Role of International Partners

in the Development of SHI in

Middle Income Countries
Indonesian Health Economics
Association meeting in Yogyakarta,
November 26-27, 2008

David W. Dunlop, AusAID Health

Adviser
 Order of Presentation
• Main Principles of International Assistance
• Common Understandings
• Ways to Help
• How AusAID has Contributed to Date
• How not to Help
• Conclusions
 I Main Principles of International
Assistance
• Paris Declaration Principles
– Ownership
– Alignment
– Harmonization/Coordination
– Managing for Results
– Mutual Accountability
 Principles in Context of SHI
Development in Indonesia
• The partner country must be in the driver’s
seat.
• Must focus on the development objectives
of the country
• Must contribute to government’s efforts to
resolve development problems
 Australia/Indonesia Partnership
Principles
GOI must request assistance
Together we:
develop a program of work
define modalities of working
report on progress
monitor for results

A Basic Question for AusAID Is whether the Activity is

aligned with Indonesia’s Medium Term Development
Plan (MTDP)?
 II Shared Understandings Re:
SHI

• Importance of improving the financing of

the health sector
• SHI has potential for improving the
sector’s financing.
• SHI should be pro-poor and improve
equity of access to improved quality
service
• There is a legal and political imperative to
expand coverage to the total population.
 III How Can Donors Contribute?
• Support the GOI’s role as the driving force
moving the SHI development forward.
• Be supportive of the newly appointed
Presidential Commission for developing
the implementation guidelines for law
40/2004.
• Undertake specific tasks which Indonesia
requests, e.g., independent option
formulation.
 Donor Contribution? 2
• If there are basic informational gaps
required for sustainability e.g.,
– health care cost analysis, or
– claims processing,
we can work in alignment with Indonesian
experts to obtain this information.
 Donor Contribution? 3
• Facilitate the process of learning about
design options, including the possibility of
the use of study tours to exemplar
localities (e.g., Korea, Japan, Germany,
Argentina or Brazil)
• Facilitate training personnel to manage
and/or implement SHI.
 IV AusAID Contributions to Date
• Working in accordance with AusAID’s
Principles of engagement with Indonesia
we have:
– Investigated with PPJK concurrence the
status of existing sub-national health
insurance and free care schemes operational
for at least a year
– developed a better practice guide to sub-
national schemes (in preparation).
AusAID Contributions to Date -2
– Together we have analysed the main
implementation issues found in the existing
schemes which has not only sub-national
importance but also broader national salience.
• Premium setting
• Coverage of the population – voluntary
schemes and the issue of Adverse
Selection
 Potential Future Activities Under
Consideration by AusAID
• Work with sub-national entities to improve
design for achieving practices which can
achieve sustainability and broaden
coverage.
• Develop a well trained cadre for managing
SHI at all levels
• Ensure a) equity of access, b) financial
protection of the poor, and c) higher quality
health services
 V How Not to Contribute
• Driving the agenda rather than following or
waiting for the guidance of all Indonesian
stakeholders

• Sticking to theoretical principles rather

than tailoring options for practical
implementation within Indonesia’s social
and political context.
 How Not to Contribute, 2
• Putting the cart before the horse given
resource constraints, including:
Setting premiums too low, or
Developing benefit packages that
cannot be delivered
• Debating the existence of sub-national
schemes when developing Law 40
guidelines given decentralization guidance
from parliament and constitutional court
 VI Conclusions
• AusAID wants to work on SHI according to the
Paris Principles: Ownership, Alignment,
Harmonization, Results, and Accountability.
• There are many roads to the development of
SHI. We want to help where you want support to
extend coverage and set appropriate premiums.
We do not come to the Table with one approach
or Design.
• Interested in supporting the GOI implement
programs for which it has made a commitment,
as is currently the case with Jamkesmas.