Health inequities occur when health services are not accessible or utilized by certain people, based on their gender, socio-economic status, ethnicity, geographic residence, or other characteristic. These inequities can result from a lack of resources required to meet the needs of vulnerable populations. The majority of health expenditures support hospitals and tertiary care; less than 25% of health expenditures reach the primary level, where most marginalized populations seek care. Consequently, disadvantaged populations are at much higher risk of adverse health outcomes. In order to improve equity and ultimately reduce maternal, newborn, and child mortality, health spending must be targeted toward disadvantaged or high risk groups.
In Indonesia, health funding decisions are made at the local level. An Evidence Based Planning and Budgeting (EBP) process was pilot tested in three districts of Papua (Boven Digoel, Jayawijaya, and Kepulauan Yapen) to train decision makers at the local level to better plan and allocate funds to match health needs. TRAction supported the development of a case study to understand how the new planning approach influences health budgeting at the local level, and to determine if health equity is considered during the planning and budgeting process.
Indonesia: Papua Province
The aim of this study was to determine the impact of Evidence Based Planning and Budgeting on equitable health service delivery. Research questions include:
The study employed both quantitative and qualitative methods to determine: 1) if funding was allocated more equitably as a result of the EBP initiative, and 2) if and how equity is considered in the budgeting process.
Quantitative data was collected through a detailed, line-item review of District Health Office budget documents before and after the EBP process was initiated. In addition, budget and program data from rural and urban Puskesmas (health centers) was collected. The data was analyzed to determine whether there were changes in the percent of money allocated for community-based versus facility-based programs, and for remote versus non-remote areas. Equitable spending was defined as larger percent increases for community-based programs and for remote areas.
Qualitative interviews were conducted after the initial quantitative analysis is completed. Interviews were done with key staff from the District and Puskesmas levels who were involved in the EBP initiative. The interviews sought to determine what factors influence the achievement of equitable MNCH budget allocation.
The research showed an increase in the MNCH budget of Boven Digoel and Kepulauan Yapen districts, while Jayawijaya district experienced a decreased MNCH budget between 2011 and 2013. Boven Digoel demonstrated an improvement in equitable budgeting although budget allocation for remote areas was still lower than expected. Jayawijaya experienced a more equitable budget allocation and program allocation. However, in Yapen neither equitable budgeting nor equitable program allocation was achieved. Several factors were found to contribute to the findings, including political commitment of local government and local DHO, district budget ceiling, availability of other sources of funding, and coordination between DHO, Bappeda and cross sectorial agencies due to EBP workshops and monitoring-evaluation visits.
This study found that several aspects of the EBP approach were beneficial for district health planners, including the emphasis on the use of local data and the workshops that brought different institutions together to discuss health issues. The study also identified a handful of external factors that influenced district health-planning processes. These include the budget ceiling, availability of other financing resources, local government commitment, and existing inter-sectorial coordination, among others. Future EBP planning initiatives must consider such external factors in order to achieve the project’s intended goal. These factors should be addressed through a more systematic approach in combination with governance strengthening initiatives.
This case study determined the impact of Evidence Based Planning and Budgeting on equitable resource allocation for maternal and child health programming. The results of this study will be shared with the Indonesian government to inform how EBP can be improved before scaling up the initiative. In addition, TRAction will synthesize the findings from this and four other equity studies to gain a global understanding of factors influencing access and utilization of facilities for delivery. Experience from this study and other TRAction projects will be used to develop qualitative research training tools
Principal Investigator: Tiara Marthias