary care ................................................................ 121 Figure 180. West Java total desired midwife ...................................................................................... 121 Figure 181. West Java total hospital bed ............................................................................................ 122 Figure 182. Central Java Population projection to 2020..................................................................... 124 Figure 183. Central Java Population Projection by age group and gender ......................................... 124 Figure 184. Changed in insurance status in Central Java .................................................................... 125 Figure 185. Central Java gaps summary.............................................................................................. 125 Figure 186. Central Java Total Desired Physician................................................................................ 126 Figure 187. Central Java total desired physician in hospital ............................................................... 126 Figure 188. Central Java total desired physician in primary care ....................................................... 126 Figure 189. Central Java total desired nurse ...................................................................................... 127 Figure 190. Central Java total desired nurse in hospital ..................................................................... 127 x

Figure 191. Central Java total desired nurse in primary care ............................................................. 128 Figure 192. Central Java total desired midwife .................................................................................. 128 Figure 193. Central Java total hospital bed......................................................................................... 129 Figure 194. DI Yogyakarta Population projection to 2020 .................................................................. 131 Figure 195. DI Yogyakarta Population Projection by age group and gender ...................................... 131 Figure 196. Changed in insurance status in DI Yogyakarta ................................................................. 132 Figure 197. DI Yogyakarta gaps summary ........................................................................................... 132 Figure 198. DI Yogyakarta Total Desired Physician ............................................................................. 133 Figure 199. DI Yogyakarta total desired physician in hospital ............................................................ 133 Figure 200. DI Yogyakarta total desired physician in primary care .................................................... 134 Figure 201. DI Yogyakarta total desired nurse .................................................................................... 134 Figure 202. DI Yogyakarta total desired nurse in hospital .................................................................. 135 Figure 203. DI Yogyakarta total desired nurse in primary care .......................................................... 135 Figure 204. DI Yogyakarta total desired midwife ................................................................................ 136 Figure 205. DI Yogyakarta total hospital bed ...................................................................................... 136 Figure 206. East Java Population projection to 2020.......................................................................... 139 Figure 207. East Java Population Projection by age group and gender .............................................. 139 Figure 208. Changed in insurance status in East Java ......................................................................... 140 Figure 209. East Java gaps summary................................................................................................... 140 Figure 210. East Java Total Desired Physician..................................................................................... 141 Figure 211. East Java total desired physician in hospital .................................................................... 141 Figure 212. East Java total desired physician in primary care ............................................................ 141 Figure 213. East Java total desired nurse ........................................................................................... 142 Figure 214. East Java total desired nurse in hospital .......................................................................... 142 Figure 215. East Java total desired nurse in primary care .................................................................. 143 Figure 216. East Java total desired midwife ....................................................................................... 143 Figure 217. East Java total hospital bed.............................................................................................. 144 Figure 218.. Banten Population projection to 2020............................................................................ 146 Figure 219. Banten Population Projection by age group and gender................................................. 146 Figure 220. Changed in insurance status in Banten ............................................................................ 147 Figure 221. Banten gaps summary...................................................................................................... 147 Figure 222. Banten Total Desired Physician........................................................................................ 148 Figure 223. Banten total desired physician in hospital ....................................................................... 148 Figure 224. Banten total desired physician in primary care ............................................................... 148 Figure 225. Banten total desired nurse .............................................................................................. 149 Figure 226. Banten total desired nurse in hospital ............................................................................. 149 Figure 227. Banten total desired nurse in primary care ..................................................................... 150 Figure 228. Banten total desired midwife .......................................................................................... 150 Figure 229. Banten total hospital bed................................................................................................. 151 Figure 230. Bali Population projection to 2020 .................................................................................. 153 Figure 231. Bali Population Projection by age group and gender ...................................................... 153 Figure 232. Changed in insurance status in Bali ................................................................................. 154 Figure 233. Bali gaps summary ........................................................................................................... 154 Figure 234. Bali Total Desired Physician ............................................................................................. 155 Figure 235. Bali total desired physician in hospital ............................................................................ 155 Figure 236. Bali total desired physician in primary care ..................................................................... 155 Figure 237. Bali total desired nurse .................................................................................................... 156 Figure 238. Bali total desired nurse in hospital .................................................................................. 156 xi

Figure 239. Bali total desired nurse in primary care ........................................................................... 157 Figure 240. Bali total desired midwife ................................................................................................ 157 Figure 241. Bali total hospital bed ...................................................................................................... 158 Figure 242. West Nusa Tenggara Population projection to 2020 ....................................................... 160 Figure 243. West Nusa Tenggara Population Projection by age group and gender ........................... 160 Figure 244. Changed in insurance status in West Nusa Tenggara ...................................................... 161 Figure 245. West Nusa Tenggara gaps summary ................................................................................ 161 Figure 246. West Nusa Tenggara Total Desired Physician .................................................................. 162 Figure 247. West Nusa Tenggara total desired physician in hospital ................................................. 162 Figure 248. West Nusa Tenggara total desired physician in primary care ......................................... 162 Figure 249. West Nusa Tenggara total desired nurse ......................................................................... 163 Figure 250. West Nusa Tenggara total desired nurse in hospital ....................................................... 163 Figure 251. West Nusa Tenggara total desired nurse in primary care ............................................... 164 Figure 252. West Nusa Tenggara total desired midwife ..................................................................... 164 Figure 253. West Nusa Tenggara total hospital bed ........................................................................... 165 Figure 254. East Nusa Tenggara Population projection to 2020 ........................................................ 167 Figure 255. East Nusa Tenggara Population Projection by age group and gender............................. 167 Figure 256. Changed in insurance status in East Nusa Tenggara........................................................ 168 Figure 257. East Nusa Tenggara gaps summary ................................................................................. 168 Figure 258. East Nusa Tenggara Total Desired Physician.................................................................... 169 Figure 259. East Nusa Tenggara total desired physician in hospital ................................................... 169 Figure 260. East Nusa Tenggara total desired physician in primary care ........................................... 169 Figure 261. East Nusa Tenggara total desired nurse .......................................................................... 170 Figure 262. East Nusa Tenggara total desired nurse in hospital ......................................................... 170 Figure 263. East Nusa Tenggara total desired nurse in primary care ................................................. 171 Figure 264. East Nusa Tenggara total desired midwife ...................................................................... 171 Figure 265. East Nusa Tenggara total hospital bed ............................................................................ 172 Figure 266. West Kalimantan Population projection to 2020 ............................................................ 174 Figure 267. West Kalimantan Population Projection by age group and gender................................. 174 Figure 268. Changed in insurance status in West Kalimantan............................................................ 175 Figure 269. West Kalimantan gaps summary ..................................................................................... 175 Figure 270. West Kalimantan Total Desired Physician........................................................................ 176 Figure 271. West Kalimantan total desired physician in hospital ....................................................... 176 Figure 272. West Kalimantan total desired physician in primary care ............................................... 176 Figure 273. West Kalimantan total desired nurse .............................................................................. 177 Figure 274. West Kalimantan total desired nurse in hospital ............................................................. 177 Figure 275. West Kalimantan total desired nurse in primary care ..................................................... 178 Figure 276. West Kalimantan total desired midwife .......................................................................... 178 Figure 277. West Kalimantan total hospital bed ................................................................................ 179 Figure 278. Central Kalimantan Population projection to 2020 ......................................................... 181 Figure 279. Central Kalimantan Population Projection by age group and gender ............................. 181 Figure 280. Changed in insurance status in Central Kalimantan ........................................................ 182 Figure 281. Central Kalimantan gaps summary .................................................................................. 182 Figure 282. Central Kalimantan total desired physician ..................................................................... 183 Figure 283. Central Kalimantan total desired physician in hospital ................................................... 183 Figure 284. Central Kalimantan total desired physician in primary care ............................................ 183 Figure 285. Central Kalimantan total desired nurse ........................................................................... 184 Figure 286. Central Kalimantan total desired nurse in hospital ......................................................... 184 xii

Figure 287. Central Kalimantan total desired nurse in primary care .................................................. 185 Figure 288. Central Kalimantan total desired midwife ....................................................................... 185 Figure 289. Central Kalimantan total hospital bed ............................................................................. 186 Figure 290. South Kalimantan Population projection to 2020 ........................................................... 188 Figure 291. South Kalimantan Population Projection by age group and gender ............................... 188 Figure 292. Changed in insurance status in South Kalimantan........................................................... 189 Figure 293. South Kalimantan gaps summary .................................................................................... 189 Figure 294. South Kalimantan Total Desired Physician ...................................................................... 190 Figure 295. South Kalimantan total desired physician in hospital ...................................................... 190 Figure 296. South Kalimantan total desired physician in primary care .............................................. 190 Figure 297. South Kalimantan total desired nurse ............................................................................. 191 Figure 298. South Kalimantan total desired nurse in hospital ............................................................ 191 Figure 299. South Kalimantan total desired nurse in primary care .................................................... 192 Figure 300. South Kalimantan total desired midwife ......................................................................... 192 Figure 301. South Kalimantan total hospital bed ............................................................................... 193 Figure 302. East Kalimantan Population projection to 2020 .............................................................. 195 Figure 303. East Kalimantan Population Projection by age group and gender .................................. 195 Figure 304. Changed in insurance status in East Kalimantan ............................................................. 196 Figure 305. East Kalimantan gaps summary ....................................................................................... 196 Figure 306. East Kalimantan Total Desired Physician ......................................................................... 197 Figure 307. East Kalimantan total desired physician in hospital ........................................................ 197 Figure 308. East Kalimantan total desired physician in primary care ................................................. 197 Figure 309. East Kalimantan total desired nurse ................................................................................ 198 Figure 310. East Kalimantan total desired nurse in hospital .............................................................. 198 Figure 311. East Kalimantan total desired nurse in primary care ....................................................... 199 Figure 312. East Kalimantan total desired midwife ............................................................................ 199 Figure 313. East Kalimantan total hospital bed .................................................................................. 200 Figure 314. North Kalimantan Population projection to 2020 ........................................................... 202 Figure 315. North Kalimantan Population Projection by age group and gender ............................... 202 Figure 316. Changed in insurance status in North Kalimantan........................................................... 203 Figure 317. North Kalimantan gaps summary .................................................................................... 203 Figure 318. North Kalimantan Total Desired Physician ...................................................................... 204 Figure 319. North Kalimantan total desired physician in hospital...................................................... 204 Figure 320. North Kalimantan total desired physician in primary care .............................................. 204 Figure 321. North Kalimantan total desired nurse ............................................................................. 205 Figure 322. North Kalimantan total desired nurse in hospital............................................................ 205 Figure 323. North Kalimantan total desired nurse in primary care .................................................... 206 Figure 324. North Kalimantan total desired midwife ......................................................................... 206 Figure 325. North Kalimantan total hospital bed ............................................................................... 207 Figure 326. North Sulawesi Population projection to 2020 ................................................................ 209 Figure 327. North Sulawesi Population Projection by age group and gender .................................... 209 Figure 328. Changed in insurance status in North Sulawesi ............................................................... 210 Figure 329. North Sulawesi gaps summary ......................................................................................... 210 Figure 330. North Sulawesi Total Desired Physician ........................................................................... 211 Figure 331. North Sulawesi total desired physician in hospital .......................................................... 211 Figure 332. North Sulawesi total desired physician in primary care .................................................. 211 Figure 333. North Sulawesi total desired nurse.................................................................................. 212 Figure 334. North Sulawesi total desired nurse in hospital ................................................................ 212 xiii

Figure 335. North Sulawesi total desired nurse in primary care ........................................................ 213 Figure 336. North Sulawesi total desired midwife.............................................................................. 213 Figure 337. North Sulawesi total hospital bed.................................................................................... 214 Figure 338. Central Sulawesi Population projection to 2020 ............................................................. 216 Figure 339. Central Sulawesi Population Projection by age group and gender ................................. 216 Figure 340. Changed in insurance status in Central Sulawesi............................................................. 217 Figure 341. Central Sulawesi gaps summary ...................................................................................... 217 Figure 342. Central Sulawesi Total Desired Physician ........................................................................ 218 Figure 343. Central Sulawesi total desired physician in hospital........................................................ 218 Figure 344. Central Sulawesi total desired physician in primary care ................................................ 218 Figure 345. Central Sulawesi total desired nurse ............................................................................... 219 Figure 346. Central Sulawesi total desired nurse in hospital.............................................................. 219 Figure 347. Central Sulawesi total desired nurse in primary care ...................................................... 220 Figure 348. Central Sulawesi total desired midwife ........................................................................... 220 Figure 349. Central Sulawesi total hospital bed ................................................................................. 221 Figure 350. South Sulawesi Population projection to 2020 ................................................................ 223 Figure 351. South Sulawesi Population Projection by age group and gender .................................... 223 Figure 352. Changed in insurance status in South Sulawesi ............................................................... 224 Figure 353. South Sulawesi gaps summary ......................................................................................... 224 Figure 354. South Sulawesi Total Desired Physician ........................................................................... 225 Figure 355. South Sulawesi total desired physician in hospital .......................................................... 225 Figure 356. South Sulawesi total desired physician in primary care .................................................. 225 Figure 357. South Sulawesi total desired nurse.................................................................................. 226 Figure 358. South Sulawesi total desired nurse in hospital ................................................................ 226 Figure 359. South Sulawesi total desired nurse in primary care ........................................................ 227 Figure 360. South Sulawesi total desired midwife.............................................................................. 227 Figure 361. South Sulawesi total hospital bed .................................................................................... 228 Figure 362. South-East Sulawesi Population projection to 2020 ........................................................ 230 Figure 363. South-East Sulawesi Population Projection by age group and gender ............................ 230 Figure 364. Changed in insurance status in South-East Sulawesi ....................................................... 231 Figure 365. South-East Sulawesi gaps summary ................................................................................. 231 Figure 366. South-East Sulawesi Total Desired Physician ................................................................... 232 Figure 367. South-East Sulawesi total desired physician in hospital .................................................. 232 Figure 368. South-East Sulawesi total desired physician in primary care .......................................... 232 Figure 369. South-East Sulawesi total desired nurse.......................................................................... 233 Figure 370. South-East Sulawesi total desired nurse in hospital ........................................................ 233 Figure 371. South-East Sulawesi total desired nurse in primary care ................................................ 234 Figure 372. South-East Sulawesi total desired midwife...................................................................... 234 Figure 373. South-East Sulawesi total hospital bed ............................................................................ 235 Figure 374. Gorontalo Population projection to 2020 ........................................................................ 237 Figure 375. Gorontalo Population Projection by age group and gender ............................................ 237 Figure 376. Changed in insurance status in Gorontalo ....................................................................... 238 Figure 377. Gorontalo gaps summary ................................................................................................. 238 Figure 378. Gorontalo Total Desired Physician ................................................................................... 239 Figure 379. Gorontalo total desired physician in hospital .................................................................. 239 Figure 380. Gorontalo total desired physician in primary care .......................................................... 239 Figure 381. Gorontalo total desired nurse.......................................................................................... 240 Figure 382. Gorontalo total desired nurse in hospital ........................................................................ 240 xiv

Figure 383. Gorontalo total desired nurse in primary care ................................................................ 241 Figure 384. Gorontalo total desired midwife...................................................................................... 241 Figure 385. Gorontalo total hospital bed............................................................................................ 242 Figure 386. West Sulawesi Population projection to 2020 ................................................................. 244 Figure 387. West Sulawesi Population Projection by age group and gender ..................................... 244 Figure 388. Changed in insurance status in West Sulawesi ................................................................ 245 Figure 389. West Sulawesi gaps summary .......................................................................................... 245 Figure 390. West Sulawesi Total Desired Physician ............................................................................ 246 Figure 391. West Sulawesi total desired physician in hospital ........................................................... 246 Figure 392. West Sulawesi total desired physician in primary care ................................................... 246 Figure 393. West Sulawesi total desired nurse ................................................................................... 247 Figure 394. West Sulawesi total desired nurse in hospital ................................................................. 247 Figure 395. West Sulawesi total desired nurse in primary care ......................................................... 248 Figure 396. West Sulawesi total desired midwife............................................................................... 248 Figure 397. West Sulawesi total hospital bed ..................................................................................... 249 Figure 398. Maluku Population projection to 2020 ............................................................................ 251 Figure 399. Maluku Population Projection by age group and gender ................................................ 251 Figure 400. Changed in insurance status in Maluku ........................................................................... 252 Figure 401. Maluku gaps summary ..................................................................................................... 252 Figure 402. Maluku total desired physician ........................................................................................ 253 Figure 403. Maluku total desired physician in hospital ...................................................................... 253 Figure 404. Maluku total desired physician in primary care .............................................................. 254 Figure 405. Maluku total desired nurse .............................................................................................. 254 Figure 406. Maluku total desired nurse in hospital ............................................................................ 255 Figure 407. Maluku total desired nurse in primary care .................................................................... 255 Figure 408. Maluku total desired midwife .......................................................................................... 256 Figure 409. Maluku total hospital bed ................................................................................................ 256 Figure 410. North Maluku Population projection to 2020 ................................................................. 258 Figure 411. North Maluku population projection by age group and gender ..................................... 258 Figure 412. Changed in insurance status in North Maluku................................................................. 259 Figure 413. North Maluku gaps summary .......................................................................................... 259 Figure 414. North Maluku Total Desired Physician............................................................................. 260 Figure 415. North Maluku total desired physician in hospital ............................................................ 260 Figure 416. North Maluku total desired physician in primary care .................................................... 260 Figure 417. North Maluku total desired nurse ................................................................................... 261 Figure 418. North Maluku total desired nurse in hospital .................................................................. 261 Figure 419. North Maluku total desired nurse in primary care .......................................................... 262 Figure 420. North Maluku total desired midwife ............................................................................... 262 Figure 421. North Maluku total hospital bed ..................................................................................... 263 Figure 422. West Papua population projection to 2020 ..................................................................... 265 Figure 423. West Papua population projection by age group and gender ......................................... 265 Figure 424. Changed in insurance status in West Papua .................................................................... 266 Figure 425. West Papua gaps summary .............................................................................................. 266 Figure 426. West Papua total desired physician ................................................................................. 267 Figure 427. West Papua total desired physician in hospital ............................................................... 267 Figure 428. West Papua total desired physician in primary care ....................................................... 267 Figure 429. West Papua total desired nurse....................................................................................... 268 Figure 430. West Papua total desired nurse in hospital ..................................................................... 268 xv

Figure 431. West Papua total desired nurse in primary care ............................................................. 269 Figure 432. West Papua total desired midwife ................................................................................... 269 Figure 433. West Papua total hospital bed ......................................................................................... 270 Figure 434. Papua Population projection to 2020 .............................................................................. 272 Figure 435. Papua population projection by age group and gender .................................................. 272 Figure 436. Changed in insurance status in Papua ............................................................................. 273 Figure 437. Papua gaps summary ....................................................................................................... 273 Figure 438. Papua Total Desired Physician ......................................................................................... 274 Figure 439. Papua total desired physician in hospital ........................................................................ 274 Figure 440. Papua total desired physician in primary care ................................................................. 274 Figure 441. Papua total desired nurse ................................................................................................ 275 Figure 442. Papua total desired nurse in hospital .............................................................................. 275 Figure 443. Papua total desired nurse in primary care....................................................................... 276 Figure 444. Papua total desired midwife ............................................................................................ 276 Figure 445. Papua total hospital bed .................................................................................................. 277

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LIST OF TABLES Table 1. Initial conditions and parameter values .................................................................................... 9 Table 2. Affordability adjustment factors based on insurance status .................................................. 14 Table 3. Adjusted* Askes 2012 rates for JKN insured group ................................................................ 15 Table 4. National Currently Available Data ........................................................................................... 24 Table 5. National 2013 capacity projected by the model ..................................................................... 24 Table 6. National total desired physicians ............................................................................................ 26 Table 7. National total desired nurses .................................................................................................. 29 Table 8. National total desired midwives ............................................................................................. 31 Table 9. National total desired hospital beds ....................................................................................... 33 Table 10. National total hospital beds .................................................................................................. 34 Table 11. Aceh currently available data ................................................................................................ 38 Table 12. Aceh 2013 capacity projected by the model ......................................................................... 38 Table 13. Aceh total desired physician ................................................................................................. 42 Table 14. Aceh total desired nurse ....................................................................................................... 43 Table 15.. Aceh total desired midwife .................................................................................................. 44 Table 16. Aceh total hospital bed ......................................................................................................... 44 Table 17. North Sumatera Currently Available Data............................................................................. 45 Table 18. North Sumatera 2013 capacity projected by the model ....................................................... 45 Table 19. North Sumatera total desired physician ............................................................................... 49 Table 20. North Sumatera total desired nurse ..................................................................................... 50 Table 21. North Sumatera total desired midwife ................................................................................. 50 Table 22. North Sumatera total hospital bed ....................................................................................... 51 Table 23. West Sumatera Currently Available Data.............................................................................. 52 Table 24. West Sumatera 2013 capacity projected by the model ........................................................ 52 Table 25. West Sumatera total desired physician ................................................................................ 56 Table 26. West Sumatera total desired nurse ...................................................................................... 57 Table 27. West Sumatera total desired midwife .................................................................................. 58 Table 28. West Sumatera total hospital bed ........................................................................................ 59 Table 29. Riau currently available data ................................................................................................. 60 Table 30. Riau 2013 capacity projected by the model .......................................................................... 60 Table 31. Riau total desired physician .................................................................................................. 64 Table 32. Riau total desired nurse ........................................................................................................ 65 Table 33. Riau total desired midwife .................................................................................................... 65 Table 34. Riau total hospital bed .......................................................................................................... 66 Table 35. Jambi Currently Available Data ............................................................................................. 67 Table 36. Jambi 2013 capacity projected by the model ....................................................................... 67 Table 37. Jambi total desired physician ................................................................................................ 71 Table 38. Jambi total desired nurse ...................................................................................................... 72 Table 39. Jambi total desired midwife .................................................................................................. 73 Table 40. Jambi total hospital bed ........................................................................................................ 73 Table 41. South Sumatera Currently Available Data............................................................................. 74 Table 42. South Sumatera 2013 capacity projected by the model ....................................................... 74 Table 43. South Sumatera total desired physician ............................................................................... 78 Table 44. South Sumatera total desired nurse ..................................................................................... 79 Table 45. South Sumatera total desired midwife ................................................................................. 79 Table 46. South Sumatera total hospital bed ....................................................................................... 80 xvii

Table 47. Bengkulu currently available data ......................................................................................... 81 Table 48. Bengkulu 2013 capacity projected by the model .................................................................. 81 Table 49. Bengkulu total desired physician .......................................................................................... 85 Table 50. Bengkulu total desired nurse ................................................................................................ 86 Table 51. Bengkulu total desired midwife ............................................................................................ 86 Table 52. Bengkulu total hospital bed .................................................................................................. 87 Table 53. Lampung currently available data ......................................................................................... 88 Table 54. Lampung 2013 capacity projected by the model .................................................................. 88 Table 55. Lampung total desired physician .......................................................................................... 92 Table 56. Lampung total desired nurse ................................................................................................ 93 Table 57. Lampung total desired midwife ............................................................................................ 93 Table 58. Lampung total hospital bed .................................................................................................. 94 Table 59. Bangka Belitung Islands currently available data .................................................................. 95 Table 60. Bangka Belitung Islands 2013 capacity projected by the model........................................... 95 Table 61. Bangka Belitung Islands total desired physician ................................................................... 99 Table 62. Bangka Belitung Islands total desired nurse ....................................................................... 100 Table 63. Bangka Belitung Islands total desired midwife ................................................................... 100 Table 64. Bangka Belitung Islands total hospital bed ......................................................................... 101 Table 65. Riau Islands currently available data................................................................................... 102 Table 66. Riau Islands 2013 capacity projected by the model............................................................ 102 Table 67. Riau Islands total desired physician .................................................................................... 106 Table 68. Riau Islands total desired nurse .......................................................................................... 107 Table 69. Riau Islands total desired midwife ...................................................................................... 107 Table 70. Riau Islands total hospital bed ............................................................................................ 108 Table 71. DKI Jakarta currently available data .................................................................................... 109 Table 72. DKI Jakarta 2013 capacity projected by the model ............................................................. 109 Table 73. DKI Jakarta total desired physician ..................................................................................... 113 Table 74. DKI Jakarta total desired nurse ........................................................................................... 114 Table 68. DKI Jakarta total desired midwife ....................................................................................... 114 Table 76. DKI Jakarta total hospital bed ............................................................................................. 115 Table 77. West Java 2013 capacity projected by the model .............................................................. 116 Table 78. West Java total desired physician ....................................................................................... 120 Table 79. West Java total desired nurse ............................................................................................. 121 Table 80. West Java total desired midwife ......................................................................................... 121 Table 81. West Java total hospital bed ............................................................................................... 122 Table 82. Central Java currently available data .................................................................................. 123 Table 83. Central Java 2013 capacity projected by the model ........................................................... 123 Table 84. Central Java total desired physician .................................................................................... 127 Table 85. Central Java total desired nurse .......................................................................................... 128 Table 86. Central Java total desired midwife ...................................................................................... 128 Table 87. Central Java total hospital bed ............................................................................................ 129 Table 88. DI Yogyakarta currently available data ............................................................................... 130 Table 89. DI Yogyakarta 2013 capacity projected by the model ........................................................ 130 Table 90. DI Yogyakarta total desired physician ................................................................................. 134 Table 91. DI Yogyakarta total desired nurse ....................................................................................... 135 Table 92. DI Yogyakarta total desired midwife ................................................................................... 136 Table 93. DI Yogyakarta total hospital bed ......................................................................................... 137 Table 94. East Java Currently Available Data ...................................................................................... 138 xviii

Table 95. East Java 2013 capacity projected by the model ................................................................ 138 Table 96. East Java total desired physician ......................................................................................... 142 Table 97. East Java total desired nurse ............................................................................................... 143 Table 98. East Java total desired midwife ........................................................................................... 143 Table 99. East Java total hospital bed ................................................................................................. 144 Table 100. Banten Currently Available Data ....................................................................................... 145 Table 101. Banten 2013 capacity projected by the model ................................................................. 145 Table 102. Banten total desired physician .......................................................................................... 149 Table 91. Banten total desired nurse .................................................................................................. 150 Table 104. Banten total desired midwife............................................................................................ 150 Table 105. Banten total hospital bed .................................................................................................. 151 Table 106. Bali currently available data .............................................................................................. 152 Table 107. Bali 2013 capacity projected by the model ....................................................................... 152 Table 108. Bali total desired physician ............................................................................................... 156 Table 109. Bali total desired nurse ..................................................................................................... 157 Table 110. Bali total desired midwife ................................................................................................. 157 Table 111. Bali total hospital bed ....................................................................................................... 158 Table 112. West Nusa Tenggara Currently Available Data ................................................................. 159 Table 113. West Nusa Tenggara 2013 capacity projected by the model ........................................... 159 Table 114. West Nusa Tenggara total desired physician .................................................................... 163 Table 115. West Nusa Tenggara total desired nurse .......................................................................... 164 Table 116. West Nusa Tenggara total desired midwife ...................................................................... 164 Table 117. West Nusa Tenggara total hospital bed ............................................................................ 165 Table 104. East Nusa Tenggara currently available data .................................................................... 166 Table 119. East Nusa Tenggara 2013 capacity projected by the model ............................................. 166 Table 120. East Nusa Tenggara total desired physician...................................................................... 170 Table 121. East Nusa Tenggara total desired nurse............................................................................ 171 Table 122. East Nusa Tenggara total desired midwife........................................................................ 171 Table 123. East Nusa Tenggara total hospital bed.............................................................................. 172 Table 124. West Kalimantan currently available data ........................................................................ 173 Table 125. West Kalimantan 2013 capacity projected by the model ................................................. 173 Table 126. West Kalimantan total desired physician .......................................................................... 177 Table 127. West Kalimantan total desired nurse ................................................................................ 178 Table 128. West Kalimantan total desired midwife............................................................................ 178 Table 129. West Kalimantan total hospital bed .................................................................................. 179 Table 114. Central Kalimantan currently available data ..................................................................... 180 Table 131. Central Kalimantan 2013 capacity projected by the model .............................................. 180 Table 132. Central Kalimantan total desired physician ...................................................................... 184 Table 133. Central Kalimantan total desired nurse ............................................................................ 185 Table 134. Central Kalimantan total desired midwife ........................................................................ 185 Table 135. Central Kalimantan total hospital bed .............................................................................. 186 Table 136. South Kalimantan currently available data ....................................................................... 187 Table 137. South Kalimantan 2013 capacity projected by the model ................................................ 187 Table 138. South Kalimantan total desired physician ......................................................................... 191 Table 139. South Kalimantan total desired nurse............................................................................... 192 Table 140. South Kalimantan total desired midwife........................................................................... 192 Table 141. South Kalimantan total hospital bed................................................................................. 193 Table 142. East Kalimantan Currently Available Data......................................................................... 194 xix

Table 143. East Kalimantan 2013 capacity projected by the model ................................................... 194 Table 144. East Kalimantan total desired physician ........................................................................... 198 Table 145. East Kalimantan total desired nurse ................................................................................. 199 Table 146. East Kalimantan total desired midwife ............................................................................. 199 Table 147. East Kalimantan total hospital bed ................................................................................... 200 Table 148. North Kalimantan currently available data ....................................................................... 201 Table 149. North Kalimantan 2013 capacity projected by the model ................................................ 201 Table 150. North Kalimantan total desired physician......................................................................... 205 Table 151. North Kalimantan total desired nurse............................................................................... 206 Table 152. North Kalimantan total desired midwife........................................................................... 206 Table 153. North Kalimantan total hospital bed................................................................................. 207 Table 154. North Sulawesi currently available data ........................................................................... 208 Table 155. North Sulawesi 2013 capacity projected by the model .................................................... 208 Table 156. North Sulawesi total desired physician ............................................................................. 212 Table 157. North Sulawesi total desired nurse ................................................................................... 213 Table 158. North Sulawesi total desired midwife ............................................................................... 213 Table 159. North Sulawesi total hospital bed ..................................................................................... 214 Table 160. Central Sulawesi currently available data ......................................................................... 215 Table 161. Central Sulawesi 2013 capacity projected by the model .................................................. 215 Table 162. Central Sulawesi total desired physician........................................................................... 219 Table 163. Central Sulawesi total desired nurse................................................................................. 220 Table 164. Central Sulawesi total desired midwife............................................................................. 220 Table 165. Central Sulawesi total hospital bed................................................................................... 221 Table 166. South Sulawesi currently available data ........................................................................... 222 Table 167. South Sulawesi 2013 capacity projected by the model .................................................... 222 Table 168. South Sulawesi total desired physician ............................................................................. 226 Table 169. South Sulawesi total desired nurse ................................................................................... 227 Table 170. South Sulawesi total desired midwife ............................................................................... 227 Table 171. South Sulawesi total hospital bed ..................................................................................... 228 Table 172. South-East Sulawesi currently available data ................................................................... 229 Table 173. South-East Sulawesi 2013 capacity projected by the model ............................................ 229 Table 174. South-East Sulawesi total desired physician ..................................................................... 233 Table 175. South-East Sulawesi total desired nurse ........................................................................... 234 Table 176. South-East Sulawesi total desired midwife ....................................................................... 234 Table 177. South-East Sulawesi total hospital bed ............................................................................. 235 Table 178. Gorontalo Currently Available Data .................................................................................. 236 Table 179. Gorontalo 2013 capacity projected by the model ............................................................ 236 Table 180. Gorontalo total desired physician ..................................................................................... 240 Table 181. Gorontalo total desired nurse ........................................................................................... 241 Table 182. Gorontalo total desired midwife ....................................................................................... 241 Table 183. Gorontalo total hospital bed ............................................................................................. 242 Table 184. West Sulawesi Currently Available Data ........................................................................... 243 Table 185. West Sulawesi 2013 capacity projected by the model ..................................................... 243 Table 186. West Sulawesi total desired physician .............................................................................. 247 Table 187. West Sulawesi total desired nurse .................................................................................... 248 Table 188. West Sulawesi total desired midwife ................................................................................ 248 Table 189. West Sulawesi total hospital bed ...................................................................................... 249 Table 190. Maluku Currently Available Data ...................................................................................... 250 xx

Table 191. Maluku 2013 capacity projected by the model ................................................................ 250 Table 165. Maluku total desired physician ......................................................................................... 254 Table 193. Maluku total desired nurse ............................................................................................... 255 Table 194. Maluku total desired midwife ........................................................................................... 256 Table 195. Maluku total hospital bed ................................................................................................. 256 Table 196. North Maluku currently available data ............................................................................. 257 Table 197. North Maluku 2013 capacity projected by the model ...................................................... 257 Table 198. North Maluku total desired physician ............................................................................... 261 Table 199. North Maluku total desired nurse ..................................................................................... 262 Table 200. North Maluku total desired midwife ................................................................................. 262 Table 201. North Maluku total hospital bed ....................................................................................... 263 Table 202. West Papua currently available data ................................................................................ 264 Table 203. West Papua 2013 capacity projected by the model ......................................................... 264 Table 204. West Papua total desired physician .................................................................................. 268 Table 205. West Papua total desired nurse ........................................................................................ 269 Table 206. West Papua total desired midwife .................................................................................... 269 Table 207. West Papua total hospital bed .......................................................................................... 270 Table 208. Papua currently available data .......................................................................................... 271 Table 209. Papua 2013 capacity projected by the model ................................................................... 271 Table 210. Papua total desired physician ........................................................................................... 275 Table 211. Papua total desired nurse ................................................................................................. 276 Table 212. Papua total desired midwife ............................................................................................. 276 Table 213. Papua total hospital bed ................................................................................................... 277

xxi

ACRONYMS AND GLOSSARY Askes

Asuransi Kesehatan/Health Insurance Program (health insurance for civil servants)

BPJS Kesehatan Badan Penyelenggara Jaminan Sosial Kesehatan/National Health Insurance Corporation DHO

District Health Officers

Jamkesmas

Jaminan Kesehatan Masyarakat/Community Health Protection Program (health insurance for the poor and near poor)

Jamkesda

Jaminan Kesehatan Daerah/District Community Health Protection Program (subnational government insurance for the poor and near poor)

Jamsostek

Jaminan Sosial Tenaga Kerja/Social Security for Labors

JKN

Jaminan Kesehatan Nasional/National Health Insurance

KIS

Kartu Indonesia Sehat/Healthy Indonesia Card

KKI

Konsil Kedokteran Indonesia/Indonesian Medical Council

MoH

Ministry of Health

PBI

Penerima Bantuan Iuran (premium subsidy recipients)

PHO

Provincial Health Officers

Puskesmas

Pusat Kesehatan Masyarakat (health center at subdistrict level, part of primary care network)

UHC

Universal Health Coverage

WHO

World Health Organization

xxii

EXECUTIVE SUMMARY In January 2014, the Government of Indonesia restructured its insurance providers under a single national health insurance (NHI/JKN) scheme, which aims to scale to universal coverage by 2019, by which time it will be the largest social health insurance scheme anywhere in the world. This modeling study aims to 1) build structure that permits deeper analysis and understanding about gaps in supply and demand; 2) examine the future demand of healthcare services as healthcare insurance expands and the healthcare supply to serve it; 3) provide recommendation to improve the adequacy of healthcare supply. This study is developed from last year’s preliminary study of national model for supply and demand projection. The model is refined and expanded into individual provincial models. In the MOH document, Rencana Aksi Pengembangan Pelayanan Kesehatan 2013-2019 (1), the need for healthcare workers was calculated using two approaches; by the ratio of life expectancy and various healthcare workers and by the standard approach used at the healthcare facilities. These approaches result in the number of healthcare workers in the Puskesmas (general practitioners, nurses, and midwives) to be adequate in terms of number, but poor in terms of distribution, and shortfall in specialists, nurses, and midwives in hospitals, with also poor distribution. These approaches provide a useful approximation but do not directly link healthcare capacities to underlying population. The model in this study draws on the MOH approach and incorporates additions to create a robust approach to yield national and province-level projections. This study accounts for dynamics of and relationship between aggregate demand for healthcare services and the capacity (supply) to fulfil that demand from three perspectives: -

Availability: are there enough physicians, nurses, midwives and hospital beds to meet demand? Accessibility: can the prospective patient easily get to the medical service provider? Affordability: does perceived out-of-pocket cost inhibit utilization?

To determine demand for medical care, the study assumes a “standard of care” that reflects the care actually provided to a class of patients with reasonable access to facilities, adequate availability of medical professionals and expenditures that are agreeable to patient and provider. Prior to 2014, enrollees in the government-sponsored medical insurance for civil servants (PT Askes) manifested those characteristics, and this study uses PT Askes utilization data from 2012 parsed by gender and age cohort. PT Askes utilization rates are adjusted for accessibility, affordability, and availability to be the standard of care as the coverage expands under JKN program. That is, the study assumes that the general population will demand care equal to that already received by civil servants. Capacity to meet demand is calculated by class of service. Physician supply takes current physician supply determined by KKI increased by medical school graduation rates and decreased by retirement, death and emigration. Similarly, nurses and midwives take current capacity from MOH data increased by training rates and decreased by projected leaving rates. Key Findings 1) Current figure for available physician visits per person per year is significantly less than desired visits. a) Number of physician visits per person per year remains low: 0.93 in 2014 and projected to be 1.01 in 2019, while the desired visits per year is 2.92 in 2014 and 3.46 in 2019. b) This results from current physician services being (1) unavailable for a lack of capacity, (2) inaccessible due to remoteness of patient needs, and (3) unaffordable because of high out-ofpocket patient costs. 1

2) Demand for healthcare services is projected to grow. a) Projected change in demand is mostly associated with expansion of health insurance coverage under JKN and the remaining change is associated with population growth, demographic (gender and age) and epidemiologic transition. b) When government-sponsored healthcare insurance coverage increases, more prospective patients come to venues of care such as hospitals and primary care venues – Puskesmas, clinics, and private physician offices. In reports to date, the demand for care greatly exceeds the capacity for delivering care. In those situations, the waiting queue and waiting times for health services grow very rapidly. When this situation occurs, the demands of some prospective patients will not be met quickly, and prospective patients withdraw from the queue without receiving care. 3) Demand for physicians is projected to grow faster than physician capacity. a) Current physician capacity is below current desired demand, and desired demand for physicians in 2019 will be 1.2x higher than that in 2014. b) The number of practicing physicians is projected to grow 10.4% p.a. between 2014 and 2019. c) The gap is between the assumed standard of care for the insured population and the projected number of physicians. The biggest physician shortage between 2014 and 2019 is about 219,000 physicians. This number will fall to 204,000 with the current rates of graduation and leaving the profession. i) Over 85% of this shortage occurs at the primary care level. d) There are 33 provinces projected to be short of physicians, with the largest shortages likely to emerge in East Java, Central Java, West Java, DKI Jakarta, Bali, and Banten due to patient referrals. 4) Nurse capacity is projected to improve above its constrained demand, but not its desired demand. a) Desired demand for nurses grows in 2019 will be 1.2x higher than that in 2014. b) The number of nurses is projected to grow 17.8% p.a. between 2014 and 2019. c) Gap is the distance between the assumed “standard of care” and the projection of nurses. The biggest nurse shortage between 2014 and 2019 is about 177,000. This number will fall to 122,000 with the current rate of production. i) Over 60% of this shortage occurs at the primary care level. d) There are 17 provinces projected to be short in nurses, with South Sulawesi, Lampung, DKI Jakarta, and Central Java projected to have the biggest shortages. 5) Midwife capacity is projected to far exceed its demand. a) There is no deficiency in midwives, but spot shortages occur due to misallocation of personnel relative to local needs. i) The surplus of midwives is the difference between international standards for birth attendance and projected births for Indonesia. b) Desired demand for midwives in 2019 will be the same as that in 2014. c) The number of midwives is projected to grow 24.0% between 2014 and 2019. 6) Demand for inpatient care is projected to grow more rapidly than growth of hospital beds. a) Hospital capacity is roughly measured in available bed-days and assumes physicians allocate practice time on the basis of acute needs: first to hospitals and the remainder to clinics and offices. b) Desired demand for hospital admissions in 2019 is expected to be 1.3x higher than that in 2014. c) The number of hospital beds is projected to grow 13.0% p.a. between 2014 and 2019. d) At the national level, the biggest beds shortage between 2014 and 2019 is about 120,000 beds. If current construction plans materialize, that will decrease to 90,000 beds. e) There are 29 provinces projected to be short of hospital beds, with the greatest deficits in DKI Jakarta, Central Java, West Java, and East Java. 2

7) Increased in efficiency in use of healthcare capacity can alleviate the shortfalls in gaps. a) Properly trained nurses and midwives give the room to mitigate the projected shortage of physicians. i) Nursing programs can be broken down into practical nurse, registered nurse, physician assistant, and licensed nurse practitioner. Continuing professional education requirements for physician assistant and licensed nurse practitioner should be robust – high hurdles associated with prescribing pharmaceuticals and providing limited procedures. ii) The existing number and rapid growth of midwives suggests midwife’s production should be slowed down and focused more on improving the depth of training with strict licensing. The program should be examined with great care to improve maternal and infant mortality rates by improved training and facilities. b) Reducing ALOS (average length of stay) by one day can: i) Reduce demand for hospital beds by 15.9%, which means getting 15.9% more of hospital beds; ii) Subsequently reduce demand for physicians and nurses providing inpatient care; iii) Also mean improving technologies at existing hospitals, which comes at a cost. Conclusion and recommendation Conclusion There are significant shortfalls in physicians, nurses, and hospital beds compared to demands of prospective patients for a reasonable standard of care. By international standards – although not necessarily, local custom – there is no deficit in midwives. In particular, the likely demand for physician and nurse services will continue to exceed available capacities at all care levels (primary, secondary, and tertiary care). For nurses, as the capacity is the function of physicians and hospital beds, the gap will probably grow as numbers of physicians and hospital beds approach ideal values. This study does not address specific medical needs such as disease-related standards of care. However, it is reasonable to conclude that insufficient treatment capacity in primary care increases the burden at the hospital level. The generous governmental funding of healthcare costs makes the shortfall in available physician services even more evident. As more Indonesians are beneficiaries of ample healthcare funding, expectations that care will be available will increase. While remote areas will remain difficult to serve in future, it is possible and even likely that more physicians and allied healthcare workers will be drawn to metropolitan areas that have modern hospital facilities, exacerbating access issues for Indonesians living in remote areas. Recommendations 1) General a) A 10 year strategic Master Plan to address patterns of migration and changes in burden of disease. The Master Plan should include human resources, infrastructure, and organization, and move delivery system to more of an OECD level delivery system. b) Primary care strengthening to reduce secondary care burden. c) Development of tax policies to encourage investment by private sector, this needs further study. d) Engage development partners, ministries, professional organizations (IDI, KKI, specialist associations, IBI, PPNI, ARRSI, Arsada, etc), private sectors, NGO. 2) Physician capacity 3

a) Increase quota and number of medical schools. The current graduation rate is approximately 7,500 physicians per year and the retirement rate is approximately 6,000 physicians per year for a net growth rate of about 1.5% per year. If the graduation rate rises to 25,000 per year over the next five years, the physician supply would approximately meet demand in about 20 years. Given the need and the extraordinary challenge, resources to increase physician training should increase to at least double the number of medical school graduates by 2020. Location of medical schools should be in strategic areas that will allow local residents to study. b) The trend to use physician extenders is increasing in many countries. Nurses receive extra training to manage and treat a wide range of medical conditions including common infectious diseases, minor injuries, and take advanced measurements of patient chronic conditions. Given the surplus of trained nurses expected in the next several years, selecting and training a cadre of several thousand each year will significantly reduce the pressure on physician visits. c) A national service commitment which places physicians in rural and remote areas for two to five years should be considered for bonded in lieu compensation, especially for medical students who otherwise may not be able to afford medical school tuition fees. There may be needs to modify incentives to attract physicians work in rural and remote areas: GP’s payment incentives of at least 20% relative to urban specialists, opportunities for education and training in-career. d) Improve the quality of medical school and provide additional training on managing chronic disease complications, and congenital and genetic conditions. e) Continuous training; face to face or distance learning. f) Allow foreign doctors into the country for a certain period of time with placement in strategic areas. 3) Nurse capacity: a) A national initiative to identify and train qualified nurses in diagnostics, screening, and treatment will reduce pressure on physicians and increase the care to prospective patients relatively quickly. Standards setting by a national commission on nurse practitioners and physician assistants should consider the needs and cultural sensitivities of Indonesians and the availability of training in schools outside the country. b) A national service commitment which places nurses in rural and remote areas. There may be needs to modify incentives: opportunities for education and training in career. c) Improve the quality of nursing school and continuous training – face to face or distance learning. d) Allow experienced foreign nurses into the country for a limited period of time with placement in strategic areas. 4) Midwifes capacity: a) Individuals who qualify for midwifery may also be considered for nursing education or medical school training. When training tuition is a financial barrier, bonded national service in lieu of tuition may offer the incentive to prospective students to consider the more difficult professional commitment. b) Improve midwife education and provide trainings to current midwives – through face to face or distance learning and collaboration with obstetricians/gynaecologists – so trainees are qualified in diagnostics, screening, and treatment on certain diseases and also in public health area. 5) Hospital capacity: a) Improve efficiencies; accelerate autonomization/corporatization of public hospitals to make them more efficient. b) Physicians gravitate to hospitals where resources are usually better than primary care facilities. Thus, hospitals tend to remove physicians from primary care facilities where the need is the greatest.

4

Hospitals are frequently viewed as centers of excellence and concentrated in attractive urban areas, which draw physicians away from clinic and office practice. Given increased investment in the private sector hospitals, national government-sustained hospitals should be planned for areas with the greatest unmet needs and established only after due consideration for the availability of physicians on staff. Building new hospitals will not alleviate the shortage of physicians and is likely to make local shortages worse. c) Public-private partnerships. d) Allow foreign capital investments in strategic areas. 6) Data gaps exist between different institutions. For example, there is a significant gap between KKI’s registered physicians and MOH’s practicing physicians which warrants for further investigations. Integrated and up to date data have to be generated across institutions.

5

6

BACKGROUND As defined by the World Health Organization (WHO), universal health coverage (UHC) means ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. The Government of Indonesia, through its national and district government have made efforts in increasing the number of people covered and the scope of coverage in the government insurance schemes. Access to healthcare for poor individuals have begun since 1998 through various social programs: Program Jaring Pengaman Sosial Bidang Kesehatan (JPS-BK) in 1998-2001, Program Dampak Pengurangan Subsidi Energi (PDPSE) in 2001, Program Kompensasi Pengurangan Subsidi Bahan Bakar Minyak (PKPS-BBM) in 2002-2004, and Askeskin in 2005 (2). In 2010, the Government of Indonesia, through five of its public and quasi-private insurance providers, covered 63% of its 236 million people. This figure increased to 76% in 2013 (3,4). Jamkesmas (Community Health Protection Program) provided services to 76.4 million poor and nearpoor individuals nationwide. Jamkesmas began as Askeskin in 2005, which only covered poor population of 36.1 million, and was renamed to Jamkesmas in 2007 and expanded to cover near-poor population, with a more comprehensive benefit package. In 2013, Jamkesmas expanded its beneficiaries up to 86.4 million individuals. Jamkesda (District Community Health Protection Program) insured around 31.6 million poor and nearpoor individuals through district funding. Following Jamkesmas implementation, there are more than 400 Jamkesda initiated across the country (5). Subsequent to the political promise after DKI Jakarta’s gubernatorial election in 2012, more than 4 million Jakartans were covered under Kartu Jakarta Sehat (Healthy Jakarta Card) by the end of 2013, increasing Jakarta’s insured population from only 25% in 2012 to 67% in 2013. Askes (Health Insurance) and TNI/Polri insured 17.4 million civil servants, police, and military, active and retired, and their dependents. The schemes were managed by a for-profit state-owned enterprise and funded by a mandatory 2% payroll tax, which entitled enrollees to treatment at government health facilities and some drugs. PT Jamsostek (Workers’ Social Security Health Insurance), insured 4.8 million private sector employees and their dependents through a variety of plans (5). Following Presidential election in 2014, KIS (Healthy Indonesia Card) was piloted to 4.4 million poor and near-poor individuals in 9 provinces; a program aimed to replace JKN card for PBI enrollees (prior holders of Jamkesmas cards). Another 1.7 million individuals on the PMKS (Penyandang Masalah Kesejahteraan Sosial) will be added to this list. These increases in insurance coverage were accompanied by increased expectations for healthcare by those covered, as evidenced by a measurable increase in patients’ visits. During the initial implementation of KJS, RSUD Tarakan, Jakarta hospital outpatient venues experienced up to 1,000 additional visits per day (6). In RSUPN Cipto Mangunkusumo, Jakarta, average patients’ visits increased three-fold, with 70% of the increased visits coming from DKI Jakarta (7). Prior to JKN implementation, RSUD dr Soetomo, Surabaya received 3,000 outpatients per day. This number increased to 5,000 visits per day following JKN implementation, which is far greater than existing capacity (8). As in every country, Indonesia’s healthcare capacity is limited. The main challenges faced by healthcare system – demographic, epidemiologic, and nutrition transitions, shifts in insurance status and general health status – cause demands on the healthcare system to increase much faster than the rate of growth in healthcare capacity (supply). A change in financial terms can occur very quickly, but it takes years to educate physicians, nurses, and midwives.

7

Measurements such as visits per day to primary care and outpatient venues and inpatient admissions are frequently misinterpreted to mean demand or patient need when they actually reflect a limitation in the capacity to diagnose and treat medical conditions. Therefore, demand- and supply-side barriers in healthcare services must be thoroughly considered according to current and future needs and strategically overcome to ensure the covered population benefits from public spending. Because government plans are set to expand coverage and increase individual benefits, the TNP2K Health Assistance Working Group wished to better understand the gap between current and future demand and healthcare capacity to serve that demand. A preliminary national-level study was done in 2013 that used System Dynamics Methodology (SDM). SDM, as described more fully below, integrates the feedback between supply and demand to provide a more cogent and comprehensive perspective. The results of that study suggested that, as financial constraints decreased, the gap would grow between the expectations of the insured and the health care system’s capacity to meet demand. In order to better understand how planned changes in the government insurance programs would affect each province, this study expands on the preliminary study to include both the national and provincial levels. The 2013 national-level study assumed a simple economic barrier and did not differentiate between the healthcare needs of men and women. In this study, each provincial population is represented by gender and insured status in four age cohorts including juvenile, fecund, mature and people over age 65 years, and seeks to estimate the gap between population demand for health care services and the capacity to fulfil that demand in each province.

8

DATA SOURCE Table 1. Initial conditions and parameter values No 1 2

Parameter Population initial values by age and gender Crude death rates by age and gender

3 4

Birth rates Insurance status

5

Registered physicians

6 7 8 9 10

Practicing physicians, nurses, and midwives Hospital capacities Average length of stay Hospital utilization rates Venue to seek care

11

Birth delivery

12

Effect of insurance status on treatment seeking behaviors Effect of accessibility on treatment seeking behavior Parameter estimates for practice patterns

13 14 15 16

Parameter estimates for information diffusion times Parameter estimates for patients migrating between provinces

Source Badan Pusat Statistik (BPS) (Statistics Indonesia), 2010 BPS Population Projection 2010 – 2035, UNDESA 2010 – 2015 BPS Population Projection 2010 – 2035 Kementerian Kesehatan (Ministry of Health (MoH)), 2013 Konsil Kedokteran Indonesia (Indonesian Medical Council), 2013 MoH, 2013 MoH, 2013 MoH, 2011 PT Askes, 2012 Susenas (National Socio Economic Survey (NSES), 2013 Indonesia Demographic and Health Survey (IDHS), 2012 Estimates by author team Survei Potensi Desa (PODES) (Village Potential Statistics), 2011 Estimates by author team from observation and survey/discussion Estimates by author team Estimates by author team

9

METHODOLOGY System dynamics modeling The national and provincial studies are supported with computer simulation models: one for each province and one for national. These models simulate the interaction between potential demand and capacity to satisfy that demand. In order to accurately simulate the interactions between supply, demand, a changing population and the plans for changing healthcare coverage, the computer models simulate certain effects of feedback and time delays. Taken from the 2013 national study, the figure below illustrates the structures of reinforcing (R) and balancing (B) feedback loops. Figure 1. Fundamental dynamics in Indonesia’s healthcare system

The figure illustrates fundamental dynamics in Indonesia’s healthcare system. The more insurance coverage Indonesia give out, the more people will think that they are entitled to a service (perceived demand). With constrained (limited) healthcare capacity, this will result in longer waiting lines. At some point, people are likely to adjust their demand according to available treatment capacity (in economic terms this is supplier-induced demand). More prospective patients will be discouraged and stop pursuing care, which will result in shorter waiting lines. Queues only tell a small part of the story – the most obvious part. However, people talk with each other – informally, through the media, and in community meetings. When capacity does not meet demand, people complain about waiting times. Their complaints are likely to discourage others from seeking healthcare, which further reduces the queue without meeting actual demand. Then, as the queue shortens, people will perceive that capacity is available and increase their demand for utilization. The cycle repeats until demand adjusts to supply—a process that can take several months. These cyclic phenomena are illustrated in the figure below.

10

Figure 2. How supply (healthcare capacities) affect demand

The red dashed line in Figure 2 simulates how demand in the healthcare marketplace adjusts to supply. When expectations for healthcare increase, such as when government insurance plans increase benefits, more prospective patients will seek care at existing facilities such as hospitals and clinics. As waiting queues increase, some prospective patients will leave the queue without receiving treatment. As this news spreads, fewer prospective patients will seek care and the queues will shorten, which means more people are left untreated. Then, as queues fall below capacity, word spreads and more people seek care. This cycle repeats until, ideally, measured demand and supply come into equilibrium. However, the gap between actual medical need and treatment capacity does not change. Demand is greater than the capacity of the healthcare system. The computer simulations developed for the current study place the population in the center of the health care system. The projections that emerge from the mathematical models simulate care-seeking behavior of the population by age cohort, gender and insured status as those attributes change over time with emphasis placed on insured status.

Population, Demand, and Supply 1. Population The simulated population levels begin with the 2010 BPS census data and estimate birth and mortality rates for four major population cohorts: • • • •

Juveniles, aged birth to 15 years Fecund (reproductive), aged 15 to 45 years Mature, aged 45 to 65 years Ageing, aged 65 and over

Concepts to simulate population projection are explained in these two papers(9,10).

11

people

ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

Figure 3. Population Data, 2010

50,000,000

45,000,000

40,000,000

35,000,000

30,000,000

25,000,000

20,000,000

15,000,000

10,000,000

5,000,000

-

Source: BPS 2010

Figure 4. Population projection to 2020

total natl population

300 M

280 M

260 M

240 M

220 M

200 M 2010 2011 2012 2013 2014 2015 2016 Date 2017 2018 2019 2020

total natl population : Indonesia

12

Figure 5. Population projection based on age group and gender Age 15 to 44 Indonesia

Age 00 to 14 Indonesia

60 M

40 M 58 M

people

people

36 M 32 M

56 M

28 M

54 M

24 M

52 M

20 M 2010 2011

2012 2013

2014 2015 Date

2016 2017

2018 2019

50 M 2010

2020

Age 00 to 14 Indonesia[male] : Indonesia Age 00 to 14 Indonesia[female] : Indonesia

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over Indonesia

Age 45 to 64 Indonesia

10 M

28 M

9M

26 M

8M

people

people

2012

Age 15 to 44 Indonesia[male] : Indonesia Age 15 to 44 Indonesia[female] : Indonesia

30 M

24 M

2011

7M

22 M

6M

20 M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64 Indonesia[male] : Indonesia Age 45 to 64 Indonesia[female] : Indonesia

5M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over Indonesia[male] : Indonesia Age 65 and over Indonesia[female] : Indonesia

These cohorts are known to exhibit (or “manifest”) significantly different healthcare-seeking behaviors. For example, virtually all births occur to women age 15 to 45 and the prevalence of dementia, diabetes, hypertension, and hyperlipidemia tend to increase with age. By representing shifts in the number of people in each age cohort, the simulated effects include demographic transitions both nationally and in each province. The age cohorts are further divided by gender to capture the differences between how and when men and women seek health care services. Health insurance status is applied to the age and gender cohorts to project the actual and scheduled changes in government health care insurance plans: • • • •

JKN insured Jamkesda insured Private insured Noninsured

In addition to providing a demographic overview, these distinctions permit analysis of how population dynamics affect healthcare utilization in 32 categories of age, gender and insured status: 4 age groups x 2 gender groups x 4 insured status groups. 2. Demand In this study, demand is assumed to arise at the level of the individual and is affected by larger market forces. Generally, in healthcare markets, demand is negotiated between a patient and physician. The aggregate result of those individual negotiations is called the standard of care, which can vary widely from country to country and within countries to reflect physician experience and procedures that are considered customary and necessary.

13

In the absence of agreed standards of care, the study uses PT Askes 2012 hospital utilization rates developed for each age and gender cohort. These rates reflect the negotiated demand of over 16 million people and well over 100 million transactions that span all provinces. The study assumes that, for the population at large, care received by PT Askes enrollees is adequate to satisfy individual demand. PT Askes utilization is the study’s standard of care and is thus assumed to represent underlying demand. Demand is affected by three market-level forces— affordability, accessibility, and availability – and is measured in three ways: ▪

Unconstrained demand: the demand for care made by the population considering awareness of individual health status.

▪

Desired/expected/real demand: the demand for care made by the population considering awareness of health status, affordability and accessibility barriers.

▪

Constrained demand: the demand for care made by the population considering awareness of health status, affordability and accessibility barriers and the availability of care (supply).

PT Askes measures inpatient and outpatient demand fulfilled at hospitals. The inpatient utilization rates carryover to the general population. Outpatient utilization rates are extrapolated to all venues of care—hospital outpatient, Puskesmas, medics and paramedics’ offices, and clinics—as reported in SUSENAS 2013 data. The rates are then adjusted using affordability adjustment factors, which are estimated based on insurance status. There are four levels of economic affordability assumed in the study. The population is disaggregated into noninsured and insured, with insured group divided into JKN, Jamkesda, and private groups. Each group so disaggregated has different utilization rates. The population covered by JKN are assumed to demand care at 90% and 80% of the PT Askes utilization rates for outpatient and inpatient care, respectively. Adjustments for other insurance plans can be seen in the table below. These adjustments reflect the expected standard of care and thus potential demand. Table 2. Affordability adjustment factors based on insurance status Insurance Status

Outpatient

Inpatient

Midwife

Noninsured

0.5

0.2

0.5

JKN insured

0.9

0.8

0.9

Jamkesda insured

0.7

0.8

0.7

Private insured

1.1

1.2

1.1

Then the rates are adjusted using accessibility adjustment factors. For accessibility, the study uses 2011 PODES survey data to measure how geographically accessible venues of care are. PODES measures the level of effort expended to obtain health care services for each village. The village-level data are weighted by population to develop a province-level degree-of-difficulty. Then, the intensity of services sought (primary or inpatient) is used to adjust the fraction of people needing care who would be likely to seek and utilize care. 14

Table 3. Adjusted* Askes 2012 rates for JKN insured group Outpatient (1o care)

Inpatient (1o care)

Outpatient (2o care)

Inpatient (2o care)

Gender

Age

Male

0-14

261.68

201.16

1.91

1.45

24.54

18.87

6.23

4.72

Female

0-14

378.50

290.96

2.42

1.84

28.00

21.52

6.97

5.28

Male

15-44

209.95

161.39

1.16

0.88

28.82

22.15

5.02

3.80

Female

15-44

243.10

186.88

2.50

1.89

32.90

25.29

5.62

4.26

Male

45-64

428.84

329.66

1.35

1.03

72.61

55.82

6.97

5.28

Female

45-64

558.69

429.48

1.90

1.44

82.34

63.30

7.74

5.87

Male

65+

437.97

336.68

1.64

1.24

77.96

59.93

8.41

6.37

Female

65+

635.84

488.79

2.53

1.92

87.90

67.57

9.30

7.04

394.32

303.13

1.93

1.46

54.38

41.81

7.03

5.33

Average

Askes 2012 Adjusted Askes 2012 Adjusted Askes 2012 Adjusted Askes 2012 Adjusted

*Formula = Askes 2012 rates * affordability adjustment factor * (1-accessibility adjustment factor) The model simulates how demand changes over time as the insurance coverage expands. Insurance coverage expansion and general health status determine the demand for healthcare. The simulations reflect demographic and epidemiologic transition through the age and gender-based utilization rates. Each time a new health cost financing program is announced, the desired demand increases because the public perceives increased affordability and does not adequately consider that the health care capacities have not increased in proportion to demand. As the more people seek care and waiting times increase, this knowledge spreads by media and word-of-mouth. Prospective users with marginal care needs are likely to not seek care, which has the effect of reducing measured demand and masking (hiding) real demand. Availability (see Supply in the next section) is a function of supply and thus is treated dynamically in the study. As expectations of affordability change over time, demand increases. However, capacity is not directly a function of demand and changes much more slowly as new facilities are constructed and as medical professionals graduate from training. Prospective patients seek care based on their expectations for capacity, and, as expectations increase, the number of patients seeking care can exceed capacity which causes waiting time in queues to increase. As the time in queue increases beyond the prospective patients’ willingness to wait, a portion leaves the queue which reduces pressure at the venues of care. As the queuing pressure decreases, more prospective patients seek care and the pressure increase again. This effect—rising and falling waiting times—gradually settles at the level of actual capacity. To adjust for flows of patients between provinces, the study considers prospective patient migration. Three provinces are assumed to attract patients because of their high concentrations of healthcare capacity. Prospective patients flow into DKI Jakarta, Bali, and East Java, and reduce demand in the remaining provinces. Care-seeking migration into and from the country is omitted from this study. Average annual number of physician visits per person varies between countries. In the US, the number of visits (to physician offices, hospital outpatient and emergency departments) is around 4 per person per year (408.2 per 100 persons) as compared to 13 visits per person per year in Japan (OECD Health

15

Data 2014).1 In the model, the estimated number in Indonesia for constrained demand is less than one-third of that in the US; 1.1 in 2014 and 1.3 in 2014, and the desired demand is about three times of our estimated constrained demand: 2.92 in 2014 and rises to 3.46 in 2019. 3. Supply Initial supplies of physicians, hospital beds, nurses, and midwives reflect the situation in 2013 and are projected to 2020. Physician supply Total physician reflects the sum of general practitioners and specialists in inpatient (hospital) and outpatient (primary care – Puskesmas, private practice, and clinics – and hospital) care. The model considers fraction of students going into medical school, fraction of medical students finishing their education, fraction of general practitioners practicing, taking specialization, not practicing, and leaving their practice (attrition) due to out-migration, retirement, disability, and death; similar pathways apply to specialists. The model used GP-registered data borne by KKI as an initial parameter. The model assumes that 12.5% of graduates continue to become specialists, a maximum of 25% of physicians are not practicing (the number was decided from a discussion with KKI in 2013). The model did not use data from MOH due to a huge gap from registered and practicing GPs and specialists, as shown in Figure 6 and 7. Possible explanation includes MOH data does not fully captured physicians practicing in private venues. Proportion of physicians in healthcare venue is taken from MOH data 2013. Proportion of general practitioners and specialists is maintained at the current level throughout each simulation. Simulating individual specialities is beyond the scope of available data. This study does not specifically address the fourth “A”: attractiveness. Physicians in some settings (e.g. clinics serving the poorest population) may not present an attractive practice to all potential patients. Physicians in other settings (e.g. private practice) may limit the number of patients they see in order to provide a higher value/price service. Physicians are presented in the aggregate and separately by venue because the claims data on which the projections are based is organized by inpatient venues and outpatient, polyclinic and office venues. The demand is served by physicians who divide their time between venues and the results are “physician equivalents”. The capacity of those doctors is measured in visits per month for outpatient and clinic care and patients per day for inpatient care. Key baseline parameters used in national physician model are: initially 300 visits per physician per month with a maximum rate of change in visit of 20%. Visits per month are an average; general practitioners in hospital outpatient services are known to see more patients than a specialist in, say, oncology. For inpatient care, the number of hospital days per month per physician is 21.5, the number of hours per day is 8, and the number of patient per hour is 3. Average months of practicing for general practitioners and specialists are 264 and 300 months, respectively. Fraction of general practitioners continuing to a specialization is assumed to be 12.5%. Fraction of nonpracticing physicians is assumed to be 25%.

1

Scorekeeping varies from country to country so these statistics are representative but not directly comparable.

16

ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

Figure 6. General practitioner: registered vs practicing, 2013

18000 16000 14000 12000 10000 8000 6000 4000 2000 0

GP-registered

Specialist-Registered GP-Practicing

Specialist-Practicing Model projection on GP-Practicing

Source: GP-Registered: KKI 2013, GP-Practicing: BPPSDM, MOH 2013

Figure 7. Specialist: registered vs practicing, 2013

7,000

6,000

5,000

4,000

3,000

2,000

1,000

-

Model projection on Specialist-Practicing

Source: Specialist-Registered: KKI 2013, Specialist-Practicing: BPPSDM, MOH 2013

17

Hospital bed supply Estimation of beds needed depends on demand for admission and Average Length of Stay (ALOS – from MOH data 2009). The capacity is projected from MOH bed data in 2013 and Rencana Aksi Pengembangan Pelayanan Kesehatan 2013-2019 (healthcare service development action plan 20132019) which aims at 1 bed per 1,000 population in the respective year for class I, II, and III beds. The assumptions estimate a national ratio of 1 bed per 900 of population to include VVIP, VIP, I, II, and III. This better represents the actual market condition, despite the small fraction of the expensive beds to the total market. In the market, when a patient prefers a less expensive bed and there are none but the patient has financial resources, the patient will choose the more expensive bed over no care. The assumption is that there are enough patients with the financial flexibility to make that move up the cost scale. (One-day care service is considered as outpatient.) The simulations account for a rate of improvement in ALOS over time and thus a change in prospective patients’ perception of inpatient capacity. The baseline ALOS used is from 2011 Jamkesmas utilization data: national ALOS of 6.5 days, with maximum change in ALOS of 1 and maximum rate of change in ALOS of up to 18%. These parameters are adjusted to currently available data for each province. Figure 8. Number of hospitals, 2013 350 300 250 200 150 100 50 ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

0

Source: BUK, MOH 2013

18

Figure 9. Number of hospital beds, 2013

ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 -

Total Beds

Model projection for Total Beds

Source: Total Beds: BUK, MOH 2013 Nurse supply The model assumptions include the fraction of students going into nursing school, fraction of nursing students finishing their education, fraction of nurses practicing and not practicing, and those leaving practice (retirement, aging, death, and migration). Nurses are assumed to be medical professionals allied to physicians. Thus, the estimates of demand for nurses are a function of demand for inpatient beds and physician visits. Key baseline parameters used in this model are: initial number of nurse is taken from BPPSDM, MOH data 2010. BPPSDM data on practicing nurse is used to predict proportion of nurse practicing in province compared to national. Average months practicing is assumed to be 240 months, nurse per bed utilized is assumed to be 0.15, and nurse to physician ratio in outpatient care is assumed to be 1.

19

Figure 10. Nurse Practicing, 2013 40000 35000 30000 25000 20000 15000 10000 5000

ACEH SUMATERA UTARA SUMATERA BARAT RIAU JAMBI SUMATERA SELATAN BENGKULU LAMPUNG KEP. BANGKA BELITUNG KEP. RIAU DKI JAKARTA JAWA BARAT JAWA TENGAH DI YOGYAKARTA JAWA TIMUR BANTEN BALI NTB NTT KALIMANTAN BARAT KALIMANTAN TENGAH KALIMANTAN SELATAN KALIMANTAN TIMUR KALIMANTAN UTARA SULAWESI UTARA SULAWESI TENGAH SULAWESI SELATAN SULAWESI TENGGARA GORONTALO SULAWESI BARAT MALUKU MALUKU UTARA PAPUA BARAT PAPUA

0

Nurse

Model projection on Nurse

Source: Nurse: BPPSDM, MOH 2013 Midwife supply The model assumptions include a fraction of students going into midwifery school, fraction of midwifery students finishing their education, fraction of midwives practicing, not practicing, and leaving their practice (retirement, aging, death, and migration). Midwife demand is a function of births at home, primary and seconday venues. The ratios used are one midwife per 35 births in hospital (healthcare facilities) and one midwife per 28 births in primary care – these ratios are drawn from international data. Key baseline parameters used in this model are: initial number of midwife from BPPSDM, MOH data 2013. Average months practicing is assumed to be 180 months.

20

Figure 11. Midwife Practicing, 2013 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 -

Midwife

Model projection on Midwife

Source: Midwife: BPPSDM, MOH 2013 Results Interpretation 1. Hospital bed, physician, and nurse In the results that follow, there are four similar plots in the hospital bed, physician, and nurse graphs: -

-

-

-

The blue line is the measured or projected “capacity”: physicians, beds, admissions, visits, nurses, etc. o Admission capacity = beds * hospital days per month ÷ Average Length Of Stay o Physician visit capacity = practicing physicians * average visits per physician per month The red line is the “desired demand”, “real demand”, or “perceived demand” – the terms can be used interchangeably. Real demand reflects the demand for care considering financial and access barriers when availability is not constrained. o Real demand = ASKES utilization rate * population by insured status * affordability adjustment * access adjustment The green line is the “constrained demand”, which is what prospective patients demand considering financial and access barriers and their perception of available care. o Constrained demand = effect of capacity on demand * ASKES utilization rate * population by insured status * affordability adjustment * access adjustment o effect of capacity on demand = a function of waiting time and the time for the population to become aware of waiting times The grey line is the “unconstrained demand”, which is what would be demanded if there were no economic or access barriers. To avoid confusion, this demand will not be presented in the results. o Unconstrained demand = ASKES utilization rate * population

21

The space between “capacity” and “real demand” serves as the gap in healthcare system which needs to be filled. Figure 12: Sample graph: hospital bed

2. Midwife -

The blue line is the “capacity”: midwife, birth The red one is the “desired demand” or “real demand” The green line is the “constrained demand” Figure 13: Sample graph: Midwife attended hospital births

Births in hospital

2M

birth/Month

1.6 M 1.2 M 800,000 400,000 0 2014

2015

2016

2017 Date

2018

2019

2020

midwife attended births available in hospital : Indonesia desired midwife attended births in hospital constrained : Indonesia midwife attended hospital births : Indonesia

22

RESULTS Projected supply and demand at national level 1. Background In its early implementation, all PT Askes’, TNI/Polri’s, Jamkesmas’, and Jamsostek’ insureds are automatically changed in their membership status into JKN enrollees. In JKN roadmap, district governments will gradually integrate their Jamkesda programs2 into JKN – full integration is expected to complete in 2016 (10). The JKN program also encourages individual registrations by those who are previously uninsured or privately insured. In 2019, nearly 100% of population is expected to be covered by JKN scheme. 2. Key Findings a. Starting in 2014, there is a gradual change in the insurance status of the population. By the year 2019, the proportions are projected to consist of 82.8% JKN, 2.5% Jamkesda3, 8.2% private, and 6.5% noninsured of the total projected population (Figure 14). b. The projected number of actual physician visits per person per year are 0.93 in 2014 and 1.01 in 2019, while the real demand for physician visits per year is 2.92 in 2014 and 3.46 in 2019. c. Between 2014 and 2019, for outpatient physician visits, actual capacity can only meet on average 31.6% of real demand. Mainly due to a change in insurance status, real demand for outpatient physician visit in 2019 will be 21.9% greater than in 2014. d. Between 2014 and 2019, actual physician capacity can only meet an average 34.0% of real demand. Mainly with a change in insurance status, real demand for physicians in 2019 will be 19.8% greater than in 2014. e. The need for nurses is largely a function of utilized hospital beds and physicians visits. between 2014 and 2019, actual nurse capacity exceeds its constrained demand but can only meet an average 72.3% of real demand. Mainly with a change in insurance status, real demand for nurses in 2019 will be 17.8% greater than in 2014. f. Over 85% of physician shortage and over 60% of nurse shortage occur at the primary care level. g. Midwife is a function of births, and there is a more than adequate supply of midwives. Between 2014 and 2019, actual midwife capacity exceeds its real demand by more than a factor of 3. This surplus might be narrower if local customs and dispersed population, which need for more midwives, are taken into account. h. Between 2014 and 2019, for hospital inpatient admissions, actual capacity can only meet an average 72% of real demand. Mainly with a change in insurance status, real demand for hospital inpatient admission in 2019 will be 27.3% greater than in 2014. i. Based on observed improvements in patient management, between 2014 and 2019 there is a reduction in Average Length Of Stay by one day to 5.5 days This increases effective hospital bed capacity by 15.9%, followed by nurse and physician capacities.

2

There are 460 schemes according to the Jamkesda study 2014 covering 63-70 million individuals (unpublished)(11). This exceeds MOH’s figure: 31.6 million individuals(3). 3 From Jamkesda study 2014 surveying 72 districts, 28.8% of district health officers and 44.9% of local governments do not have plans to integrate to BPJS(11). This model assumes by 2016 Jamkesda schemes will be integrated as mentioned in road map to JKN(12), with adjusted integration rate.

23

3. Summary of projection Currently Available Data Table 4. National Currently Available Data Parameter Population GP Registered GP Practicing Specialist Registered Specialist Practicing Nurse Midwife Hospital Hospital Bed VVIP, VIP I, II, III

Number 236,547,895 94,130 38,417 24,143 37,043 282,128 130,319 2,400 27,435 199,852

Source BPS, 2010 KKI, 2013 BPPSDM, MoH 2013 KKI, 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BUK, MoH 2013 BUK, MoH 2013 BUK, MoH 2013

Table 5. National 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 69,998 31,552 38,447 17,689 317 17,371 255100 109,430 145,670 133,225 225,967 27,725 198,242

24

Insurance status Figure 14. Change in insurance status 250,000,000 200,000,000 150,000,000 100,000,000 50,000,000 -

JKN

Jamkesda

Swasta

Tanpa asuransi

The projected changes result in a shortfall in physicians (for both inpatient and outpatient care) and hospital beds and a surplus in nurses and midwives (for both inpatient and outpatient care). In physician model, the model accounts for change of outpatient visit per physician per month as demand increases; physicians will see more patients, reducing time spent per patient. Figure 15. Gaps summary 150,000 107,156 100,000 50,000 (50,000)

physician in primary care

physician in hospital

nurse in primary care

(27,533)

(100,000)

(67,572) (109,618)

(150,000)

nurse in hospital

midwife

hospital bed hospital bed (VVIP, VIP, (I,II,III) I,II,III)

(123,985) (150,012)

(200,000)

(191,667)

(250,000)

Physician. Data for the number of trained physicians and those in practice from different sources are conflicting. The figures provided by the MOH reflect the number of physicians practicing in hospitals and Puskesmas, and not in private practice and clinics; the same is true for nurses and midwives. Productivity, quality, outcomes performance, and distribution of healthcare workers remain as key challenges which are influenced by many factors; number and quality of medical/nursing/midwifery schools, policies, programs, geography, economic development, among other things(13). Currently 25

there are 72 medical schools registered as AIPKI members; many of these schools are concentrated in DKI Jakarta (10), East Java (8), Central Java (7), North Sumatera (6), and West Java (5). Only half of the total schools are accredited(13), which calls into question the quality of the physician graduates. Nevertheless, with the current rate of production, the shortage of physicians will not improve significantly through 2020. From Figure 16, real demand for physicians is 2.8x higher than constrained demand in 2014. This figure is expected to grow to 3.1x as insurance coverage expands. For outpatient visits evidenced in Figure 20, with initial visit capacity of 300 per physician per month and a maximum rate of change in visit of 20% per month, visits that can be met with limited capacity is less than half (31.6%) of the real visit demand in 2014. By 2019, this number is even less: only 29.2% of real demand can be met. The desired number of physician visits per person per year is 3.2x higher than current figure in 2014 and is projected to increase to 3.4x in 2019. Table 6. National total desired physicians Physician shortage

Widest gap

Gap in 2019

Physician (total)

(219,200)

(204,479)

Physician in primary care

(191,667)

(183,722)

Physician in hospital

(27,533)

(20,758)

Figure 16. National total desired physicians Total physicians 300,000

physician

240,000 180,000 120,000 60,000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Indonesia desired physicians INA : Indonesia desired physicians constrained INA : Indonesia

26

Figure 17. National desired physicians in hospital 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 2014

2015

2016

Dokter di RS

2017

2018

2019

2020

Permintaan dokter di RS

Figure 18. National desired physicians in primary care 250,000 200,000 150,000 100,000 50,000 2014

2015

2016

Dokter di Yankes Primer

2017

2018

2019

2020

Permintaan dokter di Yankes Primer

27

Figure 19. National physicians providing hospital inpatient care

Physicians providing inpatient care in hospital

30,000

physician

26,000 22,000 18,000 14,000 10,000 2014

2015

2016

2017 Date

2018

2019

2020

IP physicians : Indonesia desired IP physicans INA : Indonesia desired IP physicians constrained INA : Indonesia

Figure 20. National number of physician visits at hospital and primary Physician outpatient visitsper inmonth hospital and primary care care outpatient 80 M

visit/Month

64 M 48 M 32 M 16 M 0 2014

2015

2016

2017 Date

2018

2019

2020

physician visits INA : Indonesia desired physician visits INA : Indonesia desired physician visits constrained INA : Indonesia

28

Figure 21. National physicians providing outpatient care in hospital and primary care Physicians providing outpatient care in hospital and primary care 300,000

physician

240,000 180,000 120,000 60,000 0 2014

2014

2015

2016

2016 2017 Date

2018

2018

2019

2020

physicians in outpatient office and clinic INA : Indonesia desired OP and office physicians INA : Indonesia desired OP and office physicians constrained INA : Indonesia

Nurse. Currently Indonesia has over 400 nursing schools. In Figure 22, the actual nurse capacity exceeds its constrained demand. This is because nurse is a function of physicians and hospital beds, which actual capacities are also limited. This “surplus” of nurse – between capacity and constrained demand – means these nurses are unemployed or underemployed; Indonesia has an adequate supply of nurses but not enough physicians and hospital beds. The “desired nurses” assumes Indonesia has all hospitals and doctors desired. Table 7. National total desired nurses Nurse shortage

Widest gap

Gap in 2019

Nurse (total)

(177,190)

(122,083)

Nurse in primary care

(109,618)

(85,202)

(67,572)

(36,881)

Nurse in hospital

29

Figure 22. National total desired nurses Total nurses 400,000 340,000

nurse

280,000 220,000 160,000 100,000 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity total INA : Indonesia desired total nurses INA : Indonesia desired total nurses constrained INA : Indonesia

Figure 23. National total desired nurses in hospital 250,000 200,000 150,000 100,000 50,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Perawat di RS

Permintaan perawat di RS

Figure 24. National total desired nurses in primary care 250,000 200,000 150,000 100,000 50,000 2014

2015

2016

Perawat di Yankes Primer

2017

2018

2019

2020

Permintaan perawat di Yankes Primer

30

Figure 25. National nurses providing outpatient care in hospital and primary care

Nurses providing outpatient care in hospital and primary care 300,000 240,000

nurse

180,000 120,000 60,000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurses in outpatient clinic and office INA : Indonesia desired OP and office nurses INA : Indonesia desired OP and office nurses constrained INA : Indonesia

Figure 26. National nurses providing hospital inpatient care

Nurses providing inpatient care in hospital

200,000

nurse

180,000 160,000 140,000 120,000 100,000 2014

2015

2016

2017 Date

2018

2019

2020

IP nurses INA : Indonesia desired IP nurses INA : Indonesia desired IP nurses constrained INA : Indonesia

Midwife. Midwife is a function of births. Currently Indonesia has over 750 midwifery schools. Our midwife capacity is 3.1x higher than its desired demand. This means our current midwives are unemployed or underemployed. Table 8. National total desired midwives Midwife surplus Midwife (total)

Minimum surplus 107,156

Surplus in 2019 141,200

31

Figure 27. National total desired midwives

Total midwives

200,000

midwife

160,000 120,000 80,000 40,000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives INA : Indonesia desired midwife total : Indonesia

Figure 28. National births per month in primary care

Births in primary care

4M

birth/Month

3.2 M 2.4 M 1.6 M 800,000 0 2014

2014

2015

2016

2016 2017 Date

2018

2018

2019

2020

midwife attended births available in primary care : Indonesia desired midwife attended births in primary care constrained : Indonesia midwife attended primary care births : Indonesia

32

Figure 29. National births per month in hospital

Births in hospital

2M

birth/Month

1.6 M 1.2 M 800,000 400,000 0 2014

2014

2015

2016

2016 2017 Date

2018

2018

2019

2020

midwife attended births available in hospital : Indonesia desired midwife attended births in hospital constrained : Indonesia midwife attended hospital births : Indonesia

Hospital bed. From Figure 30, between 2014 and 2019, desired demand hospital admission per month is 1.4x higher than the constrained demand. Desired demand for hospital admission in 2019 will be 1.3x higher than that in 2014. Unless significantly increased, planned hospital beds will not be able to meet this demand. Table 9. National total desired hospital beds Bed shortage

Widest gap

Gap in 2019

VVIP, VIP, I, II, III

(123,985)

(90,288)

I, II, III

(150,012)

(116,621)

Figure 30. National hospital inpatient admission per month

Hospital inpatient admissions

2M

admission/Month

1.76 M 1.52 M 1.28 M 1.04 M 800,000 2014

2015

2016

2017 Date

2018

2019

2020

IP admissions INA : Indonesia desired IP admissions INA : Indonesia desired IP admissions constrained INA : Indonesia

33

Figure 31. National hospital beds

Hospital beds

400,000 360,000

bed

320,000 280,000 240,000 200,000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity INA : Indonesia desired IP beds INA : Indonesia desired IP beds constrained INA : Indonesia

Table 10. National total hospital beds Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(123,985)

(90,288)

Hospital bed (I,II,III)

(150,012)

(116,621)

34

Projected supply and demand at provincial level Provincial model provides projection at provincial level. It accounts for patients migrating from one province to another for referral care: DKI Jakarta, Bali, and East Java are considered as recipients as most healthcare capacities are concentrated in these provinces. When available, newspaper articles capturing healthcare demands following JKN implementation and status of healthcare capacities are provided. Although anecdotal, these provide a picture of how the public perceives healthcare capacity (supply) and attempts to obtain care (desired demand). Provincial Summary Projection 2019 Figure 32. Summary projection 2019

35

Figure 33. Physician capacity distribution

Figure 34. Nurse capacity distribution

36

Figure 35. Midwife capacity distribution

Figure 36. Hospital bed capacity distribution

37

1. Aceh Aceh has 4.5 million population; 4.25 million people are covered through Jamkesda and Jaminan Kesehatan Aceh (JKA). The government of Aceh has shown great commitment to ensure its people have access to care as evidenced in increased funding allocated for JKA; from IDR 241.9 billion in 2010 to IDR 418.8 billion in 2013. For the period of 2010-2013, the government contracted PT Askes to implement JKA program. Since January 1, 2014, JKA has been integrated to JKN. As of now, around 2.6 million people are covered under JKN, comprising poor people, civil servants, TNI/POLRI, and Jamsostek enrollees. Aceh is still short in healthcare capacities. For example, in RSUD Sigli, Pidie district and RSUD Cut Nyak Dhien, patients are served in hospital corridor and on chairs due to beds shortage (12–16).

Currently available data Table 11. Aceh currently available data

4,494,410 2,165 1,383 338 852 11,003 9,383 60

% to National 1.9% 2.3% 3.6% 1.4% 2.3% 3.9% 7.2% 2.5%

631 5,396

2.3% 2.7%

Parameter Population GP Registered GP Practicing Specialist Registered Specialist Practicing Nurse Midwife Hospital Hospital Bed VVIP, VIP I, II, III

Number

Source BPS, 2010 KKI, 2013 BPPSDM, MoH 2013 KKI, 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BUK, MoH 2013 BUK, MoH 2013 BUK, MoH 2013

Table 12. Aceh 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,625 940 686 252 1 251 11,092 5,764 5,328 8,991 6,027 631 5,396

38

Figure 37. Aceh population projection to 2020 total provincial population 6M

people

5.6 M 5.2 M 4.8 M 4.4 M 4M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Aceh

Figure 38. Aceh population projection by age group and gender Age 15 to 44 1.3 M

760,000

1.26 M

720,000

1.22 M

people

people

Age 00 to 14 800,000

680,000 640,000

1.18 M 1.14 M

600,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

1.1 M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

Age 00 to 14[male] : Aceh Age 00 to 14[female] : Aceh

Age 15 to 44[male] : Aceh Age 15 to 44[female] : Aceh

Age 65 and over 300,000

460,000

240,000

420,000

180,000

380,000 340,000 300,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Aceh Age 45 to 64[female] : Aceh

people

people

Age 45 to 64 500,000

120,000 60,000 0 2010 2011

2012 2013

2014

2015 2016 Date

2017 2018

2019

2020

Age 65 and over[male] : Aceh Age 65 and over[female] : Aceh

39

Figure 39. Changed in insurance status in Aceh

NUMBER OF POPULATION

6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

YEAR JKN

Jamkesda

Private Ins

Uninsured

Summary of supply projection Figure 40. Aceh gaps summary 10,000

8,718

8,000 6,000 4,000 2,324 36

2,000

1,918

(2,000) (4,000)

physician in primary care (2,806)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(1,198)

(1,829)

40

Physician Figure 41. Aceh total desired physician

Total physicians

physician

5000

2500

0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Aceh desired physicians : Aceh desired physicians constrained : Aceh

Figure 42. Aceh total desired physician in hospital 1100

physician

1050 1000 950 900 850 800 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 43. Aceh total desired physician in primary care 4000 3500

physician

3000 2500 2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

41

Table 13. Aceh total desired physician Widest gap

Gap in 2019

Total Physician

(2,771)

(2,487)

Physician in primary care Physician in hospital

(2,806)

(2,630)

36

143

Nurse Figure 44. Aceh total desired nurse Total nurses 20,000

nurse

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Aceh total desired nurses : Aceh total desired nurses constrained : Aceh

nurse

Figure 45. Aceh total desired nurse in hospital 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

42

nurse

Figure 46. Aceh total desired nurse in primary care 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 14. Aceh total desired nurse Widest gap

Gap in 2019

Total nurse

4,354

6,547

Nurse in primary care

2,324

3,462

Nurse in hospital

1,918

3,085

Midwife Figure 47. Aceh total desired midwife Total midwives 20,000

midwife

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Aceh desired midwife total : Aceh

43

Table 15.. Aceh total desired midwife Minimum Surplus

Surplus in 2019

8,718

11,016

Midwife

Hospital Bed Figure 48. Aceh total hospital bed Hospital beds 8000

bed

7600 7200 6800 6400 6000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Aceh desired IP beds : Aceh desired IP beds constrained : Aceh

Table 16. Aceh total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(1,198)

(768)

Hospital bed (I,II,III)

(1,829)

(1,399)

44

2. North Sumatera 3.8 million of North Sumatera’s total population are covered by Jamkesmas and the remaining poor and near poor population not covered by Jamkesmas are entitled to Jamkesda Program, which exists in 33 districts. Parts of Jamkesda Program are integrated into JKN: 126,845 people from 15 districts in August 2014 and 99,000 people from 13 districts in September 2014 (17,18). Since JKN was launched, number of patients seeking care in Medan has increased, especially in Adam Malik Hospital, which is one of the referral hospitals in Sumatera. With only 721 beds, this hospital cannot compete with demand growth for inpatient care, causing many patients to seek care in A&E ward. The same condition happens in Mental Hospital in Medan. North Sumatera is also lacking in physicians. Adam Malik, Pringadi, and Sidikalang Hospitals still need many specialists due to high referral cases from other districts (19–23). Currently Available Data Table 17. North Sumatera Currently Available Data Parameter

5.5%

Source BPS, 2010

GP Registered

6,722

7.2%

KKI, 2013

GP Practicing

3,161

7.6%

BPPSDM, MoH 2013

Specialist Registered

1,392

5.9%

KKI, 2013

Specialist Practicing

2,191

6.0%

BPPSDM, MoH 2013

Nurse

8,796

3.0%

BPPSDM, MoH 2013

Midwife

13,585

9.9%

BPPSDM, MoH 2013

Hospital

166

7.0%

BUK, MoH 2013

VVIP, VIP

1,823

6.8%

BUK, MoH 2013

1,2,3

14,984

7.5%

BUK, MoH 2013

Population

Number 12,982,204

% to National

Hospital Bed

Table 18. North Sumatera 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 5,047 2,753 2,294 1,040 13 1,027 13,180 11,773 1,407 13,561 16,807 1,823 14,984

45

Figure 49. North Sumatera Population projection to 2020 total provincial population 20 M

people

17.5 M

15 M

12.5 M

10 M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Sumatera Utara

Figure 50. North Sumatera Population Projection by age group and gender Age 15 to 44 4M

2.75 M

3.75 M

people

people

Age 00 to 14 3M

2.5 M

3.25 M

2.25 M

2M 2010 2011

3.5 M

2012 2013

2014 2015 Date

2016 2017

2018 2019

3M 2010 2011 2012 2013

2020

2017 2018 2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date

2020

Age 15 to 44[male] : Sumatera Utara Age 15 to 44[female] : Sumatera Utara

Age 00 to 14[male] : Sumatera Utara Age 00 to 14[female] : Sumatera Utara

Age 65 and over 700,000

1.725 M

525,000

people

people

Age 45 to 64 2M

1.45 M

1.175 M

900,000 2010 2011 2012 2013 2014 Age 45 to 64[male] : Sumatera Utara Age 45 to 64[female] : Sumatera Utara

2014 2015 2016 Date

350,000

175,000

2015 2016 2017 2018 2019 Date

2020

Age 65 and over[male] : Sumatera Utara Age 65 and over[female] : Sumatera Utara

46

Figure 51. Changed in insurance status in North Sumatera 16,000,000 14,000,000

POPULASI

12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 52. North Sumatera gaps summary 15,000 11,969 10,000 4,582

5,000

847

physician in primary care

physician in hospital

nurse in primary care

nurse in hospital

(5,000) (5,031) (10,000)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(2,906)

(4,729)

(8,735)

47

Physician Figure 53. North Sumatera Total Desired Physician Total physicians 20,000

physician

17,200 14,400 11,600 8800 6000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sumatera Utara desired physicians : Sumatera Utara desired physicians constrained : Sumatera Utara

Figure 54. North Sumatera total desired physician in hospital 4000 3500

physician

3000 2500 2000 1500 1000 500 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 55. North Sumatera total desired physician in primary care 9000 8000

physician

7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

48

Table 19. North Sumatera total desired physician Widest gap

Gap in 2019

(4,184)

(3,362)

(5,031)

(4,561)

847

1,199

Total Physician Physician in primary care Physician in hospital

Nurse Figure 56. North Sumatera total desired nurse Total nurses 20,000 18,000

nurse

16,000 14,000 12,000 10,000 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sumatera Utara total desired nurses : Sumatera Utara total desired nurses constrained : Sumatera Utara

Figure 57. North Sumatera total desired nurse in hospital 12000 10000

nurse

8000 6000 4000 2000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

49

nurse

Figure 58. North Sumatera total desired nurse in primary care 16000 14000 12000 10000 8000 6000 4000 2000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 20. North Sumatera total desired nurse Widest gap

Gap in 2019

(4,153)

(1,418)

Nurse in primary care

4,582

6,906

Nurse in hospital

(8,735)

(8,324)

Total nurse

Midwife Figure 59. North Sumatera total desired midwife Total midwives 20,000

midwife

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sumatera Utara desired midwife total : Sumatera Utara

Table 21. North Sumatera total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

11,969

15,444 50

Hospital Bed Figure 60. North Sumatera total hospital bed Hospital beds 20,000 18,000

bed

16,000 14,000 12,000 10,000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sumatera Utara desired IP beds : Sumatera Utara desired IP beds constrained : Sumatera Utara

Table 22. North Sumatera total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(2,906)

(2,636)

Hospital bed (I,II,III)

(4,729)

(4,459)

51

3. West Sumatera 73% of West Sumatera’s total population are insured through JKN and Jamkesda. West Sumatera has gradually integrated their Jamkesda program into JKN. Currently there are 824,000 Jamkesda enrollees who have been integrated into JKN. Since JKN was implemented in early 2014, there is a marked increase in hospital utilization. With limited healthcare workers and infrastructure, this results in longer queue and high referral rates. For example, 83 out of 256 surgical patients in one hospital are referred to other hospitals. From media report, Solok Selatan district finds it hard to find specialists who are willing to work there despite high incentives (24–28). Currently Available Data Table 23. West Sumatera Currently Available Data Parameter

Number

Population

% to National

Source

4,846,909

2.0%

BPS, 2010

GP Registered

2,341

2.5%

KKI, 2013

GP Practicing

1,230

2.9%

BPPSDM, MoH 2013

Specialist Registered

495

2.1%

KKI, 2013

Specialist Practicing

816

2.2%

BPPSDM, MoH 2013

Nurse

7,513

2.6%

BPPSDM, MoH 2013

Midwife

4,633

3.4%

BPPSDM, MoH 2013

Hospital

61

2.6%

BUK, MoH 2013

585

2.2%

BUK, MoH 2013

4,627

2.3%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 24. West Sumatera 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,758 925 833 370 9 361 6,382 2,816 3,566 4,733 5,212 585 4,627

52

Figure 61. West Sumatera Population projection to 2020 total provincial population 6M

people

5.5 M

5M

4.5 M

4M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Sumatera Barat

Figure 62. West Sumatera Population Projection by age group and gender Age 15 to 44 1.2 M

775,000

1.15 M

people

people

Age 00 to 14 800,000

750,000

1.05 M

725,000

700,000 2010 2011

1.1 M

2012 2013

2014

2015 2016 Date

2017 2018

2019

1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

2020

Age 15 to 44[male] : Sumatera Barat Age 15 to 44[female] : Sumatera Barat

Age 00 to 14[male] : Sumatera Barat Age 00 to 14[female] : Sumatera Barat

Age 65 and over 300,000

550,000

225,000

500,000

450,000

400,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Sumatera Barat Age 45 to 64[female] : Sumatera Barat

people

people

Age 45 to 64 600,000

150,000

75,000

0 2010 2011 2012

2013 2014

2015 2016 2017 Date

2018 2019

2020

Age 65 and over[male] : Sumatera Barat Age 65 and over[female] : Sumatera Barat

53

Figure 63. Changed in insurance status in West Sumatera 6,000,000

POPULASI

5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 64. West Sumatera gaps summary 6,000 4,246 4,000 2,000

12

(2,000)

physician in primary care

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(625) (3,183)

(4,000) (6,000)

(2,975)

(3,560)

(5,203)

54

Physician Figure 65. West Sumatera Total Desired Physician

Total physicians

8000

4800 3200 1600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sumatera Barat desired physicians : Sumatera Barat desired physicians constrained : Sumatera Barat

Figure 66. West Sumatera total desired physician in hospital 1600 1400 1200

physician

physician

6400

1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

55

Figure 67. West Sumatera total desired physician in primary care 7000 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 25. West Sumatera total desired physician Widest gap

Gap in 2019

Total Physician

(5,191)

(4,858)

Physician in primary care

(5,203)

(5,003)

Physician in hospital

12

145

Nurse Figure 68. West Sumatera total desired nurse Total nurses 20,000 16,000

nurse

12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sumatera Barat total desired nurses : Sumatera Barat total desired nurses constrained : Sumatera Barat

56

Figure 69. West Sumatera total desired nurse in hospital 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

Nurses in hospital

2017

2018

2019

2020

Desired nurses in hospital

Figure 70. West Sumatera total desired nurse in primary care 7000 6000

nurse

5000 4000 3000 2000 1000 0 2014

2015

Nurses in primary care

2016

2017

2018

2019

2020

Desired physicians in primary care

Table 26. West Sumatera total desired nurse Widest gap

Gap in 2019

Total nurse

(3,808)

(2,454)

Nurse in primary care

(3,183)

(2,574)

Nurse in hospital

(625)

120

57

Midwife Figure 71. West Sumatera total desired midwife Total midwives 7000 5600

midwife

4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sumatera Barat desired midwife total : Sumatera Barat

Table 27. West Sumatera total desired midwife Minimum Surplus

Surplus in 2019

4,246

5,457

Midwife

Hospital Bed Figure 72. West Sumatera total hospital bed Hospital beds 9000 8200

bed

7400 6600 5800 5000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sumatera Barat desired IP beds : Sumatera Barat desired IP beds constrained : Sumatera Barat

58

Table 28. West Sumatera total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(2,975)

(2,423)

Hospital bed (I,II,III)

(3,560)

(2,989)

59

4. Riau Member of PBI-JKN in Riau number 1,304,716 people from a total population of around 6.6 million. In 2015, Jamkesda is expected to integrate into JKN. Patient overload results in a long waiting line for surgical procedure, which forces patients to seek care in other provinces or abroad. RSUD Arifin Achmad accepts nearly 1,000 people per day with limited outpatient capacity. RSUD Kota Dumai has 95% daily bed occupancy rate for class III. In RSUD Duri, 160 beds are managed by 84 nurses. From media report, there are only 5 general practitioners serving 24 Puskesmas in Kuansing district (29– 34). Currently Available Data Table 29. Riau currently available data Parameter

Number

Population GP Registered GP Practicing Specialist Registered Specialist Practicing Nurse Midwife Hospital Hospital Bed VVIP, VIP 1,2,3

5,538,367 2,215 1,182 367 781 6,986 4,476 60 719 4,174

% to National 2.3% 2.4% 2.8% 1.5% 2.1% 2.4% 3.3% 2.5%

Source BPS, 2010 KKI, 2013 BPPSDM, MoH 2013 KKI, 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BUK, MoH 2013

2.7% BUK, MoH 2013 2.1% BUK, MoH 2013

Table 30. Riau 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,663 886 777 274 2 272 6,936 2,937 3,999 3,888 4,895 719 4,176

60

Figure 73. Riau Population projection to 2020 total provincial population 7M

people

6.5 M

6M

5.5 M

5M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Riau

Figure 74. Riau Population Projection by age group and gender Age 15 to 44 2M

950,000

1.75 M

people

people

Age 00 to 14 1M

900,000

850,000

800,000 2010

1.5 M

1.25 M

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

1M 2010

2020

Age 00 to 14[male] : Riau Age 00 to 14[female] : Riau

2011

2012

2013

525,000

225,000

people

people

300,000

450,000

375,000

Age 45 to 64[male] : Riau Age 45 to 64[female] : Riau

2015 Date

2016

2017

2018

2019

2020

Age 65 and over

Age 45 to 64 600,000

300,000 2010 2011 2012 2013

2014

Age 15 to 44[male] : Riau Age 15 to 44[female] : Riau

150,000

75,000

2014 2015 2016 Date

2017 2018 2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Riau Age 65 and over[female] : Riau

61

Figure 75. Changed in insurance status in Riau 6,000,000

POPULASI

5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 76. Riau gaps summary 4,000 3,042 3,000 2,000

1,486 309

754

1,000 (1,000) (2,000) (3,000)

physician in primary care (708)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(2,102) (2,820)

(4,000)

62

Physician Figure 77. Riau Total Desired Physician Total physicians 3000

physician

2600 2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Riau desired physicians : Riau desired physicians constrained : Riau

Figure 78. Riau total desired physician in hospital 1400 1200

physician

1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 79. Riau total desired physician in primary care 1800 1600

physician

1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

63

Table 31. Riau total desired physician Widest gap Total Physician Physician in primary care Physician in hospital

Gap in 2019

(399)

(112)

(708)

(541)

309

429

Nurse Figure 80. Riau total desired nurse Total nurses 9000 7200

nurse

5400 3600 1800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Riau total desired nurses : Riau total desired nurses constrained : Riau

Figure 81. Riau total desired nurse in hospital 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

64

nurse

Figure 82. Riau total desired nurse in primary care 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 32. Riau total desired nurse Widest gap Total nurse Nurse in primary care Nurse in hospital

Gap in 2019

2,240

3,627

1,486

2,089

754

1,538

Midwife Figure 83. Riau total desired midwife Total midwives 6000

midwife

4800 3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Riau desired midwife total : Riau

Table 33. Riau total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

3,042

4,041

65

Hospital Bed Figure 84. Riau total hospital bed Hospital beds 8000

bed

7200 6400 5600 4800 4000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Riau desired IP beds : Riau desired IP beds constrained : Riau

Table 34. Riau total hospital bed Widest gap Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Gap in 2019

(2,102)

(944)

(2,820)

(1,617)

The projections for hospital beds in Riau (and all other provinces) assume a significant improvement (about 15%) in Average Length of Stay for inpatients beginning with 2015. This assumptions is considered optimistic because the average health status of new admissions is more severe than the national average. Nevertheless, as more people become entitled to low- or no-cost inpatient care, demand is greater than the capacity from 2016 forward.

66

5. Jambi 1.4 million of Jambi’s total population are insured through JKN and Jamkesda. Following JKN’s launch in early 2014, there’s a constant increase in hospital utilization. For example, in one district hospital, there were 800 patients in January, over 900 in February, and 1,500 in March. With only around 100 hospital beds, this is not adequate. The same scenario happens in the mental hospital: 270 beds for 382 patients. Lack of healthcare workers is also experienced in Jambi’s hospitals, for example in STS district hospital, Tebo District, and in hospital in Batanghari district (35–39). Currently Available Data Table 35. Jambi Currently Available Data Parameter

% to National

Number 3,092,265

1.3%

Source BPS, 2010

GP Registered

830

0.9%

KKI, 2013

GP Practicing

681

1.8%

BPPSDM, MoH 2013

Specialist Registered

140

0.6%

KKI, 2013

Specialist Practicing

412

1.1%

BPPSDM, MoH 2013

Nurse

5,356

1.9%

BPPSDM, MoH 2013

Midwife

3,139

2.4%

BPPSDM, MoH 2013

Hospital

30

1.3%

BUK, MoH 2013

360

1.3%

BUK, MoH 2013

2,292

1.2%

BUK, MoH 2013

Population

Hospital Bed VVIP, VIP I, II, III

Table 36. Jambi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 623 326 297 105 4 100 5,114 2,575 2,539 2,630 2,652 360 2,292

67

Figure 85. Jambi Population projection to 2020 total provincial population 4M

people

3.75 M

3.5 M

3.25 M

3M 2010

2011

2012

2014

2015 2016 Date

2018

2019

2020

2022

total provincial population : Jambi

Figure 86. Jambi Population Projection by age group and gender Age 15 to 44 900,000

475,000

850,000

people

people

Age 00 to 14 500,000

450,000

425,000

400,000 2010

800,000

750,000

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

700,000 2010

2020

Age 00 to 14[male] : Jambi Age 00 to 14[female] : Jambi

2011

2012

2013

200,000

350,000

150,000

people

people

2015 Date

2016

2017

2018

2019

2020

2016

2017

2018

2019

2020

Age 65 and over

Age 45 to 64 400,000

300,000

250,000

200,000 2010

2014

Age 15 to 44[male] : Jambi Age 15 to 44[female] : Jambi

100,000

50,000

2011

2012

Age 45 to 64[male] : Jambi Age 45 to 64[female] : Jambi

2013

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

Age 65 and over[male] : Jambi Age 65 and over[female] : Jambi

68

Figure 87. Changed in insurance status in Jambi 3,500,000 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 88. Jambi gaps summary 3,000

2,265

2,000 1,000 (1,000)

physician in primary care

(2,000)

physician in hospital (386)

nurse in primary care (729)

nurse in hospital (1,214)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(3,000) (4,000)

(3,114)

(5,000) (6,000)

(5,317)

(5,677)

(7,000)

69

Physician Figure 89. Jambi Total Desired Physician Total physicians 5000

physician

4000 3000 2000 1000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Jambi desired physicians : Jambi desired physicians constrained : Jambi

physician

Figure 90. Jambi total desired physician in hospital 900 800 700 600 500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 91. Jambi total desired physician in primary care 4000 3500

physician

3000 2500 2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

70

Table 37. Jambi total desired physician Widest gap

Gap in 2019

Total Physician

(3,500)

(3,332)

Physician in primary care Physician in hospital

(3,114)

(3,004)

(386)

(327)

Nurse Figure 92. Jambi total desired nurse Total nurses 8000

nurse

6400 4800 3200 1600 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Jambi total desired nurses : Jambi total desired nurses constrained : Jambi

nurse

Figure 93. Jambi total desired nurse in hospital 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

71

nurse

Figure 94. Jambi total desired nurse in primary care 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 38. Jambi total desired nurse Widest gap Total nurse Nurse in primary care Nurse in hospital

Gap in 2019

(1,943)

(824)

(729)

(177)

(1,214)

(647)

Although the shortage of nurses in Jambi is not unique, it is notably more than in other provinces. Given the surplus in nurse capacity in other provinces, the capacity shortage may not persist if human resource and recruiting policies are enhanced in the future.

Midwife Figure 95. Jambi total desired midwife Total midwives 4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Jambi desired midwife total : Jambi

72

Table 39. Jambi total desired midwife Minimum Surplus

Surplus in 2019

2,265

2,937

Midwife

Hospital Bed Figure 96. Jambi total hospital bed Hospital beds

bed

20,000

10,000

0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Jambi desired IP beds : Jambi desired IP beds constrained : Jambi desired IP beds unconstrained : Jambi

Table 40. Jambi total hospital bed Widest gap Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Gap in 2019

(5,317)

(4,218)

(5,677)

(4,590)

73

6. South Sumatera Since 2009, South Sumatera provided Jamkesda for its population not covered by any insurance. The fund is shared between provincial and district budget. As of now, its Jamkesda is not yet integrated into JKN because the premium set by JKN is too considered high by local standards (e.g. district government only pays IDR 5,000 per member per month, as opposed to IDR 19,225 for JKN). In terms of healthcare capacity, South Sumatera faces problems in numbers and distribution. RSUD Rupit, for example, located on trans-Sumatera path, serves not only people from that district, but also other districts or even provinces. With bed capacity of only 50, this hospital is severely stressed (40–43). Currently Available Data Table 41. South Sumatera Currently Available Data Parameter Population

Number

% to National

Source

4,494,410

1.90%

BPS, 2010

GP Registered

2,165

2.30%

KKI, 2013

GP Practicing

1,383

3.60%

BPPSDM, MoH 2013

Specialist Registered

338

1.40%

KKI, 2013

Specialist Practicing

852

2.30%

BPPSDM, MoH 2013

11,003

3.90%

BPPSDM, MoH 2013

Midwife

9,383

7.20%

BPPSDM, MoH 2013

Hospital

60

2.50%

BUK, MoH 2013

631

2.30%

BUK, MoH 2013

5,396

2.70%

BUK, MoH 2013

Nurse

Hospital Bed VVIP, VIP I, II, III

Table 42. South Sumatera 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,641 737 904 419 4 416 5,170 2,282 2,888 4,704 6,323 576 5,747

74

Figure 97. South Sumatera Population projection to 2020 total provincial population 9M

people

8.5 M

8M

7.5 M

7M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Sumatera Selatan

Figure 98. South Sumatera Population Projection by age group and gender Age 15 to 44 2M

1.15 M

1.75 M

people

people

Age 00 to 14 1.2 M

1.1 M

1.05 M

1M 2010

1.5 M

1.25 M

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

1M 2010

2020

Age 00 to 14[male] : Sumatera Selatan Age 00 to 14[female] : Sumatera Selatan

2011

2012

2013

2016

2017

2018

2019

2020

Age 65 and over

Age 45 to 64 400,000

300,000

people

800,000

people

2015 Date

Age 15 to 44[male] : Sumatera Selatan Age 15 to 44[female] : Sumatera Selatan

900,000

700,000

600,000

500,000 2010

2014

200,000

100,000

2011

2012

2013

2014

Age 45 to 64[male] : Sumatera Selatan Age 45 to 64[female] : Sumatera Selatan

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Sumatera Selatan Age 65 and over[female] : Sumatera Selatan

75

Figure 99. Changed in insurance status in South Sumatera 9,000,000 8,000,000

POPULASI

7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 100. South Sumatera gaps summary 6,000 3,772

4,000 2,000 (2,000)

physician in primary care

(4,000) (6,000)

physician in hospital (455)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(3,089) (4,742)

(4,313)

(8,000) (8,058) (10,000)

(8,634)

76

Physician Figure 101. South Sumatera Total Desired Physician Total physicians 8000

physician

6400 4800 3200 1600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sumatera Selatan desired physicians : Sumatera Selatan desired physicians constrained : Sumatera Selatan

physician

Figure 102. South Sumatera total desired physician in hospital 2000 1800 1600 1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 103. South Sumatera total desired physician in primary care 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

77

Table 43. South Sumatera total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap

Gap in 2019

(5,197)

(4,863)

(4,742)

(4,557)

(455)

(306)

Nurse Figure 104. South Sumatera total desired nurse Total nurses 20,000 16,000

nurse

12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sumatera Selatan total desired nurses : Sumatera Selatan total desired nurses constrained : Sumatera Selatan

nurse

Figure 105. South Sumatera total desired nurse in hospital 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

78

Figure 106. South Sumatera total desired nurse in primary care 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 44. South Sumatera total desired nurse Widest gap

Gap in 2019

Total nurse

(7,127)

(5,903)

Nurse in primary care Nurse in hospital

(3,089)

(2,571)

(4,313)

(3,332)

Midwife Figure 107. South Sumatera total desired midwife

Total midwives

7000

midwife

5600 4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sumatera Selatan desired midwife total : Sumatera Selatan

Table 45. South Sumatera total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

3,772

4,975

79

Hospital Bed Figure 108. South Sumatera total hospital bed Hospital beds 20,000 16,000

bed

12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sumatera Selatan desired IP beds : Sumatera Selatan desired IP beds constrained : Sumatera Selatan

Table 46. South Sumatera total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(8,058)

(4,700)

Hospital bed (I,II,III)

(8,634)

(5,536)

South Sumatra is severely capacity constrained in all categories. The most limited capacity is physicians. Without a substantial increase in physicians, more hospital inpatient capacity and more nursing capacity would be fruitless.

80

7. Bengkulu As of June 2014, more than 340,000 poor people insureds are integrated into JKN and around 73,000 people are covered by Jamkesda. By December 2014, more than 55% Bengkulu’s population are registered as BPJS enrollees, the remaining is still covered under Jamkesda. Healthcare workers and beds capacity remain the significant problem in Bengkulu’s healthcare system. For example in Kaur district, there are 8 Puskesmas without any physician. In RSUD Kapahiang, there is an increasing number of class III patients despite the remote location of the hospital. According to hospital Director, people believe they are entitled to healthcare through JKN(37,46–53). Currently Available Data Table 47. Bengkulu currently available data Parameter

Number

Population

% to National

Source

1,715,518

0.7%

BPS, 2010

GP Registered

478

0.5%

KKI, 2013

GP Practicing

433

1.0%

BPPSDM, MoH 2013

Specialist Registered

55

0.2%

KKI, 2013

Specialist Practicing

121

0.3%

BPPSDM, MoH 2013

Nurse

3,258

1.1%

BPPSDM, MoH 2013

Midwife

2,550

1.9%

BPPSDM, MoH 2013

Hospital

19

0.8%

BUK, MoH 2013

139

0.5%

BUK, MoH 2013

1,347

0.7%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 48. Bengkulu 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 359 214 145 41 0 41 4,429 2,569 1,860 2,691 1,486 139 1,347

81

Figure 109. Bengkulu population projection to 2020 total provincial population 2M

people

1.75 M

1.5 M

1.25 M

1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Bengkulu

Figure 110. Bengkulu Population Projection by age group and gender Age 15 to 44 500,000

275,000

475,000

people

people

Age 00 to 14 300,000

250,000

225,000

200,000 2010

450,000

425,000

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

400,000 2010

2020

Age 00 to 14[male] : Bengkulu Age 00 to 14[female] : Bengkulu

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

2017

2018

2019

2020

Age 15 to 44[male] : Bengkulu Age 15 to 44[female] : Bengkulu

Age 45 to 64 Age 65 and over

200,000 80,000

60,000

people

people

175,000

150,000

125,000

100,000 2010 2011 2012 2013 Age 45 to 64[male] : Bengkulu Age 45 to 64[female] : Bengkulu

40,000

20,000

2014 2015 2016 Date

2017 2018 2019

2020

0 2010 2011

2012

2013

2014

2015 Date

2016

Age 65 and over[male] : Bengkulu Age 65 and over[female] : Bengkulu

82

POPULASI

Figure 111. Changed in insurance status in Bengkulu 2,000,000 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 112. Bengkulu gaps summary 3,000

2,569

2,000 743

1,000 365 (1,000)

physician in primary care

physician in hospital (153)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (911)

(772)

(2,000) (2,133) (3,000)

83

Physician Figure 113. Bengkulu Total Desired Physician Total physicians 3000

physician

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Bengkulu desired physicians : Bengkulu desired physicians constrained : Bengkulu

Figure 114. Bengkulu total desired physician in hospital 400 350

physician

300 250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 115. Bengkulu total desired physician in primary care 2500

physician

2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

84

Table 49. Bengkulu total desired physician Widest gap Total Physician Physician in primary care Physician in hospital

Gap in 2019

(2,287)

(2,197)

(2,133)

(2,071)

(153)

(127)

Nurse Figure 116. Bengkulu total desired nurse Total nurses 6000

3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Bengkulu total desired nurses : Bengkulu total desired nurses constrained : Bengkulu

Figure 117. Bengkulu total desired nurse in hospital 2500 2000

nurse

nurse

4800

1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

85

Figure 118. Bengkulu total desired nurse in primary care 3500 3000

nurse

2500 2000 1500 1000 500 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 50. Bengkulu total desired nurse Widest gap Total nurse

Gap in 2019

1,108

2,000

365

883

743

1,117

Nurse in primary care Nurse in hospital

Midwife Figure 119. Bengkulu total desired midwife

Total midwives

4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Bengkulu desired midwife total : Bengkulu

Table 51. Bengkulu total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

2,569

3,256

86

Hospital Bed Figure 120. Bengkulu total hospital bed Hospital beds 3000

bed

2600 2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Bengkulu desired IP beds : Bengkulu desired IP beds constrained : Bengkulu

Table 52. Bengkulu total hospital bed Widest gap Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Gap in 2019

(772)

(250)

(911)

(444)

87

8. Lampung All Lampung’s population are covered by JKN and Jamkesda. In 2016, Jamkesda enrollees are expected to be fully integrated into JKN. Lack of hospital capacity is prominent in Lampung, in RSUDAM, 64 patients demand for hemodialysis care every day. With only one machine available, only 3 patients can be treated daily. Class III bed capacity is still lower compared to demand: 368 patients daily for 318 beds. In Bandar Lampung, nurse shortage is also reported (52–54). To provide some perspective, the population of Lampung and DKI Jakarta are both approximately 9 million people. Jakarta has about 15,000 physicians, and Lampung has about 1,500 physicians. The proportion of hospital beds and nurses are commensurate. The shortage in Lampung is severe. Currently Available Data Table 53. Lampung currently available data Parameter Population GP Registered GP Practicing Specialist Registered Specialist Practicing Nurse Midwife Hospital Hospital Bed VVIP, VIP 1,2,3

Number 7,608,405 1,454 1,019 239 453 6,805 3,761 50

% to National 3.2% 1.6% 2.4% 1.0% 1.2% 2.4% 2.7% 2.1%

545 4,229

2.0% 2.1%

Source BPS, 2010 KKI, 2013 BPPSDM, MoH 2013 KKI, 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BPPSDM, MoH 2013 BUK, MoH 2013 BUK, MoH 2013 BUK, MoH 2013

Table 54. Lampung 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,092 606 485 178 4 174 5,359 2,936 2,423 3,607 4,774 545 4,229

88

Figure 121. Lampung Population projection to 2020 total provincial population 9M

people

8.5 M

8M

7.5 M

7M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Lampung

Figure 122. Lampung Population Projection by age group and gender Age 15 to 44 2M

1.15 M

1.75 M

people

people

Age 00 to 14 1.2 M

1.1 M

1.5 M

1.25 M

1.05 M

1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

1M 2010

2020

2011

2012

Age 45 to 64

2015 Date

2016

2017

2018

2019

2020

Age 65 and over

900,000

400,000

800,000

325,000 people

people

2014

Age 15 to 44[male] : Lampung Age 15 to 44[female] : Lampung

Age 00 to 14[male] : Lampung Age 00 to 14[female] : Lampung

700,000

250,000

175,000

600,000

500,000 2010 2011

2013

2012

2013

Age 45 to 64[male] : Lampung Age 45 to 64[female] : Lampung

2014

2015 2016 Date

2017

2018

2019

2020

100,000 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Lampung Age 65 and over[female] : Lampung

89

Figure 123. Changed in insurance status in Lampung 8,000,000 7,000,000

POPULASI

6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 124. Lampung gaps summary 4,000

2,632

2,000 (2,000)

physician in primary care

physician in hospital (568)

nurse in primary care

nurse in hospital (2,408)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(4,000) (6,000)

(5,496)

(4,837)

(5,382)

(8,000) (7,974) (10,000)

90

Physician Figure 125. Lampung Total Desired Physician Total physicians 10,000

physician

8000 6000 4000 2000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Lampung desired physicians : Lampung desired physicians constrained : Lampung

Figure 126. Lampung total desired physician in hospital 1400 1200

physician

1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

physician

Figure 127. Lampung total desired physician in primary care 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

91

Table 55. Lampung total desired physician Widest gap Total Physician Physician in primary care Physician in hospital

Gap in 2019

(8,543)

(8,204)

(7,974)

(7,711)

(568)

(493)

Nurse Figure 128. Lampung total desired nurse Total nurses 20,000

nurse

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Lampung total desired nurses : Lampung total desired nurses constrained : Lampung

Figure 129. Lampung total desired nurse in hospital 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

92

Figure 130. Lampung total desired nurse in primary care 10000

nurse

8000 6000 4000 2000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 56. Lampung total desired nurse Widest gap Total nurse Nurse in primary care Nurse in hospital

Gap in 2019

(7,772)

(6,598)

(5,496)

(4,760)

(2,408)

(1,838)

Midwife Figure 131. Lampung total desired midwife

Total midwives

5000

midwife

4000 3000 2000 1000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Lampung desired midwife total : Lampung

Table 57. Lampung total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

2,632

3,555

93

Hospital Bed Figure 132. Lampung total hospital bed Hospital beds 10,000

bed

8000 6000 4000 2000 0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Lampung desired IP beds : Lampung desired IP beds constrained : Lampung

Table 58. Lampung total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(4,837)

(3,342)

Hospital bed (I,II,III)

(5,382)

(3,984)

94

9. Bangka Belitung Islands 90% of Kep Bangka Belitung’s total population is covered by Jamkesda and JKN. Physicians are short in this province and becomes more apparent as hospitals plan to upgrade their types (55–57) (58). Currently Available Data Table 59. Bangka Belitung Islands currently available data Parameter Population

Number

% to National

Source

1,223,296

0.5%

BPS, 2010

GP Registered

312

0.3%

KKI, 2013

GP Practicing

333

0.8%

BPPSDM, MoH 2013

Specialist Registered

51

0.2%

KKI, 2013

Specialist Practicing

103

0.3%

BPPSDM, MoH 2013

2,566

0.9%

BPPSDM, MoH 2013

Midwife

899

0.7%

BPPSDM, MoH 2013

Hospital

15

0.6%

BUK, MoH 2013

127

0.5%

BUK, MoH 2013

1,068

0.5%

BUK, MoH 2013

Nurse

Hospital Bed VVIP, VIP 1,2,3

Table 60. Bangka Belitung Islands 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 234 122 112 38 1 38 2,120 1,083 1,037 716 1,195 127 1,068

95

Figure 133. Bangka Belitung Islands Population projection to 2020 total provincial population 2M

people

1.75 M

1.5 M

1.25 M

1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Kep Bangka Belitung

Figure 134. Bangka Belitung Islands Population Projection by age group and gender Age 15 to 44 400,000

175,000

350,000

people

people

Age 00 to 14 200,000

150,000

300,000

250,000

125,000

100,000 2010 2011 2012

2013 2014

2015 2016 2017 Date

2018 2019

200,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

2020

Age 00 to 14[male] : Kep Bangka Belitung Age 00 to 14[female] : Kep Bangka Belitung

Age 15 to 44[male] : Kep Bangka Belitung Age 15 to 44[female] : Kep Bangka Belitung

Age 65 and over 60,000

170,000

45,000

140,000

110,000

80,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Kep Bangka Belitung Age 45 to 64[female] : Kep Bangka Belitung

people

people

Age 45 to 64 200,000

30,000

15,000

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Kep Bangka Belitung Age 65 and over[female] : Kep Bangka Belitung

96

Figure 135. Changed in insurance status in Bangka Belitung Islands 1,400,000 1,200,000

POPULASI

1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 136. Bangka Belitung Islands gaps summary 1,000 578 500

physician in primary care (500)

physician in hospital

nurse in primary care

nurse in hospital

(209)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(602) (1,000) (1,051) (1,205) (1,500)

(1,338)

(1,332)

97

Physician Figure 137. Bangka Belitung Islands Total Desired Physician Total physicians 2000

physician

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kep Bangka Belitung desired physicians : Kep Bangka Belitung desired physicians constrained : Kep Bangka Belitung

Figure 138. Bangka Belitung Islands total desired physician in hospital 400 350

physician

300 250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 139. Bangka Belitung Islands total desired physician in primary care 1600 1400

physician

1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

98

Table 61. Bangka Belitung Islands total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap

Gap in 2019

(1,548)

(1,486)

(1,338)

(1,299)

(209)

(188)

Nurse Figure 140. Bangka Belitung Islands total desired nurse Total nurses 4000 3200

nurse

2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kep Bangka Belitung total desired nurses : Kep Bangka Belitung total desired nurses constrained : Kep Bangka Belitung

Figure 141. Bangka Belitung Islands total desired nurse in hospital 2000

nurse

1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

99

Figure 142. Bangka Belitung Islands total desired nurse in primary care 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 62. Bangka Belitung Islands total desired nurse Widest gap

Gap in 2019

Total nurse

(1,653)

(1,194)

Nurse in primary care

(1,051)

(812)

Nurse in hospital

(602)

(382)

Midwife Figure 143. Bangka Belitung Islands total desired midwife Total midwives 1000

midwife

800 600 400 200 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kep Bangka Belitung desired midwife total : Kep Bangka Belitung

Table 63. Bangka Belitung Islands total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

578

761 100

Hospital Bed Figure 144. Bangka Belitung Islands total hospital bed Hospital beds 3000 2400

bed

1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kep Bangka Belitung desired IP beds : Kep Bangka Belitung desired IP beds constrained : Kep Bangka Belitung

Table 64. Bangka Belitung Islands total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,205)

(895)

(1,332)

(1,037)

101

10. Kep. Riau 35.7% of Kep Riau’s population are insured by JKN and Jamkesda. Since January 2014, shortage in hospital inpatient capacity and healthcare workers became omnipresent. Problems such as difficulties in finding beds and delayed care in primary and secondary care levels (61–64). Currently Available Data Table 65. Riau Islands currently available data Parameter

1,679,163

% to National 0.7%

BPS, 2010

GP Registered

617

0.7%

KKI, 2013

GP Practicing

540

1.3%

BPPSDM, MoH 2013

Specialist Registered

149

0.6%

KKI, 2013

Specialist Practicing

255

0.7%

BPPSDM, MoH 2013

Nurse

3,932

1.4%

BPPSDM, MoH 2013

Midwife

1,170

0.9%

BPPSDM, MoH 2013

Hospital

25

1.1%

BUK, MoH 2013

191

0.7%

BUK, MoH 2013

1,817

0.9%

BUK, MoH 2013

Population

Number

Source

Hospital Bed VVIP, VIP 1,2,3

Table 66. Riau Islands 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 463 297 166 111 8 104 2,604 1,589 1,014 1,253 2,008 191 1,817

102

Figure 145. Riau Islands Population projection to 2020 total provincial population

3M

people

2.5 M

2M

1.5 M

1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Kepulauan Riau

Figure 146. Riau Islands Population Projection by age group and gender Age 15 to 44 600,000

275,000

550,000

people

people

Age 00 to 14 300,000

250,000

225,000

200,000 2010

500,000

450,000

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

400,000 2010

2011

2012

Age 45 to 64

2015 Date

2016

2017

2018

2019

2020

Age 65 and over

200,000

70,000

150,000

52,500

people

people

2014

Age 15 to 44[male] : Kepulauan Riau Age 15 to 44[female] : Kepulauan Riau

Age 00 to 14[male] : Kepulauan Riau Age 00 to 14[female] : Kepulauan Riau

100,000

35,000

17,500

50,000

0 2010

2013

2011

2012

2013

Age 45 to 64[male] : Kepulauan Riau Age 45 to 64[female] : Kepulauan Riau

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Kepulauan Riau Age 65 and over[female] : Kepulauan Riau

103

Figure 147. Changed in insurance status in Riau Islands 1,800,000 1,600,000

POPULASI

1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 148. Riau Islands gaps summary 1,200 1,016

959

1,000 800 600 400 200

82

(200)

physician in primary care

(400)

(168)

physician in hospital (14)

nurse in primary care

nurse in hospital (310)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (109)

104

Physician Figure 149. Riau Islands Total Desired Physician Total physicians 800 740

physician

680 620 560 500 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kepulauan Riau desired physicians : Kepulauan Riau desired physicians constrained : Kepulauan Riau

Figure 150. Riau Islands total desired physician in hospital 350 300

physician

250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 151. Riau Islands total desired physician in primary care 600

physician

500 400 300 200 100 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

105

Table 67. Riau Islands total desired physician Widest gap Total Physician Physician in primary care Physician in hospital

Gap in 2019

(183)

(83)

(168)

(107)

(14)

24

Nurse Figure 152. Riau Islands total desired nurse Total nurses 4000 3200

nurse

2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kepulauan Riau total desired nurses : Kepulauan Riau total desired nurses constrained : Kepulauan Riau

nurse

Figure 153. Riau Islands total desired nurse in hospital 1600 1400 1200 1000 800 600 400 200 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

106

Figure 154. Riau Islands total desired nurse in primary care 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 68. Riau Islands total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 650 959

Gap in 2019 1,254 1,292

(310)

(38)

Midwife Figure 155. Riau Islands total desired midwife

Total midwives

2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kepulauan Riau desired midwife total : Kepulauan Riau

Table 69. Riau Islands total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,016

1,336

107

Hospital Bed Figure 156. Riau Islands total hospital bed Hospital beds 3000 2600

bed

2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kepulauan Riau desired IP beds : Kepulauan Riau desired IP beds constrained : Kepulauan Riau

Table 70. Riau Islands total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

82

227

(109)

31

108

11. DKI Jakarta Subsequent to the political promise after DKI Jakarta’s gubernatorial election in 2012, more than 4 million Jakartans were covered under Kartu Jakarta Sehat (KJS, Healthy Jakarta Card) by the end of 2013, increasing Jakarta’s insured population from only 25% in 2012 to 67% in 2013. District Health Officer of DKI Jakarta mentioned overall patients increase of 70%, with 62.4% seeking hospital outpatient care (63). During the early period of implementation of KJS, RSUD Tarakan, Jakarta received more than 1,000 outpatients per day. In RSUPN Cipto Mangunkusumo, Jakarta, average patients’ visits increased threefolds with 70% coming from DKI Jakarta and 30% referred from other provinces (7,63,64). In this model, Jakarta is estimated to receive 6.5% of national demand for outpatient care and 5% of national demand for inpatient care—a number agreed by the team—placing more burden on the supply, despite the abundance of healthcare capacity relative to other provinces. In 2008, every day, RSUPN Ciptomangunkusumo received on average 500 patients from areas outside Jakarta. In 2012, RSUD Arifin Achmad, Pekanbaru, Riau, referred 665 patients to RSUPN Ciptomangunkusumo and RS Harapan Kita(67,68). Currently Available Data Table 71. DKI Jakarta currently available data Parameter

9,607,787

% to National 4.0%

BPS, 2010

GP Registered

15,309

16.4%

KKI, 2013

GP Practicing

2,728

6.5%

Specialist Registered

5,137

21.7%

KKI, 2013

Specialist Practicing

5,931

16.1%

BPPSDM, MoH 2013

19,418

6.7%

BPPSDM, MoH 2013

Midwife

2,877

2.1%

BPPSDM, MoH 2013

Hospital

155

6.5%

BUK, MoH 2013

2,995

11.1%

BUK, MoH 2013

15,282

7.7%

BUK, MoH 2013

Population

Number

Nurse

Source

BPPSDM, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 72. DKI Jakarta 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife

Projected by the model 2013 11,495 2,929 8,566 3,837 38 3,800 37,926 5,348 32,578 2,618 109

Capacity

Projected by the model 2013

Hospital Bed VVIP, VIP I, II, III

18,277 2,995 15,282

Figure 157. DKI Jakarta Population projection to 2020 total provincial population 20 M

people

17.8 M 15.6 M 13.4 M 11.2 M 9M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Jakarta

Figure 158. DKI Jakarta Population Projection by age group and gender Age 00 to 14

Age 15 to 44

2M

3M 1.8 M

people

people

2.8 M 1.6 M 1.4 M

2.4 M 2.2 M

1.2 M

1M 2010

2.6 M

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2M 2010 2011

2020

2012 2013

2014 2015 Date

2016 2017

2018 2019

2020

Age 15 to 44[male] : Jakarta Age 15 to 44[female] : Jakarta

Age 00 to 14[male] : Jakarta Age 00 to 14[female] : Jakarta

Age 65 and over 600,000

Age 45 to 64 2M

480,000

people

people

1.74 M 1.48 M

360,000 240,000

1.22 M

120,000

960,000 700,000 2010

2011

2012

Age 45 to 64[male] : Jakarta Age 45 to 64[female] : Jakarta

2013

2014

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over[male] : Jakarta Age 65 and over[female] : Jakarta

110

POPULASI

Figure 159. Changed in insurance status in DKI Jakarta 10,000,000 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 160. DKI Jakarta gaps summary 5,000

1,400

(5,000)

physician in primary care

(10,000)

(3,030)

(15,000)

physician in hospital

nurse in primary care (420)

nurse in hospital (4,562)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(10,429)

(20,000) (25,000)

(22,732) (25,727)

(30,000)

111

Physician Figure 161. DKI Jakarta Total Desired Physician Total physicians 30,000

physician

26,000 22,000 18,000 14,000 10,000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Jakarta desired physicians : Jakarta desired physicians constrained : Jakarta

Figure 162. DKI Jakarta total desired physician in hospital 25000

physician

20000 15000 10000 5000 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 163. DKI Jakarta total desired physician in primary care 7000 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

112

Table 73. DKI Jakarta total desired physician Widest gap

Gap in 2019

(13,460)

(11,600)

(3,030)

(2,536)

(10,429)

(9,065)

Total Physician Physician in primary care Physician in hospital

Nurse Figure 164. DKI Jakarta total desired nurse Total nurses 50,000

nurse

40,000 30,000 20,000 10,000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Jakarta total desired nurses : Jakarta total desired nurses constrained : Jakarta

Figure 165. DKI Jakarta total desired nurse in hospital 50000

nurse

40000 30000 20000 10000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

113

nurse

Figure 166. DKI Jakarta total desired nurse in primary care 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 74. DKI Jakarta total desired nurse Widest gap

Gap in 2019

(4,982)

2,634

Nurse in primary care

(420)

696

Nurse in hospital

(4,562)

1,938

Total nurse

Midwife Figure 167. DKI Jakarta total desired midwife

Total midwives

4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Jakarta desired midwife total : Jakarta

Table 75. DKI Jakarta total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,400

2,097

114

Hospital Bed Figure 168. DKI Jakarta total hospital bed Hospital beds 50,000

bed

40,000 30,000 20,000 10,000 0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Jakarta desired IP beds : Jakarta desired IP beds constrained : Jakarta

Table 76. DKI Jakarta total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(22,732)

(22,182)

(25,727)

(24,005)

115

12. West Java As of 1 December 2014, about 21.4 million out of 46 million West Java’s total population are enrolled under JKN. Healthcare capacity constrained remains as problems in West Java, for example RSUD Subang District which reported to lack in physicians and beds. District Health Officer also admits that West Java is still lacking in midwives (67–69). Currently Available Data Figure 169. West Java Currently Available Data Parameter

43,053,732

% to National 18.1%

BPS, 2010

GP Registered

14,691

15.8%

KKI, 2013

GP Practicing

4,757

11.4%

BPPSDM, MoH 2013

Specialist Registered

3,455

14.6%

KKI, 2013

Specialist Practicing

5,562

15.1%

BPPSDM, MoH 2013

Nurse

31,030

10.8%

BPPSDM, MoH 2013

Midwife

13,263

9.7%

BPPSDM, MoH 2013

Hospital

281

11.9%

BUK, MoH 2013

2,978

11.1%

BUK, MoH 2013

24,489

12.3%

BUK, MoH 2013

Population

Number

Source

Hospital Bed VVIP, VIP 1,2,3

Table 77. West Java 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 11,031 4,768 6,263 2,581 22 2,559 23,894 7,677 16,217 12,863 27,475 2,979 24,496

116

Figure 170. West Java Population projection to 2020 total provincial population 50 M

people

48 M

46 M

44 M

42 M

40 M 2010 2011

2012 2013

2014 2015 Date

2016 2017

2018 2019

2020

total provincial population : Jawa Barat

Figure 171. West Java Population Projection by age group and gender Age 00 to 14 Age 15 to 44

7M 12 M 11.6 M

6.2 M people

people

6.6 M

5.8 M 5.4 M 5M 2010

11.2 M 10.8 M 10.4 M

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

10 M 2010 2011 2012

2020

Age 00 to 14[male] : Jawa Barat Age 00 to 14[female] : Jawa Barat

2013 2014

2015 2016 2017 Date

2018 2019

2020

Age 15 to 44[male] : Jawa Barat Age 15 to 44[female] : Jawa Barat

Age 65 and over Age 45 to 64

3M

5M

2.4 M

people

people

4.6 M

4.2 M

1.2 M

3.8 M

600,000

3.4 M

3M 2010

1.8 M

2011

2012

Age 45 to 64[male] : Jawa Barat Age 45 to 64[female] : Jawa Barat

2013

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Jawa Barat Age 65 and over[female] : Jawa Barat

117

Figure 172. Changed in insurance status in West Java 45,000,000 40,000,000

POPULASI

35,000,000 30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 173. West Java gaps summary 10,000

7,203

921

5,000 (5,000)

physician in primary care

physician in hospital

nurse in primary care

(10,000)

nurse in hospital (8,315)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(15,000) (20,000)

(17,116) (20,096)

(25,000) (30,000) (35,000) (40,000)

(34,107) (37,307)

118

Physician Figure 174. West Java Total Desired Physician Total physicians 60,000 48,000 physician

36,000 24,000 12,000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Jawa Barat desired physicians : Jawa Barat desired physicians constrained : Jawa Barat

Figure 175. West Java total desired physician in hospital 12000

physician

10000 8000 6000 4000 2000 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 176. West Java total desired physician in primary care 45000 40000

physician

35000 30000 25000 20000 15000 10000 5000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

119

Table 78. West Java total desired physician Widest gap

Gap in 2019

Total Physician

(36,387)

(33,956)

Physician in primary care Physician in hospital

(37,307)

(35,889)

921

1,933

Nurse Figure 177. West Java total desired nurse Total nurses 70,000

nurse

56,000 42,000 28,000 14,000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Jawa Barat total desired nurses : Jawa Barat total desired nurses constrained : Jawa Barat

Figure 178. West Java total desired nurse in hospital 30000 25000

nurse

20000 15000 10000 5000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

120

Figure 179. West Java total desired nurse in primary care 50000

nurse

40000 30000 20000 10000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 79. West Java total desired nurse Widest gap

Gap in 2019

(42,421)

(36,621)

(34,107)

(31,871)

(8,315)

(4,750)

Total nurse Nurse in primary care Nurse in hospital

Midwife Figure 180. West Java total desired midwife

Total midwives

20,000

midwife

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Jawa Barat desired midwife total : Jawa Barat

Table 80. West Java total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

7,203

10,494

121

Hospital Bed Figure 181. West Java total hospital bed Hospital beds 50,000

bed

44,000 38,000 32,000 26,000 20,000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Jawa Barat desired IP beds : Jawa Barat desired IP beds constrained : Jawa Barat

Table 81. West Java total hospital bed Widest gap

Gap in 2019

Hospital bed (VVIP,VIP,I,II,III)

(17,116)

(8,929)

Hospital bed (I,II,III)

(20,096)

(12,549)

West Java inpatient bed capacity is set to grow significantly, but the staffing (physicians, nurses, technicians) and ancillary services (laboratory, screening, operating theaters) are not likely to keep pace unless there is a substantial redistribution from other provinces—an undesirable policy.

122

13. Central Java BPJS Central Java and DI Yogyakarta mentioned that more than half of Central Java’s population are covered through JKN. The BPJS branch office targeted that by the end of 2014, 60% of total population can be served (70,71). Beds are still lacking in healthcare facilities. Everyday, beds in several hospitals are almost fully occupied. In RSUP dr Kariadi Semarang, the waiting line for inpatient admission is up to 2,500 patients for class III and VIP until end of 2014. From January to October 2014, there is an 8% increase of hospital inpatients (72,73). Currently Available Data Table 82. Central Java currently available data Parameter

Number

Population

% to National

Source

32,382,657

13.6%

BPS, 2010

GP Registered

9,145

9.8%

KKI, 2013

GP Practicing

4,821

11.5%

BPPSDM, MoH 2013

Specialist Registered

2,373

10.0%

KKI, 2013

Specialist Practicing

4,397

12.0%

BPPSDM, MoH 2013

Nurse

31,802

11.0%

BPPSDM, MoH 2013

Midwife

16,833

12.3%

BPPSDM, MoH 2013

Hospital

282

11.9%

BUK, MoH 2013

3,947

14.7%

BUK, MoH 2013

25,391

12.8%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 83. Central Java 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 6,867 3,494 3,373 1,773 59 1,713 23,933 7,303 16,630 16,506 29,343 3,947 25,396

123

Figure 182. Central Java Population projection to 2020 total provincial population 40 M 38 M

people

36 M

34 M

32 M

30 M 2010 2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Jawa Tengah

Figure 183. Central Java Population Projection by age group and gender Age 15 to 44 8M

4.6 M

7.8 M

4.2 M

7.6 M

people

people

Age 00 to 14 5M

3.8 M

7.2 M

3.4 M 3M 2010 2011 2012 2013

7.4 M

2014 2015 2016 Date

2017 2018 2019

7M 2010 2011

2020

Age 00 to 14[male] : Jawa Tengah Age 00 to 14[female] : Jawa Tengah

2012 2013

2014 2015 Date

2016 2017

2018 2019

2020

Age 15 to 44[male] : Jawa Tengah Age 15 to 44[female] : Jawa Tengah

Age 65 and over 3M

Age 45 to 64 4M

2.6 M

people

people

3.8 M 3.6 M

2.2 M

1.8 M

3.4 M 1.4 M

3.2 M 3M 2010 2011 2012 2013

2014 2015 2016 Date

Age 45 to 64[male] : Jawa Tengah Age 45 to 64[female] : Jawa Tengah

2017 2018 2019

2020

1M 2010 2011 2012 2013

2014 2015 2016 Date

2017 2018 2019

2020

Age 65 and over[male] : Jawa Tengah Age 65 and over[female] : Jawa Tengah

124

Figure 184. Changed in insurance status in Central Java 35,000,000

POPULATION

30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 185. Central Java gaps summary 20,000 13,696 10,000 (10,000)

physician in primary care

physician in hospital (2,517)

nurse in primary care

nurse in hospital (9,750)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(20,000) (21,029) (24,975)

(30,000) (31,025) (40,000)

(35,102)

125

Physician Figure 186. Central Java Total Desired Physician Total physicians 50,000 40,000 physician

30,000 20,000 10,000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Jawa Tengah desired physicians : Jawa Tengah desired physicians constrained : Jawa Tengah

physician

Figure 187. Central Java total desired physician in hospital 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 188. Central Java total desired physician in primary care 45000 40000

physician

35000 30000 25000 20000 15000 10000 5000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

126

Table 84. Central Java total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (37,618)

Gap in 2019 (36,213)

(35,102)

(34,241)

(2,517)

(1,972)

Nurse Figure 189. Central Java total desired nurse Total nurses 70,000 56,000

nurse

42,000 28,000 14,000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Jawa Tengah total desired nurses : Jawa Tengah total desired nurses constrained : Jawa Tengah

Figure 190. Central Java total desired nurse in hospital 30000 25000

nurse

20000 15000 10000 5000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

127

Figure 191. Central Java total desired nurse in primary care 50000 40000

nurse

30000 20000 10000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 85. Central Java total desired nurse Widest gap

Gap in 2019

(40,775)

(35,579)

(31,025)

(29,250)

(9,750)

(6,329)

Total nurse Nurse in primary care Nurse in hospital

Midwife Figure 192. Central Java total desired midwife Total midwives 30,000

midwife

24,000 18,000 12,000 6000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Jawa Tengah desired midwife total : Jawa Tengah

Table 86. Central Java total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

13,696

17,924

128

Hospital Bed Figure 193. Central Java total hospital bed Hospital beds 60,000 52,000

bed

44,000 36,000 28,000 20,000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Jawa Tengah desired IP beds : Jawa Tengah desired IP beds constrained : Jawa Tengah

Table 87. Central Java total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(21,029)

(17,047)

(24,975)

(20,845)

129

14. DI Yogyakarta Integration of Yogyakarta’s Jamkesda’s enrollees are predicted to finish in 2016. Two days following JKN launch, people seeking outpatient care in RSUD Sleman District increased by 50%. Bed capacity is still low in some districts. Similar to RS Jogja, the hospitals often had to defer patients for admission, lengthening the waiting time. Everyday, more than 200 patients go to internal medicine clinic at RS Jogja which only has 4 internists. Overall, there are 700 people seeking care at RS Jogja daily – 5% more compared to the period just before JKN was implemented (74–78). Currently Available Data Table 88. DI Yogyakarta currently available data Parameter

Number

Population

% to National

Source

3,457,491

1.5%

BPS, 2010

GP Registered

2,813

3.0%

KKI, 2013

GP Practicing

1,408

3.4%

BPPSDM, MoH 2013

919

3.9%

KKI, 2013

Specialist Practicing

1,237

3.4%

BPPSDM, MoH 2013

Nurse

6,746

2.3%

BPPSDM, MoH 2013

Midwife

1,699

1.2%

BPPSDM, MoH 2013

Hospital

70

3.0%

BUK, MoH 2013

781

2.9%

BUK, MoH 2013

8,465

4.3%

BUK, MoH 2013

Specialist Registered

Hospital Bed VVIP, VIP 1,2,3

Table 89. DI Yogyakarta 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 2,112 1,218 894 686 87 599 2,363 624 1,740 1,134 9,246 781 8,465

130

Figure 194. DI Yogyakarta Population projection to 2020 total provincial population

3.5 M

people

3.48 M

3.46 M

3.44 M

3.42 M

3.4 M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : DI Yogyakarta

Figure 195. DI Yogyakarta Population Projection by age group and gender Age 15 to 44 900,000

Age 00 to 14 400,000

860,000

people

people

380,000 820,000

780,000

360,000 340,000

740,000

320,000

700,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

300,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 00 to 14[male] : DI Yogyakarta Age 00 to 14[female] : DI Yogyakarta

Age 15 to 44[male] : DI Yogyakarta Age 15 to 44[female] : DI Yogyakarta

Age 45 to 64 Age 65 and over

500,000 300,000 260,000

420,000 380,000

people

people

460,000

220,000 180,000

340,000

140,000

300,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

100,000 2010

Age 45 to 64[male] : DI Yogyakarta Age 45 to 64[female] : DI Yogyakarta

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : DI Yogyakarta Age 65 and over[female] : DI Yogyakarta

131

Figure 196. Changed in insurance status in DI Yogyakarta 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 197. DI Yogyakarta gaps summary 5,000 3,986 4,000 3,205 3,000 2,000

685 874

1,000 (1,000) (2,000)

physician in primary care (731)

physician in hospital

nurse in primary care

nurse in hospital (1,044)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(1,410)

132

Physician Figure 198. DI Yogyakarta Total Desired Physician Total physicians 4000

physician

3600 3200 2800 2400 2000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : DI Yogyakarta desired physicians : DI Yogyakarta desired physicians constrained : DI Yogyakarta

DI Yogayakarta is renowned for physician training and attracts a substantial number of physicians. Yogyakarta is source of trained medical personnel for other provinces.

physician

Figure 199. DI Yogyakarta total desired physician in hospital 1800 1600 1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

133

Figure 200. DI Yogyakarta total desired physician in primary care 2500

physician

2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 90. DI Yogyakarta total desired physician Widest gap

Gap in 2019

(41)

286

(731)

(546)

685

832

Total Physician Physician in primary care Physician in hospital

Nurse Figure 201. DI Yogyakarta total desired nurse Total nurses 5000 4400

nurse

3800 3200 2600 2000 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : DI Yogyakarta total desired nurses : DI Yogyakarta total desired nurses constrained : DI Yogyakarta

134

Figure 202. DI Yogyakarta total desired nurse in hospital 3500 3000

nurse

2500 2000 1500 1000 500 0 2014

2015

2016

Nurses in hospital

2017

2018

2019

2020

Desired nurses in hospital

Figure 203. DI Yogyakarta total desired nurse in primary care 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in primary care

2016

2017

2018

2019

2020

Desired physicians in primary care

Table 91. DI Yogyakarta total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap

Gap in 2019

(2,444)

(1,819)

(1,410)

(1,269)

(1,044)

(550)

135

Midwife Figure 204. DI Yogyakarta total desired midwife Total midwives 2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : DI Yogyakarta desired midwife total : DI Yogyakarta

Table 92. DI Yogyakarta total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

874

1,174

Hospital Bed Figure 205. DI Yogyakarta total hospital bed Hospital beds 10,000 8800

bed

7600 6400 5200 4000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : DI Yogyakarta desired IP beds : DI Yogyakarta desired IP beds constrained : DI Yogyakarta

136

Table 93. DI Yogyakarta total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

3,986

4,351

3,205

3,570

137

15. East Java 44% of East Java’s total population are insured by JKN and Jamkesda (BPJKD – Badan Penyelenggara Jaminan Kesehatan Daerah). BPJKD is not yet integrated into JKN. Following JKN implementation, there is a marked increase in utilization. For example, in Dr. Soetomo Hospital, there is an increase of 2,000 patients per day (from 3,000 to 5,000 or 67%). Patients come from other provinces: Kupang, NTT, among others. There is also an increase in voluntary participation evidenced by long lines of people seeking enrolment at BPJS offices. As of 2015, 40% of total hospitals are contracted by BPJS. East Java also lacks in healthcare workers: numbers and distributions (8,79,80). In this model, East Java is estimated to receive 3% of national demand for outpatient care and 1% of national demand for inpatient care-a number agreed by the team-placing more burden to the supply. Currently Available Data Table 94. East Java Currently Available Data Parameter

Number

Population

% to National

Source

37,476,757

15.8%

BPS, 2010

GP Registered

11,983

12.9%

KKI, 2013

GP Practicing

4,574

10.9%

BPPSDM, MoH 2013

Specialist Registered

3,460

14.6%

KKI, 2013

Specialist Practicing

4,786

13.0%

BPPSDM, MoH 2013

Nurse

32,833

11.4%

BPPSDM, MoH 2013

Midwife

15,555

11.3%

BPPSDM, MoH 2013

Hospital

330

13.9%

BUK, MoH 2013

3,568

13.3%

BUK, MoH 2013

26,879

13.5%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 95. East Java 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 8,998 3,922 5,075 2,585 25 2,560 21,833 7,706 14,127 15,527 30,457 3,569 26,888

138

Figure 206. East Java Population projection to 2020 total provincial population

39 M

people

38.6 M

38.2 M

37.8 M

37.4 M

37 M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Jawa Timur

Figure 207. East Java Population Projection by age group and gender Age 00 to 14

Age 15 to 44

5M

10 M 9.6 M

4.6 M

people

people

4.8 M

4.4 M 4.2 M

9.2 M 8.8 M 8.4 M 8M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

4M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

Age 15 to 44[male] : Jawa Timur Age 15 to 44[female] : Jawa Timur

Age 00 to 14[male] : Jawa Timur Age 00 to 14[female] : Jawa Timur

Age 45 to 64

Age 65 and over

5M

3M 2.6 M

4.2 M 3.8 M 3.4 M 3M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Jawa Timur Age 45 to 64[female] : Jawa Timur

people

people

4.6 M

2.2 M 1.8 M 1.4 M 1M 2010 2011 2012 2013

2014 2015 2016 Date

2017 2018 2019

2020

Age 65 and over[male] : Jawa Timur Age 65 and over[female] : Jawa Timur

139

Figure 208. Changed in insurance status in East Java 40,000,000 35,000,000

POPULASI

30,000,000 25,000,000 20,000,000 15,000,000 10,000,000 5,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 209. East Java gaps summary 20,000 12,478 10,000 (10,000)

physician in primary care

physician in hospital

nurse in primary care

(8,005)

(20,000)

nurse in hospital

(17,322)

midwife

hospital bed (VVIP, VIP, I,II,III) (11,799)

hospital bed (I,II,III) (15,369)

(30,000) (40,000)

(33,744) (37,840)

(50,000)

140

Physician Figure 210. East Java Total Desired Physician Total physicians 60,000

physician

48,000 36,000 24,000 12,000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Jawa Timur desired physicians : Jawa Timur desired physicians constrained : Jawa Timur

physician

Figure 211. East Java total desired physician in hospital 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 212. East Java total desired physician in primary care 45000 40000

physician

35000 30000 25000 20000 15000 10000 5000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

141

Table 96. East Java total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (45,845)

Gap in 2019 (43,536)

(37,840)

(36,608)

(8,005)

(6,927)

Nurse Figure 213. East Java total desired nurse Total nurses 80,000

nurse

64,000 48,000 32,000 16,000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Jawa Timur total desired nurses : Jawa Timur total desired nurses constrained : Jawa Timur

Figure 214. East Java total desired nurse in hospital 35000 30000

nurse

25000 20000 15000 10000 5000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

142

Figure 215. East Java total desired nurse in primary care 50000

nurse

40000 30000 20000 10000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 97. East Java total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (51,065)

Gap in 2019 (45,585)

(33,744)

(31,578)

(17,322)

(14,007)

Midwife Figure 216. East Java total desired midwife Total midwives 30,000

midwife

24,000 18,000 12,000 6000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Jawa Timur desired midwife total : Jawa Timur

Table 98. East Java total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

12,478

16,516

143

Hospital Bed Figure 217. East Java total hospital bed Hospital beds 50,000

bed

46,000 42,000 38,000 34,000 30,000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Jawa Timur desired IP beds : Jawa Timur desired IP beds constrained : Jawa Timur

Table 99. East Java total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(11,799)

(4,318)

(15,369)

(8,303)

144

16. Banten Around 3.2 million Banten’s poor people are covered under PBI-JKN and 0.5 million are under Jamkesda. Provincial government allocates IDR 28 billion for JKN program. The distribution of healthcare workers is uneven with most located in urban areas: 3,000 of 3,893 Banten’s general practitioners are in Tangerang Raya, 237 are in Serang. The same pattern applies to specialists. According to Banten’s head of district health officer, Banten is short in all types of healthcare workers. Patients have to wait for beds and operation schedule. In one of the contracted private hospitals following JKN implementation, there was an increase of 1,000 patients per month (81–87). Currently Available Data Table 100. Banten Currently Available Data Parameter Population

Number

% to National

Source

10,632,166

4.5%

BPS, 2010

GP Registered

4,436

4.8%

KKI, 2013

GP Practicing

1,382

3.3%

BPPSDM, MoH 2013

897

3.8%

KKI, 2013

Specialist Practicing

1,603

4.4%

BPPSDM, MoH 2013

Nurse

7,882

2.7%

BPPSDM, MoH 2013

Midwife

3,516

2.6%

BPPSDM, MoH 2013

Hospital

81

3.4%

BUK, MoH 2013

796

3.0%

BUK, MoH 2013

6,900

3.5%

BUK, MoH 2013

Specialist Registered

Hospital Bed VVIP, VIP 1,2,3

Table 101. Banten 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 3,330 1,477 1,853 670 3 667 3,948 1,089 2,859 3,109 7,698 796 6,901

145

Figure 218.. Banten Population projection to 2020 total provincial population

20 M

people

18 M 16 M 14 M 12 M 10 M 2010

2011

2013

2014 2016 Date

2017

2019

total provincial population : Banten

Figure 219. Banten Population Projection by age group and gender Age 15 to 44

Age 00 to 14 3M

1.8 M

2.8 M

1.6 M

2.6 M

people

people

2M

1.4 M

2.4 M 2.2 M

1.2 M 1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

2M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

Age 00 to 14[male] : Banten Age 00 to 14[female] : Banten

Age 15 to 44[male] : Banten Age 15 to 44[female] : Banten

Age 65 and over 500,000

1.72 M

400,000

1.44 M

300,000

1.16 M 880,000 600,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Banten Age 45 to 64[female] : Banten

people

people

Age 45 to 64 2M

200,000 100,000 0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Banten Age 65 and over[female] : Banten

146

Figure 220. Changed in insurance status in Banten 12,000,000

POPULASI

10,000,000 8,000,000 6,000,000 4,000,000 2,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 221. Banten gaps summary 4,000 493

1,410

2,000 (2,000)

physician in primary care

physician in hospital

nurse in primary care

(4,000)

nurse in hospital (3,582)

(6,000)

midwife

hospital bed (VVIP, VIP, I,II,III) (3,913)

hospital bed (I,II,III)

(4,709)

(8,000) (10,000) (12,000)

(11,392)

(11,761)

(14,000)

147

Physician Figure 222. Banten Total Desired Physician Total physicians 20,000

physician

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Banten desired physicians : Banten desired physicians constrained : Banten

Figure 223. Banten total desired physician in hospital 3500 3000

physician

2500 2000 1500 1000 500 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 224. Banten total desired physician in primary care 14000 12000

physician

10000 8000 6000 4000 2000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

148

Table 102. Banten total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (10,898)

Gap in 2019 (10,049)

(11,392)

(10,855)

493

806

Nurse Figure 225. Banten total desired nurse Total nurses 20,000 16,000

nurse

12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Banten total desired nurses : Banten total desired nurses constrained : Banten

Figure 226. Banten total desired nurse in hospital 7000 6000

nurse

5000 4000 3000 2000 1000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

149

Figure 227. Banten total desired nurse in primary care 14000 12000

nurse

10000 8000 6000 4000 2000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 103. Banten total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (15,342)

Gap in 2019 (14,057)

(11,761)

(11,213)

(3,582)

(2,844)

Midwife Figure 228. Banten total desired midwife Total midwives 5000

midwife

4000 3000 2000 1000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Banten desired midwife total : Banten

Table 104. Banten total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,410

2,208

150

Hospital Bed Figure 229. Banten total hospital bed Hospital beds 20,000

bed

17,400 14,800 12,200 9600 7000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Banten desired IP beds : Banten desired IP beds constrained : Banten

Table 105. Banten total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(3,913)

(2,003)

(4,709)

(2,943)

151

17. Bali In 2010, Bali launched Jaminan Kesehatan Bali Mandara (JKBM) program promising low-cost healthcare for all. In a population of 4 million, 2.7 million are JKBM insured and only 70,000 have registered to JKN. Relatively easy access and availability and comprehensive care provided by JKBM account for delay in JKBM integration into JKN (88). In this model, Bali is estimated to receive 3% of national demand for outpatient care and 1% of national demand for inpatient care—a number agreed by the team—placing more burden on the supply. Currently Available Data Table 106. Bali currently available data Parameter

Number

Population

% to National

Source

3,890,757

1.6%

BPS, 2010

GP Registered

2,919

3.1%

KKI, 2013

GP Practicing

1,069

2.6%

BPPSDM, MoH 2013

858

3.6%

KKI, 2013

Specialist Practicing

1,146

3.1%

BPPSDM, MoH 2013

Nurse

6,515

2.3%

BPPSDM, MoH 2013

Midwife

2,252

1.6%

BPPSDM, MoH 2013

Hospital

57

2.4%

BUK, MoH 2013

932

3.5%

BUK, MoH 2013

4,064

2.0%

BUK, MoH 2013

Specialist Registered

Hospital Bed VVIP, VIP 1,2,3

Table 107. Bali 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 2,192 814 1,378 641 7 634 4,581 958 3,622 2,557 4,996 932 4,064

152

Figure 230. Bali Population projection to 2020 total provincial population 5M

people

4.6 M

4.2 M

3.8 M

3.4 M

3M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Bali

Figure 231. Bali Population Projection by age group and gender Age 15 to 44 1M

560,000

980,000

520,000

960,000

people

people

Age 00 to 14 600,000

480,000

940,000

440,000

920,000

400,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

900,000 2010 2011

Age 00 to 14[male] : Bali Age 00 to 14[female] : Bali

2012 2013

2014 2015 Date

2016 2017

2018 2019

2020

100,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date

2020

Age 15 to 44[male] : Bali Age 15 to 44[female] : Bali

Age 65 and over Age 45 to 64

300,000

500,000

260,000

people

people

460,000 420,000

220,000 180,000

380,000

140,000

340,000 300,000 2010

2011

2012

Age 45 to 64[male] : Bali Age 45 to 64[female] : Bali

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Bali Age 65 and over[female] : Bali

153

Figure 232. Changed in insurance status in Bali 4,000,000 3,500,000

POPULASI

3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 233. Bali gaps summary 4,000 2,289 2,000 (2,000)

physician in primary care

physician in hospital

(4,000)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(3,778)

(3,949) (6,000)

(6,165) (8,000) (10,000)

(7,097) (7,091) (9,662)

(12,000)

154

Physician Figure 234. Bali Total Desired Physician Total physicians 20,000

physician

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Bali desired physicians : Bali desired physicians constrained : Bali

physician

Figure 235. Bali total desired physician in hospital 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 236. Bali total desired physician in primary care 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

155

Table 108. Bali total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (11,040)

Gap in 2019 (10,255)

(3,949)

(3,743)

(7,091)

(6,512)

Nurse Figure 237. Bali total desired nurse Total nurses 20,000

nurse

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Bali total desired nurses : Bali total desired nurses constrained : Bali

nurse

Figure 238. Bali total desired nurse in hospital 16000 14000 12000 10000 8000 6000 4000 2000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

156

Figure 239. Bali total desired nurse in primary care 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 109. Bali total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (13,439)

Gap in 2019 (12,013)

(3,778)

(3,499)

(9,662)

(8,514)

Midwife Figure 240.Total Bali total desired midwife midwives 4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Bali desired midwife total : Bali

Table 110. Bali total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

2,289

2,947

157

Hospital Bed Figure 241. Bali total hospital bed Hospital beds 20,000

bed

16,000 12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Bali desired IP beds : Bali desired IP beds constrained : Bali

Table 111. Bali total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(6,165)

(5,022)

(7,097)

(5,687)

158

18. West Nusa Tenggara As of March 2014, there was no significant increase in service using JKN card in puskesmas in North Lombok. Shortfall in general practitioners and specialists are present in NTB for primary and secondary care levels (89–91). In RSUD Sumbawa, due to under capacity and demand overload, patients are treated in the hallway (92). Currently Available Data Table 112. West Nusa Tenggara Currently Available Data Parameter Population

Number

% to National

Source

4,500,212

1.9%

BPS, 2010

GP Registered

694

0.7%

KKI, 2013

GP Practicing

651

1.6%

BPPSDM, MoH 2013

Specialist Registered

119

0.5%

KKI, 2013

Specialist Practicing

382

1.0%

BPPSDM, MoH 2013

Nurse

5,041

1.7%

BPPSDM, MoH 2013

Midwife

2,211

1.6%

BPPSDM, MoH 2013

Hospital

24

1.0%

BUK, MoH 2013

287

1.1%

BUK, MoH 2013

2,189

1.1%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 113. West Nusa Tenggara 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 521 251 271 89 1 87 4,988 2,945 2,043 3,680 2,477 287 2,189

159

Figure 242. West Nusa Tenggara Population projection to 2020 total provincial population 6M

people

5.6 M 5.2 M 4.8 M 4.4 M 4M 2010 2011 2012

2013 2014

2015 2016 2017 Date

2018 2019

2020

total provincial population : NTB

Figure 243. West Nusa Tenggara Population Projection by age group and gender Age 00 to 14 800,000

Age 15 to 44 2M

760,000

people

people

1.8 M

720,000

680,000

640,000

600,000 2010 2011

1.6 M 1.4 M 1.2 M

2012 2013

2014 2015 Date

2016 2017

2018 2019

1M 2010

2020

Age 00 to 14[male] : NTB Age 00 to 14[female] : NTB

2011

2012

2013

2016

2017

2018

2019

2020

2017

2018

2019

2020

Age 65 and over

Age 45 to 64 300,000

460,000

240,000

420,000

180,000

people

people

2015 Date

Age 15 to 44[male] : NTB Age 15 to 44[female] : NTB

500,000

380,000

120,000

340,000 300,000 2010 2011

2014

60,000

2012 2013

Age 45 to 64[male] : NTB Age 45 to 64[female] : NTB

2014 2015 Date

2016 2017

2018 2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

Age 65 and over[male] : NTB Age 65 and over[female] : NTB

160

Figure 244. Changed in insurance status in West Nusa Tenggara 6,000,000

POPULASI

5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 245. West Nusa Tenggara gaps summary 4,000

3,139

3,000 2,000 1,000 (1,000)

physician in primary care

(2,000) (3,000)

physician in hospital (267)

nurse in primary care

(2,850)

(4,000)

(17)in nurse hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (1,800)

(1,513)

(5,000) (6,000)

(5,706)

(7,000)

161

Physician Figure 246. West Nusa Tenggara Total Desired Physician Total physicians 7000

physician

5600 4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : NTB desired physicians : NTB desired physicians constrained : NTB

Figure 247. West Nusa Tenggara total desired physician in hospital 700 600

physician

500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 248. West Nusa Tenggara total desired physician in primary care 7000 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

162

Table 114. West Nusa Tenggara total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (5,973)

Gap in 2019 (5,797)

(5,706)

(5,574)

(267)

(223)

Nurse Figure 249. West Nusa Tenggara total desired nurse Total nurses 9000

nurse

7200 5400 3600 1800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : NTB total desired nurses : NTB total desired nurses constrained : NTB

Figure 250. West Nusa Tenggara total desired nurse in hospital 3000 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

163

Figure 251. West Nusa Tenggara total desired nurse in primary care 7000 6000

nurse

5000 4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 115. West Nusa Tenggara total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (2,775)

Gap in 2019 (1,733)

(2,850)

(2,197)

(17)

464

Midwife Figure 252. West Nusa Tenggara total desired midwife

Total midwives

6000

midwife

4800 3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : NTB desired midwife total : NTB

Table 116. West Nusa Tenggara total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

3,139

4,080

164

Hospital Bed Figure 253. West Nusa Tenggara total hospital bed Hospital beds 5000

bed

4400 3800 3200 2600 2000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : NTB desired IP beds : NTB desired IP beds constrained : NTB

Table 117. West Nusa Tenggara total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,513)

(682)

(1,800)

(1,017)

165

19. East Nusa Tenggara 3.3 million out of 4.6 million of NTT’s population are enrolled under JKN; 2.6 million of which are under JKN PBI. Shortfalls in healthcare worker and hospital facilities present. For example in RSU Kota Kupang, only 50 out of 100 hospital beds are used due to lack of rooms (93,94). Emergency unit in RSUD Prof Dr WZ Johannes Kupang is short in beds due to patients’ increase (95). Currently Available Data Table 118. East Nusa Tenggara currently available data Parameter

Number

Population

% to National

Source

4,683,827

2.0%

BPS, 2010

GP Registered

512

0.5%

KKI, 2013

GP Practicing

698

1.7%

BPPSDM, MoH 2013

Specialist Registered

75

0.3%

KKI, 2013

Specialist Practicing

275

0.7%

BPPSDM, MoH 2013

Nurse

6,422

2.2%

BPPSDM, MoH 2013

Midwife

3,139

2.3%

BPPSDM, MoH 2013

Hospital

41

1.7%

BUK, MoH 2013

255

0.9%

BUK, MoH 2013

2,968

1.5%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 119. East Nusa Tenggara 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 384 215 169 56 0 56 6,535 3,590 2,945 3,675 3,223 255 2,968

166

Figure 254. East Nusa Tenggara Population projection to 2020 total provincial population 6M

people

5.6 M 5.2 M 4.8 M 4.4 M 4M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : NTT

Figure 255. East Nusa Tenggara Population Projection by age group and gender Age 15 to 44 Age 00 to 14

2M

900,000

1.78 M

people

people

860,000 820,000

1.56 M

780,000

1.34 M

740,000

1.12 M

700,000 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

900,000 2010 2011

2020

2012 2013

Age 45 to 64

2017 2018

2019

2020

2017

2019

2020

Age 65 and over

500,000

300,000

460,000

260,000

420,000

220,000

people

people

2015 2016 Date

Age 15 to 44[male] : NTT Age 15 to 44[female] : NTT

Age 00 to 14[male] : NTT Age 00 to 14[female] : NTT

380,000 340,000 300,000 2010

2014

180,000 140,000

2011

2012

Age 45 to 64[male] : NTT Age 45 to 64[female] : NTT

2013

2014

2015 Date

2016

2017

2018

2019

2020

100,000 2010

2011

2012

2013

2014

2015 Date

2016

2018

Age 65 and over[male] : NTT Age 65 and over[female] : NTT

167

Figure 256. Changed in insurance status in East Nusa Tenggara 6,000,000

POPULASI

5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 257. East Nusa Tenggara gaps summary 4,000 3,225 3,000 2,000

1,557 798

1,000 (1,000)

physician in primary care

physician in hospital (253)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III) (1,478)

(2,000) (2,020)

hospital bed (I,II,III)

(1,733)

(3,000)

168

Physician Figure 258. East Nusa Tenggara Total Desired Physician Total physicians 3000

physician

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : NTT desired physicians : NTT desired physicians constrained : NTT

Figure 259. East Nusa Tenggara total desired physician in hospital 600

physician

500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 260. East Nusa Tenggara total desired physician in primary care 2500

physician

2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

169

Table 120. East Nusa Tenggara total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (2,261)

Gap in 2019 (2,177)

(2,020)

(1,960)

(253)

(217)

Nurse Figure 261. East Nusa Tenggara total desired nurse Total nurses 9000 7200

nurse

5400 3600 1800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : NTT total desired nurses : NTT total desired nurses constrained : NTT

nurse

Figure 262. East Nusa Tenggara total desired nurse in hospital 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

170

Figure 263. East Nusa Tenggara total desired nurse in primary care 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 121. East Nusa Tenggara total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 2,468

Gap in 2019 3,777

1,557

2,265

798

1,512

Midwife Figure 264. East Nusa Tenggara total desired midwife

Total midwives

5000

midwife

4000 3000 2000 1000 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : NTT desired midwife total : NTT

Table 122. East Nusa Tenggara total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

3,225

4,169

171

Hospital Bed Figure 265. East Nusa Tenggara total hospital bed Hospital beds 5000

bed

4600 4200 3800 3400 3000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : NTT desired IP beds : NTT desired IP beds constrained : NTT

Table 123. East Nusa Tenggara total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,478)

(643)

(1,733)

(958)

172

20. West Kalimantan As of March 8th 2014, 38% of West Kalimantan’s total population are enrolled under JKN. Voluntary participation is still minimal. Shortfall in physicians remains significant; 50% of Puskesmas are located in remote areas and they all need physicians. Around 65% of patients in RSUD dr. Soedarso in Pontianak are JKN patients (96–98). Currently Available Data Table 124. West Kalimantan currently available data Parameter Population

Number

% to National

Source

4,395,983

1.8%

BPS, 2010

GP Registered

756

0.8%

KKI, 2013

GP Practicing

639

1.5%

BPPSDM, MoH 2013

Specialist Registered

164

0.7%

KKI, 2013

Specialist Practicing

343

0.9%

BPPSDM, MoH 2013

Nurse

9,467

3.3%

BPPSDM, MoH 2013

Midwife

2,308

1.7%

BPPSDM, MoH 2013

Hospital

42

1.8%

BUK, MoH 2013

260

1.0%

BUK, MoH 2013

3,913

2.0%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 125. West Kalimantan 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 568 298 269 123 1 121 6,432 4,430 2,002 2,518 4,173 260 3,913

173

Figure 266. West Kalimantan Population projection to 2020 total provincial population 6M

people

5.6 M 5.2 M 4.8 M 4.4 M

4M 2010 2011

2012 2013

2014

2015 2016 Date

2017 2018

2019

2020

total provincial population : Kalimantan Barat

Figure 267. West Kalimantan Population Projection by age group and gender Age 15 to 44 2M

760,000

1.8 M

720,000

1.6 M

people

people

Age 00 to 14 800,000

680,000

1.4 M

1.2 M

640,000

600,000 2010 2011

2012 2013

2014

2015 2016 Date

2017 2018

2019

1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

2020

Age 15 to 44[male] : Kalimantan Barat Age 15 to 44[female] : Kalimantan Barat

Age 00 to 14[male] : Kalimantan Barat Age 00 to 14[female] : Kalimantan Barat

Age 65 and over Age 45 to 64

300,000

500,000

240,000

people

people

460,000

420,000

120,000

380,000

60,000

340,000

300,000 2010

180,000

2011

2012

2013

2014

Age 45 to 64[male] : Kalimantan Barat Age 45 to 64[female] : Kalimantan Barat

2015 Date

2016

2017

2018

2019

2020

0 2010 2011

2012 2013

2014

2015 2016 Date

2017 2018

2019

2020

Age 65 and over[male] : Kalimantan Barat Age 65 and over[female] : Kalimantan Barat

174

Figure 268. Changed in insurance status in West Kalimantan 4,500,000 4,000,000

POPULASI

3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply surplus/shortage Figure 269. West Kalimantan gaps summary 2,500

2,143

1,969

2,000 1,500 1,000 500 (500)

physician in primary care

(1,000)

physician in hospital (209)

nurse in primary care

nurse in hospital (451)

(1,500)

midwife

hospital bed (VVIP, VIP, I,II,III) (877)

hospital bed (I,II,III) (1,137)

(2,000) (2,500)

(2,234)

175

Physician Figure 270. West Kalimantan Total Desired Physician Total physicians 4000

physician

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kalimantan Barat desired physicians : Kalimantan Barat desired physicians constrained : Kalimantan Barat

Figure 271. West Kalimantan total desired physician in hospital 700 600

physician

500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 272. West Kalimantan total desired physician in primary care 3000

physician

2500 2000 1500 1000 500 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

176

Table 126. West Kalimantan total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (2,443)

Gap in 2019 (2,317)

(2,234)

(2,146)

(209)

(171)

Nurse Figure 273. West Kalimantan total desired nurse Total nurses 9000 7200

nurse

5400 3600 1800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kalimantan Barat total desired nurses : Kalimantan Barat total desired nurses constrained : Kalimantan Barat

Figure 274. West Kalimantan total desired nurse in hospital 3000 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

177

Figure 275. West Kalimantan total desired nurse in primary care 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 127. West Kalimantan total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 1,769

Gap in 2019 2,998

2,143

3,026

(451)

(28)

Midwife Figure 276. West Kalimantan total desired midwife

Total midwives

4000 3200

midwife

2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kalimantan Barat desired midwife total : Kalimantan Barat

Table 128. West Kalimantan total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,969

2,615

178

Hospital Bed Figure 277. West Kalimantan total hospital bed Hospital beds 6000 5600

bed

5200 4800 4400 4000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kalimantan Barat desired IP beds : Kalimantan Barat desired IP beds constrained : Kalimantan Barat

Table 129. West Kalimantan total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(877)

(550)

(1,137)

(863)

179

21. Central Kalimantan BPJS branch office in Palangkaraya mentioned a drastic increase of JKN voluntary participants since end of March to early June 2010 (from 6,000 to 16,240). There is also an increase of patients at RSUD dr. Doris Sylvanus since JKN was launched in early 2014. With only 254 hospital beds, RSUD dr. Doris Sylvanus needs to increase efficiency in patients management and adds more beds. Shortfall in physicians presents in almost healthcare facilities (99–102). Currently Available Data Table 130. Central Kalimantan currently available data Parameter

Number

Population

% to National

Source

2,212,089

0.9%

BPS, 2010

GP Registered

486

0.5%

KKI, 2013

GP Practicing

465

1.1%

BPPSDM, MoH 2013

Specialist Registered

81

0.3%

KKI, 2013

Specialist Practicing

129

0.4%

BPPSDM, MoH 2013

Nurse

4,607

1.6%

BPPSDM, MoH 2013

Midwife

1,851

1.4%

BPPSDM, MoH 2013

Hospital

19

0.8%

BUK, MoH 2013

217

0.8%

BUK, MoH 2013

1,229

0.6%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 131. Central Kalimantan 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 365 240 126 60 2 58 4,808 3,010 1,798 1,747 1,446 1,015 431

180

Figure 278. Central Kalimantan Population projection to 2020 total provincial population 3M

people

2.8 M 2.6 M 2.4 M 2.2 M

2M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Kalimantan Tengah

Figure 279. Central Kalimantan Population Projection by age group and gender Age 15 to 44 700,000

380,000

660,000

360,000

620,000

people

people

Age 00 to 14 400,000

340,000

540,000

320,000

300,000 2010

580,000

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

500,000 2010

2020

2011

2012

2013

Age 45 to 64

2016

2017

2018

2019

2020

Age 65 and over

300,000

100,000

260,000

80,000

220,000 people

people

2015 Date

Age 15 to 44[male] : Kalimantan Tengah Age 15 to 44[female] : Kalimantan Tengah

Age 00 to 14[male] : Kalimantan Tengah Age 00 to 14[female] : Kalimantan Tengah

180,000

60,000

40,000

140,000 100,000 2010

2014

20,000

2011

2012

2013

2014

Age 45 to 64[male] : Kalimantan Tengah Age 45 to 64[female] : Kalimantan Tengah

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Kalimantan Tengah Age 65 and over[female] : Kalimantan Tengah

181

Figure 280. Changed in insurance status in Central Kalimantan 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 281. Central Kalimantan gaps summary 1,838

2,000

1,490 1,500 1,000

652

500 (500)

physician in primary care

physician in hospital (91)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (244)

(1,000) (1,097)

(1,044)

(1,500)

182

Physician Figure 282. Central Kalimantan total desired physician Total physicians 2000

physician

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kalimantan Tengah desired physicians : Kalimantan Tengah desired physicians constrained : Kalimantan Tengah

Figure 283. Central Kalimantan total desired physician in hospital 300

physician

250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 284. Central Kalimantan total desired physician in primary care 1600 1400

physician

1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

183

Table 132. Central Kalimantan total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (1,188)

Gap in 2019 (1,119)

(1,097)

(1,047)

(91)

(72)

Nurse Figure 285. Central Kalimantan total desired nurse Total nurses 7000 5600

nurse

4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kalimantan Tengah total desired nurses : Kalimantan Tengah total desired nurses constrained : Kalimantan Tengah

Figure 286. Central Kalimantan total desired nurse in hospital 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

184

Figure 287. Central Kalimantan total desired nurse in primary care 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 133. Central Kalimantan total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 2,547

Gap in 2019 3,472

1,838

2,423

652

1,049

Midwife Figure 288. CentralTotal Kalimantan total desired midwife midwives 3000

midwife

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kalimantan Tengah desired midwife total : Kalimantan Tengah

Table 134. Central Kalimantan total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,490

1,937

185

Hospital Bed Figure 289. Central Kalimantan total hospital bed Hospital beds 3000 2600

bed

2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kalimantan Tengah desired IP beds : Kalimantan Tengah desired IP beds constrained : Kalimantan Tengah

Table 135. Central Kalimantan total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,044)

(663)

(244)

(188)

186

22. South Kalimantan RSUD Anshari Saleh Banjarmasin reported four times increase in patients admission following JKN launch. RSUD Anshari Saleh has 200 hospital beds and they are always full. The director plans to increase the beds (103), but where the attending physicians will come from is an open question. Currently Available Data Table 136. South Kalimantan currently available data Parameter

Number

Population

% to National

Source

3,626,616

1.5%

BPS, 2010

GP Registered

972

1.0%

KKI, 2013

GP Practicing

779

1.9%

BPPSDM, MoH 2013

Specialist Registered

210

0.9%

KKI, 2013

Specialist Practicing

491

1.3%

BPPSDM, MoH 2013

Nurse

6,239

2.2%

BPPSDM, MoH 2013

Midwife

2,771

2.0%

BPPSDM, MoH 2013

Hospital

34

1.4%

BUK, MoH 2013

489

1.8%

BUK, MoH 2013

3,187

1.6%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 137. South Kalimantan 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 730 424 305 157 3 153 5,342 2,719 2,624 2,894 3,676 489 3,187

187

Figure 290. South Kalimantan Population projection to 2020 total provincial population 5M 4.6 M

people

4.2 M 3.8 M 3.4 M 3M 2010 2011

2012

2013 2014

2015 Date

2016 2017

2018

2019

2020

total provincial population : Kalimantan Selatan

Figure 291. South Kalimantan Population Projection by age group and gender Age 15 to 44 1M

580,000

980,000

560,000 people

people

Age 00 to 14 600,000

540,000

960,000

940,000

520,000

920,000

500,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

900,000 2010

Age 00 to 14[male] : Kalimantan Selatan Age 00 to 14[female] : Kalimantan Selatan

2011

2012

Age 45 to 64

2015 Date

2016

2017

2018

2019

2020

2017

2018

2019

2020

Age 65 and over 200,000

360,000

160,000

320,000

120,000

people

people

2014

Age 15 to 44[male] : Kalimantan Selatan Age 15 to 44[female] : Kalimantan Selatan

400,000

280,000 240,000 200,000 2010

2013

80,000 40,000

2011

2012

2013

2014

Age 45 to 64[male] : Kalimantan Selatan Age 45 to 64[female] : Kalimantan Selatan

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

Age 65 and over[male] : Kalimantan Selatan Age 65 and over[female] : Kalimantan Selatan

188

Figure 292. Changed in insurance status in South Kalimantan 4,000,000 3,500,000

POPULASI

3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 293. South Kalimantan gaps summary 3,000

2,403

2,000 1,000 (1,000)

physician in primary care

(2,000)

physician in hospital (236)

nurse in primary care (1,916)

nurse (140)in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(2,004) (2,493)

(3,000) (4,000) (5,000)

(4,353)

189

Physician Figure 294. South Kalimantan Total Desired Physician Total physicians 6000

physician

4800 3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kalimantan Selatan desired physicians : Kalimantan Selatan desired physicians constrained : Kalimantan Selatan

Figure 295. South Kalimantan total desired physician in hospital 800 700

physician

600 500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 296. South Kalimantan total desired physician in primary care 6000

physician

5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

190

Table 138. South Kalimantan total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (4,589)

Gap in 2019 (4,364)

(4,353)

(4,182)

(236)

(182)

Nurse Figure 297. South Kalimantan total desired nurse Total nurses 8000 6400

nurse

4800 3200 1600 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kalimantan Selatan total desired nurses : Kalimantan Selatan total desired nurses constrained : Kalimantan Selatan

Figure 298. South Kalimantan total desired nurse in hospital 3500 3000

nurse

2500 2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

191

Figure 299. South Kalimantan total desired nurse in primary care 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 139. South Kalimantan total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (2,056)

Gap in 2019 (899)

(1,916)

(1,289)

(140)

390

Midwife Figure 300. South Kalimantan total desired midwife

Total midwives

4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kalimantan Selatan desired midwife total : Kalimantan Selatan

Table 140. South Kalimantan total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

2,403

3,143

192

Hospital Bed Figure 301. South Kalimantan total hospital bed Hospital beds 6000 5400

bed

4800 4200 3600 3000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kalimantan Selatan desired IP beds : Kalimantan Selatan desired IP beds constrained : Kalimantan Selatan

Table 141. South Kalimantan total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(2,004)

(1,825)

(2,493)

(2,298)

193

23. East Kalimantan According to head of BPJS office in East Kalimantan, the enthusiasm to register as JKN enrollees is high; As of April 2014, out of 1.6 million JKN enrollees, there are 31,000 voluntary participants. Some Jamkesda programs have not yet been integrated into JKN and with plans of integration in 2016. The governor of East Kalimantan reports there is shortfall in healthcare workers, especially physicians, especially in remote areas. RSU A Wahab Sjahranie, which receives patients from East and North Kalimantan, reports shortfall in class III beds. The hospital management revitalized one unused building to become class III hospital wards (104–107). Currently Available Data Table 142. East Kalimantan Currently Available Data Parameter

Number

Population

% to National

Source

3,028,487

1.3%

BPS, 2010

GP Registered

1,305

1.4%

KKI, 2013

GP Practicing

1,080

2.6%

BPPSDM, MoH 2013

Specialist Registered

322

1.4%

KKI, 2013

Specialist Practicing

613

1.7%

BPPSDM, MoH 2013

Nurse

7,181

2.5%

BPPSDM, MoH 2013

Midwife

2,356

1.7%

BPPSDM, MoH 2013

Hospital

44

1.9%

BUK, MoH 2013

710

2.6%

BUK, MoH 2013

3,840

1.9%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 143. East Kalimantan 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 980 499 481 241 0 240 4,713 1,954 2,759 1,341 4,550 710 3,840

194

Figure 302. East Kalimantan Population projection to 2020 total provincial population 4M

people

3.8 M 3.6 M 3.4 M 3.2 M 3M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Kalimantan Timur

Figure 303. East Kalimantan Population Projection by age group and gender Age 15 to 44

Age 00 to 14

900,000

500,000 860,000

460,000

people

people

480,000 820,000

440,000

780,000

420,000

740,000

400,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date

700,000 2010

2020

Age 00 to 14[male] : Kalimantan Timur Age 00 to 14[female] : Kalimantan Timur

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2016

2017

2018

2019

2020

2020

Age 15 to 44[male] : Kalimantan Timur Age 15 to 44[female] : Kalimantan Timur

Age 45 to 64 Age 65 and over

400,000 200,000

340,000

220,000 160,000 100,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Kalimantan Timur Age 45 to 64[female] : Kalimantan Timur

people

people

160,000

280,000

120,000 80,000 40,000 0 2010

2011

2012

2013

2014

2015 Date

Age 65 and over[male] : Kalimantan Timur Age 65 and over[female] : Kalimantan Timur

195

Figure 304. Changed in insurance status in East Kalimantan 4,000,000 3,500,000

POPULASI

3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 305. East Kalimantan gaps summary 1,200

1,058

1,000

860

945

800 534

600 226

400 200 (200)

physician in primary care

(400) (600)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (176)

(496)

196

Physician Figure 306. East Kalimantan Total Desired Physician Total physicians 2000

physician

1800 1600 1400 1200 1000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kalimantan Timur desired physicians : Kalimantan Timur desired physicians constrained : Kalimantan Timur

physician

Figure 307. East Kalimantan total desired physician in hospital 900 800 700 600 500 400 300 200 100 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 308. East Kalimantan total desired physician in primary care 1200

physician

1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

197

Table 144. East Kalimantan total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (270)

Gap in 2019 (103)

(496)

(403)

226

300

Nurse Figure 309. East Kalimantan total desired nurse Total nurses 6000 4800

nurse

3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kalimantan Timur total desired nurses : Kalimantan Timur total desired nurses constrained : Kalimantan Timur

nurse

Figure 310. East Kalimantan total desired nurse in hospital 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

198

Figure 311. East Kalimantan total desired nurse in primary care 3000 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 145. East Kalimantan total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 1,947

Gap in 2019 2,880

1,058

1,453

860

1,427

Midwife Figure 312. East Kalimantan total desired midwife Total midwives 2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kalimantan Timur desired midwife total : Kalimantan Timur

Table 146. East Kalimantan total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

945

1,289

199

Hospital Bed Figure 313. East Kalimantan total hospital bed Hospital beds 5000 4600

bed

4200 3800 3400 3000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kalimantan Timur desired IP beds : Kalimantan Timur desired IP beds constrained : Kalimantan Timur

Table 147. East Kalimantan total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

534

674

(176)

(36)

200

24. North Kalimantan Shortfall in healthcare workers especially in physicians presents in all level of care in North Kalimantan (108–110). Since JKN was launched, there is an increase in patient visits every month, as reported in RSUD Nunukan; 369 in January to 625 in August for outpatients, and 159 to 257 for inpatients. Local government reports that more than 100 patients coming to RSUD Nunukan are referred to hospitals in Malaysia due to physician shortage (108,111). Currently Available Data Table 148. North Kalimantan currently available data Parameter

Number

Population

% to National

Source

524,656

0.2%

BPS, 2010

166

0.2%

KKI, 2013

-

0.0%

BPPSDM, MoH 2013

35

0.1%

KKI, 2013

Specialist Practicing

-

0.0%

BPPSDM, MoH 2013

Nurse

-

0.0%

BPPSDM, MoH 2013

Midwife

-

0.0%

BPPSDM, MoH 2013

Hospital

7

0.3%

BUK, MoH 2013

80

0.3%

BUK, MoH 2013

431

0.2%

BUK, MoH 2013

GP Registered GP Practicing Specialist Registered

Hospital Bed VVIP, VIP 1,2,3

Table 149. North Kalimantan 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 125 64 61 26 0 26 1,641 680 960 520 511 80 431

201

Figure 314. North Kalimantan Population projection to 2020 total provincial population 600,000

people

580,000 560,000 540,000 520,000

500,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Kalimantan Utara

Figure 315. North Kalimantan Population Projection by age group and gender Age 15 to 44 200,000

88,000

180,000

86,000

160,000

people

people

Age 00 to 14 90,000

84,000

140,000

82,000

120,000

80,000 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

100,000 2010

2020

Age 00 to 14[male] : Kalimantan Utara Age 00 to 14[female] : Kalimantan Utara

2013

2014

2015 Date

2016

2017

2018

2019

2020

30,000

24,000

52,000

44,000

people

people

2012

Age 65 and over

Age 45 to 64 60,000

18,000

36,000

12,000

28,000

6000

20,000 2010

2011

Age 15 to 44[male] : Kalimantan Utara Age 15 to 44[female] : Kalimantan Utara

2011

2012

2013

2014

Age 45 to 64[male] : Kalimantan Utara Age 45 to 64[female] : Kalimantan Utara

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014

2015 2016 2017 2018 2019 Date

2020

Age 65 and over[male] : Kalimantan Utara Age 65 and over[female] : Kalimantan Utara

202

Figure 316. Changed in insurance status in North Kalimantan 600,000

POPULASI

500,000 400,000 300,000 200,000 100,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 317. North Kalimantan gaps summary 800 672 600 472 358

400 200

6

(200) (400)

physician in primary care

(296)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III) (165)

hospital bed (I,II,III) (244)

203

Physician Figure 318. North Kalimantan Total Desired Physician Total physicians 500 400

physician

300 200 100 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Kalimantan Utara desired physicians : Kalimantan Utara desired physicians constrained : Kalimantan Utara

Figure 319. North Kalimantan total desired physician in hospital 120

physician

100 80 60 40 20 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 320. North Kalimantan total desired physician in primary care 400 350

physician

300 250 200 150 100 50 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

204

Table 150. North Kalimantan total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (290)

Gap in 2019 (265)

(296)

(281)

6

16

Nurse Figure 321. North Kalimantan total desired nurse Total nurses 3000 2400

nurse

1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Kalimantan Utara total desired nurses : Kalimantan Utara total desired nurses constrained : Kalimantan Utara

Figure 322. North Kalimantan total desired nurse in hospital 1400 1200

nurse

1000 800 600 400 200 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

205

Figure 323. North Kalimantan total desired nurse in primary care 1000

nurse

800 600 400 200 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 151. North Kalimantan total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 1,039

Gap in 2019 1,357

358

493

672

864

Midwife Figure 324. NorthTotal Kalimantan total desired midwife midwives 800

midwife

640 480 320 160 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Kalimantan Utara desired midwife total : Kalimantan Utara

Table 152. North Kalimantan total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

472

605

206

Hospital Bed Figure 325. North Kalimantan total hospital bed Hospital beds 700 660

bed

620 580 540 500 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Kalimantan Utara desired IP beds : Kalimantan Utara desired IP beds constrained : Kalimantan Utara

Table 153. North Kalimantan total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(165)

(112)

(244)

(188)

207

25. North Sulawesi Following JKN implementation, there is an increase in patients’ admission. For example, in RSUD Tondano, there is an increase from 300 to 2,000 outpatient visits per month. Shortfalls in beds and healthcare workers remain as barriers (112–114). For example, emergency unit in RSUP Kandow is lacking in beds and nurses (115). Currently Available Data Table 154. North Sulawesi currently available data Parameter

Number

Population

% to National

Source

2,270,596

1.0%

BPS, 2010

GP Registered

1,955

2.1%

KKI, 2013

GP Practicing

1,010

2.4%

BPPSDM, MoH 2013

Specialist Registered

341

1.4%

KKI, 2013

Specialist Practicing

447

1.2%

BPPSDM, MoH 2013

Nurse

5,645

2.0%

BPPSDM, MoH 2013

Midwife

1,469

1.1%

BPPSDM, MoH 2013

Hospital

41

1.7%

BUK, MoH 2013

351

1.3%

BUK, MoH 2013

3,935

2.0%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 155. North Sulawesi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 1,468 862 606 254 5 249 4,820 2,005 2,815 1,688 4,286 351 3,935

208

Figure 326. North Sulawesi Population projection to 2020 total provincial population 3M 2.8 M

people

2.6 M 2.4 M 2.2 M 2M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Sulawesi Utara

Figure 327. North Sulawesi Population Projection by age group and gender Age 15 to 44

Age 00 to 14

600,000

360,000

580,000

320,000

560,000

people

people

400,000

280,000

540,000

240,000

520,000

200,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

500,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 15 to 44[male] : Sulawesi Utara Age 15 to 44[female] : Sulawesi Utara

Age 00 to 14[male] : Sulawesi Utara Age 00 to 14[female] : Sulawesi Utara

Age 65 and over 200,000

280,000

160,000

260,000

120,000

people

people

Age 45 to 64 300,000

240,000

40,000

220,000 200,000 2010

80,000

2011

2012

2013

2014

Age 45 to 64[male] : Sulawesi Utara Age 45 to 64[female] : Sulawesi Utara

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Sulawesi Utara Age 65 and over[female] : Sulawesi Utara

209

Figure 328. Changed in insurance status in North Sulawesi 2,500,000

POPULASI

2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 329. North Sulawesi gaps summary 2,000 1,515 1,500 1,000

334

706

500

221

(500)

physician in primary care (524)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(1,000) (1,500) (2,000)

(1,411) (1,762)

210

Physician Figure 330. North Sulawesi Total Desired Physician Total physicians 2000 1800

physician

1600 1400 1200 1000 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sulawesi Utara desired physicians : Sulawesi Utara desired physicians constrained : Sulawesi Utara

Figure 331. North Sulawesi total desired physician in hospital 1200

physician

1000 800 600 400 200 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 332. North Sulawesi total desired physician in primary care 1600 1400

physician

1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

211

Table 156. North Sulawesi total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (190)

Gap in 2019 31

(524)

(387)

334

419

Nurse Figure 333. North Sulawesi total desired nurse Total nurses 7000 5600

nurse

4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sulawesi Utara total desired nurses : Sulawesi Utara total desired nurses constrained : Sulawesi Utara

nurse

Figure 334. North Sulawesi total desired nurse in hospital 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

212

Figure 335. North Sulawesi total desired nurse in primary care 3000 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 157. North Sulawesi total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 928

Gap in 2019 1,857

706

1,106

221

751

Midwife Figure 336. North Sulawesi total desired midwife

Total midwives

3000

midwife

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sulawesi Utara desired midwife total : Sulawesi Utara

Table 158. North Sulawesi total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,515

1,945

213

Hospital Bed Figure 337. North Sulawesi total hospital bed Hospital beds 6000 5400

bed

4800 4200 3600 3000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sulawesi Utara desired IP beds : Sulawesi Utara desired IP beds constrained : Sulawesi Utara

Table 159. North Sulawesi total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,411)

(1,411)

(1,762)

(1,762)

214

26. Central Sulawesi 85% of Central Sulawesi’s population are registered as JKN enrollees. Physicians and hospital beds for JKN enrollees are still lacking (116,117). In 2014, there are in average 150-200 daily visits in hospital and 25-76 daily visits in Puskesmas (118). Currently Available Data Table 160. Central Sulawesi currently available data Parameter

Number

Population

% to National

Source

2,635,009

1.1%

BPS, 2010

GP Registered

404

0.4%

KKI, 2013

GP Practicing

534

1.3%

BPPSDM, MoH 2013

Specialist Registered

102

0.4%

KKI, 2013

Specialist Practicing

274

0.7%

BPPSDM, MoH 2013

Nurse

6,804

2.4%

BPPSDM, MoH 2013

Midwife

2,495

1.8%

BPPSDM, MoH 2013

Hospital

28

1.2%

BUK, MoH 2013

249

0.9%

BUK, MoH 2013

2,458

1.2%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 161. Central Sulawesi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 304 147 156 76 1 75 4,717 2,751 1,966 2,375 2,707 249 2,458

215

Figure 338. Central Sulawesi Population projection to 2020 total provincial population

3M

people

2.8 M

2.6 M

2.4 M

2.2 M

2M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Sulawesi Tengah

Figure 339. Central Sulawesi Population Projection by age group and gender Age 15 to 44 800,000

480,000

760,000

460,000

720,000

people

people

Age 00 to 14 500,000

440,000

680,000

420,000

640,000

400,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

600,000 2010 2011

Age 00 to 14[male] : Sulawesi Tengah Age 00 to 14[female] : Sulawesi Tengah

260,000

160,000

220,000

120,000

180,000

80,000

140,000

40,000

2012

2013

2014

Age 45 to 64[male] : Sulawesi Tengah Age 45 to 64[female] : Sulawesi Tengah

2015 2016 Date

2017 2018

2019

2020

Age 65 and over 200,000

people

people

Age 45 to 64

2011

2014

Age 15 to 44[male] : Sulawesi Tengah Age 15 to 44[female] : Sulawesi Tengah

300,000

100,000 2010

2012 2013

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date

2020

Age 65 and over[male] : Sulawesi Tengah Age 65 and over[female] : Sulawesi Tengah

216

Figure 340. Changed in insurance status in Central Sulawesi 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 341. Central Sulawesi gaps summary 2,500

2,089

2,000 1,312

1,500 1,000 500 (500)

physician in primary care

(1,000) (1,500) (2,000) (2,500)

physician in hospital (224)

nurse in primary care

nurse in hospital (192)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(1,446) (1,938)

(2,187)

217

Physician Figure 342. Central Sulawesi Total Desired Physician Total physicians 3000 2400

physician

1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sulawesi Tengah desired physicians : Sulawesi Tengah desired physicians constrained : Sulawesi Tengah

physician

Figure 343. Central Sulawesi total desired physician in hospital 500 450 400 350 300 250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 344. Central Sulawesi total desired physician in primary care 1800 1600

physician

1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

218

Table 162. Central Sulawesi total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (1,670)

Gap in 2019 (1,589)

(1,446)

(1,396)

(224)

(194)

Nurse Figure 345. Central Sulawesi total desired nurse Total nurses 6000 4800

nurse

3600 2400 1200 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sulawesi Tengah total desired nurses : Sulawesi Tengah total desired nurses constrained : Sulawesi Tengah

Figure 346. Central Sulawesi total desired nurse in hospital 3000 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

219

nurse

Figure 347. Central Sulawesi total desired nurse in primary care 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 163. Central Sulawesi total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 1,120

Gap in 2019 2,081

1,312

1,861

(192)

220

Midwife Figure 348. Central Sulawesi total desired midwife Total midwives 4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sulawesi Tengah desired midwife total : Sulawesi Tengah

Table 164. Central Sulawesi total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

2,089

2,697

220

Hospital Bed Figure 349. Central Sulawesi total hospital bed Hospital beds 5000 4400

bed

3800 3200 2600 2000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sulawesi Tengah desired IP beds : Sulawesi Tengah desired IP beds constrained : Sulawesi Tengah

Table 165. Central Sulawesi total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(1,938)

(1,356)

(2,187)

(1,674)

221

27. South Sulawesi Around 60% of population in South Sulawesi are covered under Jamkesda and 35% under JKN. In 2015, provincial government plans to integrate all Jamkesda programs into JKN. Shortfall in healthcare workers, especially physicians, remains as problem (119,120). Currently Available Data Table 166. South Sulawesi currently available data Parameter

Number

Population

% to National

Source

8,034,776

3.4%

BPS, 2010

GP Registered

3,484

3.7%

KKI, 2013

GP Practicing

1,464

3.5%

BPPSDM, MoH 2013

995

4.2%

KKI, 2013

1,402

3.8%

BPPSDM, MoH 2013

12,436

4.3%

BPPSDM, MoH 2013

Midwife

5,264

3.8%

BPPSDM, MoH 2013

Hospital

84

3.5%

BUK, MoH 2013

VVIP, VIP

1,457

5.4%

BUK, MoH 2013

1,2,3

7,804

3.9%

BUK, MoH 2013

Specialist Registered Specialist Practicing Nurse

Hospital Bed

Table 167. South Sulawesi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 2,616 1,292 1,324 743 3 740 5,813 2,496 3,317 2,757 9,261 1,457 7,804

222

Figure 350. South Sulawesi Population projection to 2020 total provincial population 9M

8.8 M

people

8.6 M

8.4 M

8.2 M

8M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Sulawesi Selatan

Figure 351. South Sulawesi Population Projection by age group and gender Age 15 to 44 3M

1.8 M

2.6 M

1.6 M

2.2 M

people

people

Age 00 to 14 2M

1.4 M

1.8 M

1.2 M

1.4 M

1M 2010 2011 2012 2013 2014

2015 2016 2017 2018 2019 Date

1M 2010

2020

Age 00 to 14[male] : Sulawesi Selatan Age 00 to 14[female] : Sulawesi Selatan

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over

Age 45 to 64

500,000

840,000

400,000

780,000

300,000

people

people

2012

Age 15 to 44[male] : Sulawesi Selatan Age 15 to 44[female] : Sulawesi Selatan

900,000

720,000

200,000

100,000

660,000

600,000 2010

2011

2011

2012

2013

Age 45 to 64[male] : Sulawesi Selatan Age 45 to 64[female] : Sulawesi Selatan

2014

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over[male] : Sulawesi Selatan Age 65 and over[female] : Sulawesi Selatan

223

POPULASI

Figure 352. Changed in insurance status in South Sulawesi 10,000,000 9,000,000 8,000,000 7,000,000 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 353. South Sulawesi gaps summary 4,000 1,677

57

2,000 (2,000)

physician in primary care

physician in hospital

nurse in primary care

nurse in hospital

(4,000)

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

(4,644)

(6,000) (5,955)

(6,000)

(8,000) (10,000) (9,933) (12,000)

(11,389)

(14,000)

224

Physician Figure 354. South Sulawesi Total Desired Physician Total physicians 10,000 8000

physician

6000 4000 2000 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sulawesi Selatan desired physicians : Sulawesi Selatan desired physicians constrained : Sulawesi Selatan

Figure 355. South Sulawesi total desired physician in hospital 2400

physician

2300 2200 2100 2000 1900 1800 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 356. South Sulawesi total desired physician in primary care 8000 7000

physician

6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

225

Table 168. South Sulawesi total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (5,898)

Gap in 2019 (5,434)

(5,955)

(5,694)

57

260

Nurse Figure 357. South Sulawesi total desired nurse Total nurses 20,000 16,000

nurse

12,000 8000 4000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sulawesi Selatan total desired nurses : Sulawesi Selatan total desired nurses constrained : Sulawesi Selatan

Figure 358. South Sulawesi total desired nurse in hospital 10000

nurse

8000 6000 4000 2000 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

226

nurse

Figure 359. South Sulawesi total desired nurse in primary care 8000 7000 6000 5000 4000 3000 2000 1000 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 169. South Sulawesi total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (10,318) (4,644)

Gap in 2019 (9,055) (4,083)

(6,000)

(4,971)

Midwife Figure 360. South Sulawesi total desired midwife Total midwives 4000

midwife

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sulawesi Selatan desired midwife total : Sulawesi Selatan

Table 170. South Sulawesi total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,677

2,383

227

Hospital Bed Figure 361. South Sulawesi total hospital bed Hospital beds 20,000

bed

16,000 12,000 8000 4000 0 2014

2014

2015

2016

2016 2017 Date

2018

2018

2019

2020

current IP capacity : Sulawesi Selatan desired IP beds : Sulawesi Selatan desired IP beds constrained : Sulawesi Selatan

Table 171. South Sulawesi total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(9,933)

(8,896)

(11,389)

(10,212)

228

28. South-East Sulawesi As of April 2014, more than 50% of South-East Sulawesi population are covered under JKN. There is not enough hospital beds to serve JKN patients. Shortfall in healthcare workers also presents (121– 123). Currently Available Data Table 172. South-East Sulawesi currently available data Parameter

Number

Population

% to National

Source

2,232,586

0.9%

BPS, 2010

GP Registered

343

0.4%

KKI, 2013

GP Practicing

445

1.1%

BPPSDM, MoH 2013

Specialist Registered

81

0.3%

KKI, 2013

Specialist Practicing

130

0.4%

BPPSDM, MoH 2013

Nurse

3,801

1.3%

BPPSDM, MoH 2013

Midwife

1,769

1.3%

BPPSDM, MoH 2013

Hospital

25

1.1%

BUK, MoH 2013

146

0.5%

BUK, MoH 2013

1,521

0.8%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 173. South-East Sulawesi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 257 169 89 60 5 56 5,081 3,321 1,761 1,900 1,667 146 1,521

229

Figure 362. South-East Sulawesi Population projection to 2020 total provincial population 3M

people

2.8 M

2.6 M

2.4 M

2.2 M

2M 2010 2011 2012 2013

2014 2015 2016 Date

2017 2018 2019

2020

total provincial population : Sulawesi Tenggara

Figure 363. South-East Sulawesi Population Projection by age group and gender Age 15 to 44 600,000

460,000

580,000

420,000

560,000

people

people

Age 00 to 14 500,000

380,000

540,000

340,000

520,000

300,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 00 to 14[male] : Sulawesi Tenggara Age 00 to 14[female] : Sulawesi Tenggara

500,000 2010

Age 45 to 64

260,000

160,000

220,000

120,000

people

people

200,000

180,000

80,000

140,000

40,000

2011

2012

2013

2014

Age 45 to 64[male] : Sulawesi Tenggara Age 45 to 64[female] : Sulawesi Tenggara

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over

300,000

100,000 2010

2011

Age 15 to 44[male] : Sulawesi Tenggara Age 15 to 44[female] : Sulawesi Tenggara

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over[male] : Sulawesi Tenggara Age 65 and over[female] : Sulawesi Tenggara

230

Figure 364. Changed in insurance status in South-East Sulawesi 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 365. South-East Sulawesi gaps summary 2,000

1,626

1,619

1,500 1,000 564 500 (500)

physician in primary care

(1,000)

physician in hospital (183)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III) (814)

hospital bed (I,II,III) (960)

(1,500) (2,000)

(1,708)

231

Physician Figure 366. South-East Sulawesi Total Desired Physician Total physicians 3000

physician

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sulawesi Tenggara desired physicians : Sulawesi Tenggara desired physicians constrained : Sulawesi Tenggara

Figure 367. South-East Sulawesi total desired physician in hospital 350 300

physician

250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

physician

Figure 368. South-East Sulawesi total desired physician in primary care 2000 1800 1600 1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

232

Table 174. South-East Sulawesi total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (1,891)

Gap in 2019 (1,805)

(1,708)

(1,642)

(183)

(163)

Nurse Figure 369. South-East Sulawesi total desired nurse Total nurses 7000 5600

nurse

4200 2800 1400 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sulawesi Tenggara total desired nurses : Sulawesi Tenggara total desired nurses constrained : Sulawesi Tenggara

Figure 370. South-East Sulawesi total desired nurse in hospital 2500

nurse

2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

233

Figure 371. South-East Sulawesi total desired nurse in primary care 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 175. South-East Sulawesi total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 2,191

Gap in 2019 3,222

1,626

2,295

564

927

Midwife Figure 372. South-East Sulawesi total desired midwife

Total midwives

3000

midwife

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sulawesi Tenggara desired midwife total : Sulawesi Tenggara

Table 176. South-East Sulawesi total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,619

2,107

234

Hospital Bed Figure 373. South-East Sulawesi total hospital bed Hospital beds 3000 2600

bed

2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sulawesi Tenggara desired IP beds : Sulawesi Tenggara desired IP beds constrained : Sulawesi Tenggara

Table 177. South-East Sulawesi total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(814)

(442)

(960)

(626)

235

29. Gorontalo As reported by BPJS’ branch office in Gorontalo, 87.6% of Gorontalo’s total population are covered by JKN. Jamkesda program (Jaminan Kesehatan Semesta) is already integrated into JKN since midFebruary 2014. According to Gorontalo’s DHO, Gorontalo still needs physicians and midwives (124– 126) (127). A long queuing line is reported in hospital for patients with JKN card (128). The shortage of medical professionals is severe. Currently Available Data Table 178. Gorontalo Currently Available Data Parameter Population

Number

% to National

Source

1,040,164

0.4%

BPS, 2010

GP Registered

253

0.3%

KKI, 2013

GP Practicing

249

0.6%

BPPSDM, MoH 2013

Specialist Registered

51

0.2%

KKI, 2013

Specialist Practicing

137

0.4%

BPPSDM, MoH 2013

1,598

0.6%

BPPSDM, MoH 2013

Midwife

680

0.5%

BPPSDM, MoH 2013

Hospital

12

0.5%

BUK, MoH 2013

VVIP, VIP

157

0.6%

BUK, MoH 2013

1,2,3

960

0.5%

BUK, MoH 2013

Nurse

Hospital Bed

Table 179. Gorontalo 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 190 98 92 38 1 38 1,994 916 1,078 767 1,117 157 960

236

Figure 374. Gorontalo Population projection to 2020 total provincial population 2M

people

1.8 M 1.6 M 1.4 M 1.2 M 1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Gorontalo

Figure 375. Gorontalo Population Projection by age group and gender Age 15 to 44 300,000

180,000

280,000

160,000

260,000

people

people

Age 00 to 14 200,000

140,000 120,000

240,000 220,000

100,000 2010 2011

2012 2013

2014 2015 Date

2016 2017

2018 2019

200,000 2010

2020

Age 00 to 14[male] : Gorontalo Age 00 to 14[female] : Gorontalo

2011

2012

2013

2016

2017

2016

2017

2018

2019

2020

Age 65 and over

Age 45 to 64 50,000

174,000

40,000

148,000

30,000

people

people

2015 Date

Age 15 to 44[male] : Gorontalo Age 15 to 44[female] : Gorontalo

200,000

122,000

20,000

96,000 70,000 2010

2014

10,000

2011

2012

Age 45 to 64[male] : Gorontalo Age 45 to 64[female] : Gorontalo

2013

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2018

2019

2020

Age 65 and over[male] : Gorontalo Age 65 and over[female] : Gorontalo

237

Figure 376. Changed in insurance status in Gorontalo 1,200,000

POPULASI

1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 377. Gorontalo gaps summary 1,000 652 444

500 (500)

physician in primary care

physician in hospital (20)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III) (436)

(611) (279)

(1,000) (1,500) (1,478) (2,000)

238

Physician Figure 378. Gorontalo Total Desired Physician Total physicians 2000

physician

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Gorontalo desired physicians : Gorontalo desired physicians constrained : Gorontalo

Figure 379. Gorontalo total desired physician in hospital 155 150

physician

145 140 135 130 125 120 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 380. Gorontalo total desired physician in primary care 1800 1600

physician

1400 1200 1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

239

Table 180. Gorontalo total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (1,498)

Gap in 2019 (1,430)

(1,478)

(1,427)

(20)

(4)

Nurse Figure 381. Gorontalo total desired nurse Total nurses 3000

nurse

2400 1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Gorontalo total desired nurses : Gorontalo total desired nurses constrained : Gorontalo

nurse

Figure 382. Gorontalo total desired nurse in hospital 1600 1400 1200 1000 800 600 400 200 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

240

Figure 383. Gorontalo total desired nurse in primary care 2000

nurse

1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 181. Gorontalo total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap (167)

Gap in 2019 263

(611)

(400)

444

664

Midwife Figure 384. Gorontalo total desired midwife

Total midwives

2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Gorontalo desired midwife total : Gorontalo

Table 182. Gorontalo total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

652

849

241

Hospital Bed Figure 385. Gorontalo total hospital bed Hospital beds 2000

bed

1800 1600 1400 1200 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Gorontalo desired IP beds : Gorontalo desired IP beds constrained : Gorontalo

Table 183. Gorontalo total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(279)

(222)

(436)

(364)

242

30. West Sulawesi Shortfall in healthcare workers remains as major barrier in healthcare service provision in West Sulawesi (129–131). Currently Available Data Table 184. West Sulawesi Currently Available Data Parameter

Number

Population

% to National

Source

1,158,651

0.5%

BPS, 2010

GP Registered

111

0.1%

KKI, 2013

GP Practicing

233

0.6%

BPPSDM, MoH 2013

Specialist Registered

23

0.1%

KKI, 2013

Specialist Practicing

33

0.1%

BPPSDM, MoH 2013

1,627

0.6%

BPPSDM, MoH 2013

Midwife

895

0.7%

BPPSDM, MoH 2013

Hospital

9

0.4%

BUK, MoH 2013

69

0.3%

BUK, MoH 2013

646

0.3%

BUK, MoH 2013

Nurse

Hospital Bed VVIP, VIP 1,2,3

Table 185. West Sulawesi 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 83 62 21 17 17 1,821 1,449 372 695 715 69 646

243

Figure 386. West Sulawesi Population projection to 2020 total provincial population 2M 1.8 M

people

1.6 M 1.4 M 1.2 M 1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Sulawesi Barat

Figure 387. West Sulawesi Population Projection by age group and gender Age 00 to 14

Age 15 to 44

300,000

400,000 360,000

220,000

people

people

260,000

180,000

280,000 240,000

140,000

100,000 2010

320,000

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

200,000 2010 2011 2012 2013

2020

Age 45 to 64

2020

Age 65 and over

200,000

50,000

174,000

40,000

148,000

people

people

2017 2018 2019

Age 15 to 44[male] : Sulawesi Barat Age 15 to 44[female] : Sulawesi Barat

Age 00 to 14[male] : Sulawesi Barat Age 00 to 14[female] : Sulawesi Barat

122,000 96,000 70,000 2010

2014 2015 2016 Date

30,000 20,000 10,000

2011

2012

2013

Age 45 to 64[male] : Sulawesi Barat Age 45 to 64[female] : Sulawesi Barat

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Sulawesi Barat Age 65 and over[female] : Sulawesi Barat

244

Figure 388. Changed in insurance status in West Sulawesi 1,400,000 1,200,000

POPULASI

1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 389. West Sulawesi gaps summary 800 534

600

419

400 200 (200)

physician in primary care

(400)

physician in hospital (88)

nurse in primary care

nurse in hospital (153)

(600)

midwife

hospital bed (VVIP, VIP, I,II,III) (368)

hospital bed (I,II,III) (437)

(800) (1,000) (1,200)

(1,051)

245

Physician Figure 390. West Sulawesi Total Desired Physician Total physicians 2000 1600

physician

1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Sulawesi Barat desired physicians : Sulawesi Barat desired physicians constrained : Sulawesi Barat

Figure 391. West Sulawesi total desired physician in hospital 140 120

physician

100 80 60 40 20 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 392. West Sulawesi total desired physician in primary care 1200

physician

1000 800 600 400 200 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

246

Table 186. West Sulawesi total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (1,138)

Gap in 2019 (1,106)

(1,051)

(1,022)

(88)

(83)

Nurse Figure 393. West Sulawesi total desired nurse Total nurses 3000 2400

nurse

1800 1200 600 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Sulawesi Barat total desired nurses : Sulawesi Barat total desired nurses constrained : Sulawesi Barat

Figure 394. West Sulawesi total desired nurse in hospital 600 500

nurse

400 300 200 100 0 2014

2015

2016

Nurses in hospital

2017

2018

2019

2020

Desired nurses in hospital

247

Figure 395. West Sulawesi total desired nurse in primary care 2000

nurse

1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 187. West Sulawesi total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 269

Gap in 2019 636

419

712

(153)

(76)

Midwife Figure 396. West Sulawesi total desired midwife

Total midwives

1000

midwife

800 600 400 200 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Sulawesi Barat desired midwife total : Sulawesi Barat

Table 188. West Sulawesi total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

534

713

248

Hospital Bed Figure 397. West Sulawesi total hospital bed Hospital beds 2000 1740

bed

1480 1220 960 700 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Sulawesi Barat desired IP beds : Sulawesi Barat desired IP beds constrained : Sulawesi Barat

Table 189. West Sulawesi total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(368)

(139)

(437)

(229)

249

31. Maluku As of June 2014, 60% of Maluku’s total population are enrolled under JKN. Shortfall in healthcare workers, mainly physicians, remains as major barrier for health service provision. For example, there is only one physician in hospital located in Tamilouw (132–135). The shortage of medical professionals in Maluku is severe. Currently Available Data Table 190. Maluku Currently Available Data Parameter

Number

Population

% to National

Source

1,533,506

0.6%

BPS, 2010

GP Registered

221

0.2%

KKI, 2013

GP Practicing

390

0.9%

BPPSDM, MoH 2013

Specialist Registered

40

0.2%

KKI, 2013

Specialist Practicing

118

0.3%

BPPSDM, MoH 2013

Nurse

5,075

1.8%

BPPSDM, MoH 2013

Midwife

1,323

1.0%

BPPSDM, MoH 2013

Hospital

27

1.1%

BUK, MoH 2013

131

0.5%

BUK, MoH 2013

1,776

0.9%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 191. Maluku 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 69,998 31,552 38,447 17,689 317 17,371 255100 109,430 145,670 133,225 225,967 27,725 198,242

250

Figure 398. Maluku Population projection to 2020 total provincial population 2M

people

1.8 M 1.6 M 1.4 M 1.2 M 1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Maluku

Figure 399. Maluku Population Projection by age group and gender Age 15 to 44 500,000

280,000

460,000

260,000

420,000

people

people

Age 00 to 14 300,000

240,000

380,000

220,000

340,000

200,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

300,000 2010 2011 2012 2013

Age 00 to 14[male] : Maluku Age 00 to 14[female] : Maluku

2014 2015 2016 Date

2017 2018 2019

2020

Age 15 to 44[male] : Maluku Age 15 to 44[female] : Maluku

Age 45 to 64 200,000 Age 65 and over 70,000

180,000

56,000

people

people

160,000

140,000

120,000

100,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date Age 45 to 64[male] : Maluku Age 45 to 64[female] : Maluku

42,000

28,000 14,000

2020

0 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

Age 65 and over[male] : Maluku Age 65 and over[female] : Maluku

251

Figure 400. Changed in insurance status in Maluku 1,800,000 1,600,000

POPULASI

1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 401. Maluku gaps summary 3,000 2,440

2,500 2,000 1,500

1,232

1,000 500

119

(500) (1,000)

physician in primary care (378)

physician in hospital (75)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III) (214)

hospital bed (I,II,III) (345)

252

Physician Figure 402. Maluku total desired physician Total physicians 700

physician

560 420 280 140 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Maluku desired physicians : Maluku desired physicians constrained : Maluku

physician

Figure 403. Maluku total desired physician in hospital 200 180 160 140 120 100 80 60 40 20 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

253

Figure 404. Maluku total desired physician in primary care 600

physician

500 400 300 200 100 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 192. Maluku total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (451)

Gap in 2019 (419)

(378)

(356)

(75)

(63)

Nurse Figure 405. Maluku total desired nurse Total nurses 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Maluku total desired nurses : Maluku total desired nurses constrained : Maluku

254

nurse

Figure 406. Maluku total desired nurse in hospital 1600 1400 1200 1000 800 600 400 200 0 2014

2015

2016

Nurses in hospital

2017

2018

2019

2020

Desired nurses in hospital

nurse

Figure 407. Maluku total desired nurse in primary care 4000 3500 3000 2500 2000 1500 1000 500 0 2014

2015

Nurses in primary care

2016

2017

2018

2019

2020

Desired physicians in primary care

Table 193. Maluku total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 2,587

Gap in 2019 3,319

2,440

2,969

119

351

255

Midwife Figure 408. Maluku total desired midwife

Total midwives

2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Maluku desired midwife total : Maluku

Table 194. Maluku total desired midwife Minimum Surplus

Surplus in 2019

1,232

1,588

Midwife

Hospital Bed Figure 409. Maluku total hospital bed Hospital beds 3000

bed

2600 2200 1800 1400 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Maluku desired IP beds : Maluku desired IP beds constrained : Maluku

Table 195. Maluku total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(214)

(138)

(345)

(269)

256

32. North Maluku According to the Vice Governor, all districts are still lacking in physicians, mainly specialists, pushing patients to go to RSUD Kota Ternate for care (136). Currently Available Data Table 196. North Maluku currently available data Parameter

Number

Population

% to National

Source

1,038,087

0.4%

BPS, 2010

GP Registered

147

0.2%

KKI, 2013

GP Practicing

272

0.7%

BPPSDM, MoH 2013

Specialist Registered

28

0.1%

KKI, 2013

Specialist Practicing

84

0.2%

BPPSDM, MoH 2013

Nurse

3,123

1.1%

BPPSDM, MoH 2013

Midwife

1,086

0.8%

BPPSDM, MoH 2013

Hospital

18

0.8%

BUK, MoH 2013

VVIP, VIP

169

0.6%

BUK, MoH 2013

1,2,3

949

0.5%

BUK, MoH 2013

Hospital Bed

Table 197. North Maluku 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 166 97 69 30 0 30 3,819 2,759 1,060 1,388 1,907 131 1,776

257

Figure 410. North Maluku Population projection to 2020 total provincial population 2M 1.8 M

people

1.6 M 1.4 M 1.2 M 1M 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date total provincial population : Maluku Utara

Figure 411. North Maluku population projection by age group and gender Age 00 to 14

Age 15 to 44

200,000

300,000 280,000

160,000 people

people

180,000

140,000 120,000

260,000 240,000 220,000

100,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

200,000 2010

Age 00 to 14[male] : Maluku Utara Age 00 to 14[female] : Maluku Utara

2011

2012

2013

Age 45 to 64

2016

2017

2018

2019

2020

2016

2017

2018

2019

2020

Age 65 and over 50,000

172,000

40,000

144,000

30,000

people

people

2015 Date

Age 15 to 44[male] : Maluku Utara Age 15 to 44[female] : Maluku Utara

200,000

116,000 88,000 60,000 2010

2014

20,000 10,000

2011

2012

2013

Age 45 to 64[male] : Maluku Utara Age 45 to 64[female] : Maluku Utara

2014

2015 Date

2016

2017

2018

2019

2020

0 2010

2011

2012

2013

2014

2015 Date

Age 65 and over[male] : Maluku Utara Age 65 and over[female] : Maluku Utara

258

Figure 412. Changed in insurance status in North Maluku 1,400,000 1,200,000

POPULASI

1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 413. North Maluku gaps summary 2,000

1,779

1,500 1,006 1,000 500 137 (500)

physician in primary care

physician in hospital

(140)

(55)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III) (394)

hospital bed (I,II,III) (563)

(1,000)

259

Physician Figure 414. North Maluku Total Desired Physician Total physicians 400 320

physician

240 160 80 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Maluku Utara desired physicians : Maluku Utara desired physicians constrained : Maluku Utara

Figure 415. North Maluku total desired physician in hospital 140 120

physician

100 80 60 40 20 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 416. North Maluku total desired physician in primary care 250

physician

200 150 100 50 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

260

Table 198. North Maluku total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (195)

Gap in 2019 (174)

(140)

(126)

(55)

(47)

Nurse Figure 417. North Maluku total desired nurse Total nurses 4000 3200

nurse

2400 1600 800 0 2014 2014 2015 2016 2016 2017 2018 2018 2019 2020 Date nurse capacity province total : Maluku Utara total desired nurses : Maluku Utara total desired nurses constrained : Maluku Utara

Figure 418. North Maluku total desired nurse in hospital 1200 1000

nurse

800 600 400 200 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

261

Figure 419. North Maluku total desired nurse in primary care 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 199. North Maluku total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 1,926

Gap in 2019 2,442

1,779

2,137

137

305

Midwife Figure 420. North Maluku total desired midwife

Total midwives

2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Maluku Utara desired midwife total : Maluku Utara

Table 200. North Maluku total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,006

1,295

262

Hospital Bed Figure 421. North Maluku total hospital bed Hospital beds 2000 1800

bed

1600 1400 1200 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Maluku Utara desired IP beds : Maluku Utara desired IP beds constrained : Maluku Utara

Table 201. North Maluku total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

(394)

(334)

(563)

(492)

263

33. West Papua All West Papuans are covered under JKN. Shortage in healthcare workers, especially in physicians, remains as problem (137,138). Currently Available Data Table 202. West Papua currently available data Parameter

Number

Population

% to National

Source

1,073,817

0.5%

BPS, 2010

GP Registered

189

0.2%

KKI, 2013

GP Practicing

297

0.7%

BPPSDM, MoH 2013

Specialist Registered

34

0.1%

KKI, 2013

Specialist Practicing

108

0.3%

BPPSDM, MoH 2013

2,710

0.9%

BPPSDM, MoH 2013

Midwife

895

0.7%

BPPSDM, MoH 2013

Hospital

17

0.7%

BUK, MoH 2013

65

0.2%

BUK, MoH 2013

1,204

0.6%

BUK, MoH 2013

Nurse

Hospital Bed VVIP, VIP 1,2,3

Table 203. West Papua 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 142 79 63 26 6 19 2,632 1,621 1,011 992 1,269 65 1,204

264

Figure 422. West Papua population projection to 2020 total provincial population 2M 1.8 M

people

1.6 M 1.4 M 1.2 M 1M 2010

2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Papua Barat

Figure 423. West Papua population projection by age group and gender Age 15 to 44 300,000

280,000

260,000

260,000

220,000

people

people

Age 00 to 14 300,000

240,000

180,000

220,000

140,000

200,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date

100,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 15 to 44[male] : Papua Barat Age 15 to 44[female] : Papua Barat

Age 00 to 14[male] : Papua Barat Age 00 to 14[female] : Papua Barat

Age 65 and over 40,000 Age 45 to 64 100,000

32,000

60,000

people

people

80,000

24,000

16,000

40,000 20,000 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 45 to 64[male] : Papua Barat Age 45 to 64[female] : Papua Barat

8000

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over[male] : Papua Barat Age 65 and over[female] : Papua Barat

265

Figure 424. Changed in insurance status in West Papua 1,400,000 1,200,000

POPULASI

1,000,000 800,000 600,000 400,000 200,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 425. West Papua gaps summary 1,600

1,430

1,400 1,200 909

1,000 800

662

600

488

423

400 200 (200)

physician in primary care

physician in hospital

(400)

(197)

(18)

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

266

Physician Figure 426. West Papua total desired physician Total physicians 400 320 physician

240 160 80 0 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Papua Barat desired physicians : Papua Barat desired physicians constrained : Papua Barat

Figure 427. West Papua total desired physician in hospital 120

physician

100 80 60 40 20 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 428. West Papua total desired physician in primary care 300

physician

250 200 150 100 50 0 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

267

Table 204. West Papua total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap (214)

Gap in 2019 (181)

(197)

(173)

(18)

(8)

Nurse Figure 429. West Papua total desired nurse Total nurses 4000

nurse

3200 2400 1600 800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Papua Barat total desired nurses : Papua Barat total desired nurses constrained : Papua Barat

Figure 430. West Papua total desired nurse in hospital 1400 1200

nurse

1000 800 600 400 200 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

268

Figure 431. West Papua total desired nurse in primary care 2500

nurse

2000 1500 1000 500 0 2014

2015

2016

Nurses in primary care

2017

2018

2019

2020

Desired physicians in primary care

Table 205. West Papua total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 2,103

Gap in 2019 2,627

1,430

1,749

662

878

Midwife Figure 432. West Papua total desired midwife

Total midwives

2000

midwife

1600 1200 800 400 0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Papua Barat desired midwife total : Papua Barat

Table 206. West Papua total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

909

1,165

269

Hospital Bed Figure 433. West Papua total hospital bed Hospital beds 2000 1740

bed

1480 1220 960 700 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Papua Barat desired IP beds : Papua Barat desired IP beds constrained : Papua Barat

Table 207. West Papua total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

488

548

423

482

270

34. Papua Around 80% of Papuans are covered under JKN, the remaining will hopefully be enrolled in 2015. Healthcare workers remain short (139,140). Everyday RSUD Dok II Jayapura serves about 1,000 patients (700-800 outpatients and 300 inpatients). This number exceeds healthcare workers number the hospital has (141,142). In RSUD Biak Numfor, since early January 2014, there is a 100% increase in admission. Prior to 2014, there were 200-300 patients. This figure increased to 500-600 patients in 2014 (143). Currently Available Data Table 208. Papua currently available data Parameter

Number

Population

% to National

Source

2,519,986

1.1%

BPS, 2010

GP Registered

611

0.7%

KKI, 2013

GP Practicing

733

1.8%

BPPSDM, MoH 2013

Specialist Registered

93

0.4%

KKI, 2013

Specialist Practicing

202

0.5%

BPPSDM, MoH 2013

Nurse

5,482

1.9%

BPPSDM, MoH 2013

Midwife

1,921

1.4%

BPPSDM, MoH 2013

Hospital

36

1.5%

BUK, MoH 2013

141

0.5%

BUK, MoH 2013

2,852

1.4%

BUK, MoH 2013

Hospital Bed VVIP, VIP 1,2,3

Table 209. Papua 2013 capacity projected by the model Capacity General physician - GP in primary care - GP in hospital Specialist - Specialist in primary care - Specialist in hospital Nurse - Nurse in primary care - Nurse in hospital Midwife Hospital Bed VVIP, VIP I, II, III

Projected by the model 2013 459 265 193 69 2 68 6,402 3,883 2,519 2,075 2,993 141 2,852

271

Figure 434. Papua Population projection to 2020 total provincial population 4M

people

3.6 M

3.2 M

2.8 M

2.4 M

2M 2010 2011

2012

2013

2014

2015 Date

2016

2017

2018

2019

2020

total provincial population : Papua

Figure 435. Papua population projection by age group and gender Age 15 to 44

Age 00 to 14

800,000

500,000 780,000

420,000

people

people

460,000

760,000

380,000

740,000

340,000

720,000

300,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Date

700,000 2010 2011

2020

Age 00 to 14[male] : Papua Age 00 to 14[female] : Papua

2012 2013

2014

2015 2016 Date

2017 2018

2019

2020

Age 15 to 44[male] : Papua Age 15 to 44[female] : Papua

Age 65 and over Age 45 to 64

200,000

300,000

160,000

people

people

240,000 180,000 120,000

80,000 40,000

60,000 0 2010

120,000

2011

2012

Age 45 to 64[male] : Papua Age 45 to 64[female] : Papua

2013

2014

2015 Date

2016

2017

2018

2019

2020

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Date Age 65 and over[male] : Papua Age 65 and over[female] : Papua

272

Figure 436. Changed in insurance status in Papua 3,500,000 3,000,000

POPULASI

2,500,000 2,000,000 1,500,000 1,000,000 500,000 -

TAHUN JKN

Jamkesda

Swasta

Tanpa asuransi

Summary of supply projection Figure 437. Papua gaps summary 3,787

4,000 3,500 3,000 2,500

1,951

2,000

1,632

1,500 895

1,000

754

52

500 (500)

physician in primary care (46)

physician in hospital

nurse in primary care

nurse in hospital

midwife

hospital bed (VVIP, VIP, I,II,III)

hospital bed (I,II,III)

273

Physician Figure 438. Papua Total Desired Physician Total physicians 700

physician

660 620 580 540 500 2014

2015

2016

2017 Date

2018

2019

2020

Practicing Physicians : Papua desired physicians : Papua desired physicians constrained : Papua

Figure 439. Papua total desired physician in hospital 350 300

physician

250 200 150 100 50 0 2014

2015

2016

Physicians in hospital

2017

2018

2019

2020

Desired physicians in hospital

Figure 440. Papua total desired physician in primary care 330 320

physician

310 300 290 280 270 260 250 2014

2015

2016

Physicians in primary care

2017

2018

2019

2020

Desired physicians in primary care

274

Table 210. Papua total desired physician

Total Physician Physician in primary care Physician in hospital

Widest gap 7

Gap in 2019 76

(46)

(4)

52

80

Nurse Figure 441. Papua total desired nurse Total nurses 9000 7200

nurse

5400 3600 1800 0 2014

2015

2016

2017 Date

2018

2019

2020

nurse capacity province total : Papua total desired nurses : Papua total desired nurses constrained : Papua

Figure 442. Papua total desired nurse in hospital 3500 3000

nurse

2500 2000 1500 1000 500 0 2014

2015

Nurses in hospital

2016

2017

2018

2019

2020

Desired nurses in hospital

275

Figure 443. Papua total desired nurse in primary care 6000 5000

nurse

4000 3000 2000 1000 0 2014

2015

2016

2017

Nurses in primary care

2018

2019

2020

Desired physicians in primary care

Table 211. Papua total desired nurse

Total nurse Nurse in primary care Nurse in hospital

Widest gap 5,439 3,787

Gap in 2019 6,673 4,524

1,632

2,149

Midwife Figure 444. Papua total desired midwife

Total midwives

midwife

3000

1500

0 2014

2015

2016

2017 Date

2018

2019

2020

practicing midwives in province : Papua desired midwife total : Papua

Table 212. Papua total desired midwife

Midwife

Minimum Surplus

Surplus in 2019

1,951

2,482

276

Hospital Bed Figure 445. Papua total hospital bed Hospital beds 4000

bed

3400 2800 2200 1600 1000 2014

2015

2016

2017 Date

2018

2019

2020

current IP capacity : Papua desired IP beds : Papua desired IP beds constrained : Papua

Table 213. Papua total hospital bed

Hospital bed (VVIP,VIP,I,II,III) Hospital bed (I,II,III)

Widest gap

Gap in 2019

895

1,001

754

856

277

STRENGTHS AND LIMITATIONS A single computer model form is applied to each province and to the national-level. Parameter values and initial conditions are estimated consistently. Thus, the projections provided here are comparable from province to province and province to country. The population projections begin with measured census data and apply birth and mortality rates consistently from year to year and across all provinces. A single standard of care is applied consistently from province to province and across all population cohorts. In the event that the reader wishes to update parameter values or change initial conditions, such changes to the simulation model will change results but will not affect the model logic (structure of equation). The study includes a significant number of predictions. However, the reader should consider that these predictions are more qualitative than quantitative: 1. Each province model comprises over one thousand equations that include 375 parameters and initial values. The research team estimated many of the parameters. Results should be reviewed by “system participants”, like Ministry of Health (MOH), Provincial Health Officers (PHO), National Health Insurance Corporation (BPJS Kesehatan), professional organizations (physicians, nurses, midwives), and healthcare facility managers. 2. Time series data about capacities such as the number of physicians, nurses, midwifes, hospitals beds, and clinical venues are not readily available, if at all. Therefore, no attempt was made to calibrate the models to reproduce past patterns of utilization. 3. Future health system conditions are partly a function of many policies such as local investment in insect control, portable water and public sanitation that affect infectious disease prevalence, and which are beyond the scope of this study. 4. Pharmaceuticals access—a significant feature of the health care system—is separately studied. 5. Birth and mortality rates are difficult to predict because they are affected by socio-economic conditions beyond the scope of this work, and therefore, each province model includes a population simulation based on current average birth and mortality rates. 6. Midwife over-capacity in all provinces warrants closer examination and possible revision of parameters. While the research team attempted to use recently measured data whenever it was available and to make reasonable estimates when it was not available, the study is a basic platform and provides a basis for health systems policy discussions.

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