Indonesia : Supporting Essential Health Actions and Transformation Program
The proposed results-based lending (RBL) program will support the Ministry of Health (MOH) of Indonesia to implement a nationwide primary care transformation that increases access to quality gender- and climate-responsive primary care services. It builds on earlier Asian Development Bank (ADB) support in responding to the coronavirus disease (COVID-19) pandemic and aims to accelerate implementation of the Government of Indonesia's post-pandemic Health System Transformation Agenda (HSTA). The program will standardize a model of integrated primary care and strengthen public health laboratories, improve the capacity of primary care and laboratory workers (including climate awareness and gender responsiveness), and enhance digital coordination and reporting systems. The program results are aligned with the National Medium-Term Development Plan 2020-2024 and the MOH Strategic Plan 2020-2024.
Banzon, Eduardo P.
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|Supporting Essential Health Actions and Transformation Program
|Country / Economy
|Project Type / Modality of Assistance
|Source of Funding / Amount
|OP1: Addressing remaining poverty and reducing inequalities
OP2: Accelerating progress in gender equality
OP3: Tackling climate change, building climate and disaster resilience, and enhancing environmental sustainability
OP6: Strengthening governance and institutional capacity
|Sector / Subsector
Health / Health sector development and reform
|Gender equity theme
|The proposed results-based lending (RBL) program will support the Ministry of Health (MOH) of Indonesia to implement a nationwide primary care transformation that increases access to quality gender- and climate-responsive primary care services. It builds on earlier Asian Development Bank (ADB) support in responding to the coronavirus disease (COVID-19) pandemic and aims to accelerate implementation of the Government of Indonesia's post-pandemic Health System Transformation Agenda (HSTA). The program will standardize a model of integrated primary care and strengthen public health laboratories, improve the capacity of primary care and laboratory workers (including climate awareness and gender responsiveness), and enhance digital coordination and reporting systems. The program results are aligned with the National Medium-Term Development Plan 2020-2024 and the MOH Strategic Plan 2020-2024. All Indonesians will benefit from the program, particularly the poor, women and children, and other vulnerable groups who rely more heavily on primary health services.
|Project Rationale and Linkage to Country/Regional Strategy
Socio-economic context. Indonesia enjoyed steady economic growth with an average gross domestic product (GDP) growth rate of about 5.0% per year between 2009 and 2019, but the economy contracted by 2.1% in 2021 due to mobility restrictions needed to manage the pandemic. With restrictive measures lifted, Indonesia is recovering with annual GDP growth of 3.7% in 2021 and 5.3% in 2022 with projected growth of 4.8% in 2023 and 5.0% in 2024. The poverty rate fell to 9.6% in 2022 from 10.2% in 2020. The unemployment rate fell to 5.9% in 2022 from 7.1% in 2020. The pandemic highlighted the importance of a strong and responsive health system, particularly primary care, in helping sustain economic growth and poverty reduction.
Health status and challenges. While Indonesians' health has improved steadily since 2010, the pandemic reversed some prior gains. Life expectancy had increased from 68.7 years in 2010 to 70.5 years in 2019 but fell back to 68.8 years in 2020. The maternal mortality ratio decreased from 219 (per 100,000 live births) in 2010 to 157 in 2019, then increased to 173 in 2020. The infant mortality rate declined steadily from 27.9 (per 1,000 live births) in 2010 to 20.1 in 2019 and 19.5 in 2020. Indonesia's performance on key population health indicators trails behind that of Viet Nam, which has a similar level of gross national income per capita, as well as those of richer countries in Southeast Asia such as Thailand and Malaysia.
Indonesia is in an epidemiological transition and faces a double burden of disease with the coexistence of communicable diseases and noncommunicable diseases (NCDs). Tuberculosis, dengue fever, malaria, HIV/AIDS, lymphatic filariasis, and other neglected tropical diseases are still of significant concern. The incidence of tuberculosis decreased to 301 per 100,000 people in 2020 from 342 in 2010 but remains higher compared to Malaysia (90), Thailand (144), and Viet Nam (171). Polio re-emerged in Indonesia in 2023 after the country was declared polio-free in 2014. Noncommunicable conditions have become the top causes of mortality including stroke, ischaemic heart disease, diabetes mellitus, and hypertensive heart disease. Nutrition challenges persist, with the prevalence of stunting and obesity among children under 5 years of age estimated at 21.6% (stunting) and 3.5% (obesity) in 2022. Stunting and malnutrition threaten the long-term economic productivity of the population, with its cost estimated at 2%-3% of GDP.
Recovering from the pandemic. Indonesia was severely impacted by COVID-19 with a total of 6.8 million confirmed cases and 161,918 confirmed deaths reported as of 12 September 2023. Indonesia experienced three waves of strong outbreaks in January and July 2021 and in February 2022, with more than 10,000 daily confirmed new cases. Key population health indicators were negatively impacted. The pandemic caused the disruption of the immunization program and declining vaccine coverage, resulting in the re-emergence of polio. There are some signs of post-pandemic recovery including the restoration of essential health services and increased investments for long-term recovery and resilience.
Gaps in primary care delivery and financing. Prevention and management of many communicable diseases and NCDs require effective primary care and community outreach programs. In Indonesia, primary care services are provided by puskesmas (community health centers), pustus (auxiliary puskesmas or government sub-health clinics), poskedes (village health posts), klinik pratama (private primary care clinics), and posyandu (integrated service post). Currently, primary care services are unable to meet people's needs and expectations because of a lack of integration and standardization of primary care services and because primary care services are carried out by disease-based programs (e.g., malaria program or tuberculosis program) rather than based on client needs and a life-cycle approach. There are inadequate and maldistributed primary care workers with capacity gaps due to a lack of structured recruitment and training. Ensuring consistency in the quality of services provided by kaders spread all over the country is difficult. Shortages in medical equipment and consumables hinder the continuous provision of health services. The 2019 Health Facility Research Study determined that only 75% of puskesmas can handle a complete set of 144 diagnoses and only 77% can provide the full services needed for antenatal, delivery, and postnatal care. Primary care financing is fragmented and dependent on sub-national government priorities and capacities, resulting in insufficient financing to procure necessary health equipment, ensure adequate staffing, sustain provision of quality services, and address geographic inequality.
Climate change and health. The government's National Health Adaptation Plan (NHAP) recognizes that climate change results in increased intensity of heat, extreme rainfall, sea-level rise, and air pollution, which in turn trigger health risks. These include heightened risks for communicable diseases and NCDs, and nutritional problems. A conservative estimate of the potential losses resulting from changes in climate-related diseases is around 1.86% of GDP. In the Enhanced Nationally Determined Contribution of Indonesia, health is identified as a priority sector, and multiple health actions are required to address vulnerabilities to climate change. By 2045, 11 cities in Indonesia are projected to be highly vulnerable to vector- and water-borne diseases, such as dengue, malaria, and diarrhea. These climate-sensitive health risks disproportionately affect those most vulnerable and disadvantaged including women, children, ethnic minorities, low-income families, migrants, elderly, and people with disabilities. The NHAP includes risk and vulnerability mapping based on climate variability, and health and socioeconomic indicators which inform health interventions and preparedness plans, with focus on vulnerable groups. The NHAP calls for increased national capacity in building health systems and health sectors that are ready and resilient to climate change, particularly the readiness and resilience of primary care services.
Indonesia's Health System Transformation Agenda. To strengthen the health system, address the country's health needs, and respond to future pandemics and climate change, the government has launched the HSTA, in alignment with its National Medium-Term Development Plan 2020-2024. The comprehensive HSTA program has six pillars that aim at the transformation of: (i) primary care, to promote health, prevent diseases, and improve capacity and capability of primary care; (ii) secondary care, to increase access to and quality of diagnosis, treatment, and specialty care at the secondary level; (iii) health system resilience, to promote self-reliance in the pharmaceutical and medical devices sector and enhance resilience against health emergencies; (iv) health financing, to achieve accessible, sufficient, and sustainable allocation and efficient utilization of financing for health; (v) health talent, to increase the supply and quality of needed human resources for health; and (vi) health technology, to maximize the use of technology, digitalization, and biotechnology in the health sector. The MOH reframed its budget to focus financing for the six pillars, and it is strengthening its capacity for implementing the HSTA including enhancing its policy and strategy, implementation support, and monitoring system.
Primary care transformation. The vision for a transformed and strengthened primary care system is an expanded network of primary care providers that implements lifecycle-based standardized care, supported by revitalized tier-1 labkesmas (public health laboratories) capable of early detection and surveillance. The aim is to expedite further reductions in, among others, maternal mortality, neonatal and child mortality, stunting, and tuberculosis, and NCDs through improved primary and secondary prevention services. The transformation emphasizes integrating and standardizing health services in primary care facilities and labkesmas. The lifecycle-based approach also considers emerging health needs for older people and adolescents, as well as mental health. It will strengthen health promotion and community empowerment and expand community-based maternal and child health care, elderly care, and mental health services, including recognizing and handling of gender-based violence. It will promote the use of digital tools in primary care and tier-1 labkesmas and the various information platforms related to health and climate change. It aims to improve the quality and competitiveness of health human resources, including their increased awareness of climate change, and the adoption of mitigation and adaptation measures against climate change.
Justification for results-based lending. The proposed program will support primary care transformation measures, as well as health talent and health technology transformation measures that support primary care transformation. The RBL modality is deemed the most suitable as it (i) supports the government-owned HSTA program and the commitment to implement these reforms; (ii) creates incentives for the government to deliver results against the program targets; (iii) drives performance-based financing allocation; and (iv) helps the government focus on critical results and system reforms, rather than specific transactions and expenditures. The RBL program will promote institutional development and help strengthen MOH institutional capacity, particularly for the Directorate General of Public Health and the Bureau of Planning and Budgeting, in reform planning and implementation, procurement, monitoring, and evaluation. The RBL program will help design and integrate gender and climate change mainstreaming activities under the HSTA. It will lead to improved service readiness of primary care and tier-1 labkesmas and the widespread adoption of digital tools and interoperability of health information systems. The MOH has strong ownership of the HSTA program and has demonstrated institutional capacities to implement World Bank program-for-results financing, which is similar to the RBL modality. It will also help leverage and catalyze increased government and development partner resources for the reforms supported by the RBL program.
The RBL program is aligned with ADB's Strategy 2030 operational priorities (OPs), specifically: OP1 (addressing remaining poverty and reducing inequalities) by enhancing population health and universal health coverage; OP2 (accelerating progress in gender equality) by improving responsiveness of primary care services to the needs of women and vulnerable populations; OP3 (tackling climate change, building climate and disaster resilience, and enhancing environment sustainability) by promoting climate-change awareness and green practice in health care; and OP6 (strengthening governance and institutional capacity) by supporting MOH in policy development and implementation. The program will contribute to achieving the Sustainable Development Goals (SDGs) for health (SDG 3), including accelerating the reductions in maternal and child mortality (SDGs 3.1 and 3.2), childhood stunting (SDG 2.2), and strengthening disease control through improved access to quality primary care services and laboratory services. It will also contribute to eliminating all forms of violence against women and girls (SDG 5.2) and help ensure universal access to sexual and reproductive health services (SDG 5.6). It will also support SDG 13a to mobilize climate financing from all sources.
Maternal and child mortality reduced and disease control and nutrition status improved
|Description of Outcome
Access to quality gender- and climate-responsive primary care services increased
|Progress Toward Outcome
|Description of Project Outputs
Life cycle-based integrated and standardized primary care model adopted and strengthened
Public health laboratories in primary care strengthened
Capacity of primary care and public health laboratory workers, including climate awareness and gender responsiveness, improved
Digital coordination and reporting of integrated primary care services and public health laboratories expanded
|Status of Implementation Progress (Outputs, Activities, and Issues)
|Summary of Environmental and Social Aspects
|Stakeholder Communication, Participation, and Consultation
|During Project Design
|During Project Implementation
|The TA will provide a total of 25 person-months of international consultants and 150 person-months of national consultants to (i) facilitate program implementation, and (ii) strengthen the institutional and operational capacity of the program agencies. ADB will engage the individual consultants via individual consultancy selection following the ADB Procurement Policy (2017, as amended from time to time) and its associated project administration instructions and/or staff instructions.
|Procurement will follow the ADB Procurement Policy (2017, as amended from time to time) and Procurement Regulations for ADB Borrowers (2017, as amended from time to time).
|Responsible ADB Officer
|Banzon, Eduardo P.
|Responsible ADB Department
|Responsible ADB Division
|Human and Social Development Sector Office (SG-HSD)
Ministry of Health
|01 May 2023 to 05 May 2023
|17 Nov 2023
|Last Review Mission
|Last PDS Update
|17 Nov 2023
|17 Nov 2023
|22 Nov 2023
|28 Dec 2023
|30 Jun 2026
|Total (Amount in US$ million)
|Cumulative Contract Awards
|06 Jan 2024
|06 Jan 2024
|17 Nov 2023
|30 Jun 2026
|Financing Plan/TA Utilization
|06 Jan 2024
Project Data Sheets (PDS) contain summary information on the project or program. Because the PDS is a work in progress, some information may not be included in its initial version but will be added as it becomes available. Information about proposed projects is tentative and indicative.
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|Loan Agreement (Ordinary Operations) for Loan 4381-INO: Supporting Essential Health Actions and Transformation Program
|Loan Agreement (Ordinary Resources)
|Supporting Health System Transformation for Improved Primary Care: Technical Assistance Report
|Technical Assistance Reports
|Supporting Essential Health Actions and Transformation Program: Program Implementation Document
|Project/Program Administration Manual
|Supporting Essential Health Actions and Transformation Program: Report and Recommendation of the President
|Reports and Recommendations of the President
|Supporting Essential Health Actions and Transformation Program: Initial Poverty and Social Analysis
|Initial Poverty and Social Analysis
Safeguard Documents See also: Safeguards
Safeguard documents provided at the time of project/facility approval may also be found in the list of linked documents provided with the Report and Recommendation of the President.
|Supporting Essential Health Actions and Transformation Program: Program Safeguard Systems Assessment
|Program Safeguard Systems Assessments
|Supporting Essential Health Actions and Transformation Program: Draft Program Safeguard Systems Assessment
|Program Safeguard Systems Assessments
Evaluation Documents See also: Independent Evaluation
None currently available.
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The Access to Information Policy (AIP) establishes the disclosure requirements for documents and information ADB produces or requires to be produced in its operations to facilitate stakeholder participation in ADB's decision-making. For more information, refer to the Safeguard Policy Statement, Operations Manual F1, and Operations Manual L3.
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