Setting priorities for healthcare interventions in Indonesia: a comprehensive conceptual framework – International Journal for Equity in Health

Report on Strategic Health Priority Setting for Sustainable Development Goals

Introduction: Aligning Health Systems with the 2030 Agenda

Effective priority setting in healthcare is fundamental to achieving Universal Health Coverage (UHC) and, consequently, the broader Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being). The allocation of finite resources requires transparent, evidence-based frameworks to address competing health needs, a challenge prominently faced by lower and middle-income countries like Indonesia. This report synthesizes key principles from existing literature to outline a strategic approach to health priority setting, emphasizing its role in reducing health inequalities (SDG 10) and fostering robust partnerships (SDG 17).

The Imperative for Priority Setting: Addressing Indonesia’s Health Landscape

Indonesia’s progress towards the SDGs is contingent on its ability to manage a complex public health landscape. Strategic resource allocation is not merely a financial exercise but a critical component of sustainable development, ensuring that investments yield the greatest impact on population health and equity.

Addressing the Double Burden of Disease for SDG 3.4

A primary challenge is the “double burden” of disease, where the nation confronts both communicable and non-communicable diseases (NCDs). This dual challenge strains health systems and complicates resource allocation.

• Chronic NCDs: The rising prevalence of hypertension, diabetes, and cardiovascular diseases imposes a significant economic and social burden, directly impeding progress on SDG Target 3.4 (reduce by one-third premature mortality from NCDs).
• Infectious Diseases: Endemic and emerging acute virus infections continue to demand resources for surveillance, prevention (e.g., vaccination), and treatment.

Achieving Universal Health Coverage (SDG 3.8)

Indonesia’s National Health Insurance scheme (JKN) is a cornerstone of its commitment to UHC, a key target of SDG 3.8. Effective priority setting is essential to ensure the sustainability and equity of the JKN program.

1. Financial Protection: UHC aims to protect households from catastrophic health expenditure, a critical factor in poverty reduction and achieving SDG 1 (No Poverty).
2. Equitable Access: Ensuring that UHC reduces urban-rural disparities and improves access for all socioeconomic groups is vital for advancing SDG 10 (Reduced Inequalities).
3. Service Quality: Prioritization must extend beyond coverage to include the quality and availability of essential health services, from maternal health to long-term care.

Frameworks for Evidence-Informed and Equitable Decision-Making

To align with the principles of the SDGs, priority-setting processes must be systematic, transparent, and inclusive. Several methodologies are available to guide decision-makers.

Health Technology Assessment (HTA)

HTA is a critical tool for making evidence-based decisions about which health interventions, medicines, and technologies should be publicly funded. Institutionalizing HTA supports the development of effective and accountable institutions, a component of SDG 16.

• Cost-Effectiveness Analysis: Evaluates whether the health gains from an intervention (measured in metrics like Quality-Adjusted Life Years or Disability-Adjusted Life Years) justify its cost.
• Budget Impact Analysis: Assesses the financial affordability of adopting a new intervention within the existing health budget, ensuring fiscal sustainability.
• Evidence Synthesis: Involves systematic reviews of clinical effectiveness, economic evaluations, and real-world data to inform policy.

Multi-Criteria Decision Analysis (MCDA)

MCDA provides a framework for making decisions based on multiple, explicit criteria, moving beyond cost-effectiveness alone. This approach is crucial for integrating equity and other social values into priority setting, directly supporting SDG 10.

Key Criteria in MCDA Frameworks:

1. Disease Severity and Burden: Prioritizing conditions with the highest impact on population health.
2. Effectiveness of Intervention: The proven ability of an intervention to improve health outcomes.
3. Cost-Effectiveness and Affordability: Ensuring efficient use of resources.
4. Equity and Fairness: Considering the impact on disadvantaged populations and reducing health disparities.
5. Feasibility and Acceptability: Assessing the practical, cultural, and political viability of implementation.

Stakeholder Engagement and Accountability

Engaging a wide range of stakeholders—including patients, community leaders, healthcare providers, and policymakers—is essential for legitimate and sustainable decision-making. This participatory approach embodies the spirit of SDG 17 (Partnerships for the Goals).

• Accountability for Reasonableness (A4R): A framework ensuring that priority-setting decisions are transparent, based on relevant evidence and values, and subject to appeal and revision.
• Deliberative Processes: Methods like the Delphi technique and Nominal Group Technique can be used to achieve consensus among diverse expert and public groups.

Conclusion: Integrating Priority Setting into the National SDG Strategy

Strategic priority setting is an indispensable tool for accelerating progress towards the health-related SDGs in Indonesia and globally. By systematically applying evidence-based and value-driven frameworks like HTA and MCDA, health systems can optimize resource allocation to address the most significant disease burdens, reduce inequalities, and ensure the financial sustainability of Universal Health Coverage. Fostering transparent, accountable, and participatory decision-making processes will build resilient health systems capable of meeting the transformative ambitions of the 2030 Agenda for Sustainable Development.

Analysis of Sustainable Development Goals in the Article

SDG 3: Good Health and Well-being

This is the most prominent SDG throughout the article’s references. The core themes revolve around improving health outcomes, strengthening healthcare systems, and ensuring access to care, which are central to SDG 3.

• Universal Health Coverage (UHC): Numerous references discuss the implementation, challenges, and impact of national health insurance schemes, particularly Indonesia’s Jaminan Kesehatan Nasional (JKN), and the broader goal of UHC. This includes topics like financial protection, access to services, and health financing (Refs 16, 35, 45, 96, 97, 98, 222, 223, 245, 246).
• Non-Communicable Diseases (NCDs): The article highlights the significant burden of chronic and non-communicable diseases such as cardiovascular disease, hypertension, diabetes, and cancer. It addresses their costs, risk factors, and the need for prioritization and prevention (Refs 7, 8, 12, 29, 43, 47, 56, 63, 64).
• Health Systems Strengthening: There is a clear focus on improving healthcare infrastructure, strengthening the health workforce, and enhancing health technology assessment (HTA) to support policy and decision-making (Refs 6, 21, 36, 79, 80, 229, 230, 241, 243).
• Access to Medicines and Vaccines: Several references mention the importance of access to affordable medicines and the introduction of vaccination programs (e.g., rotavirus), including their cost-effectiveness and public acceptance (Refs 19, 34, 38, 48, 64, 109, 218, 219).

SDG 10: Reduced Inequalities

The article addresses the issue of inequality within the context of health, which is a key component of SDG 10. The references explore disparities in health access and outcomes among different population groups.

• Health Equity: The theme of fairness, equity, and reducing disparities in healthcare is explicitly and implicitly discussed. This includes urban-rural disparities in hospital utilization, socioeconomic inequality in health outcomes, and the impact of health insurance on inequality (Refs 16, 17, 33, 116, 117, 118, 121, 122, 128, 135).
• Inclusion of Vulnerable Populations: The challenges of extending health coverage to the poor and those in the informal sector are highlighted, pointing to the need for inclusive policies to ensure no one is left behind (Refs 25, 227, 228, 246).

SDG 17: Partnerships for the Goals

The importance of collaboration to achieve health goals is a recurring theme, aligning with the principles of SDG 17.

• Multi-stakeholder Collaboration: The references mention the role of public-private partnerships, community participation, and intersectoral collaborations in strengthening the health workforce, implementing health programs, and making decisions (Refs 21, 22, 127, 219, 220, 235, 265). This emphasizes that achieving complex goals like UHC requires cooperation between government, the private sector, and civil society.

Specific Targets Identified

Targets under SDG 3: Good Health and Well-being

• Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. This target is directly relevant to the numerous references discussing the burden, costs, and management of NCDs like cardiovascular disease, diabetes, and hypertension in Indonesia and other low- and middle-income countries (Refs 7, 29, 43, 47, 63, 64).
• Target 3.8: Achieve universal health coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. This is the most central target, supported by a vast number of references focusing on Indonesia’s national health insurance (JKN), health financing challenges, access to care, and the overall goal of UHC (Refs 16, 45, 96, 97, 222, 223, 224, 225, 226, 240, 245, 246).
• Target 3.b: Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines. This is addressed in references concerning the economic evaluation, prioritization, and public acceptance of vaccines (e.g., rotavirus, pneumococcal) and the management and pricing of medicines under national insurance schemes (Refs 19, 34, 48, 64, 217, 218, 219).
• Target 3.c: Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries. This target is reflected in discussions about strengthening Indonesia’s health workforce, addressing healthcare gaps in rural/remote areas (“healthcare deserts”), and the importance of human resources for achieving UHC (Refs 21, 165, 230, 231, 241, 256, 267, 268).

Target under SDG 10: Reduced Inequalities

• Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status. In the context of this article, this target relates to ensuring equitable access to healthcare. The references on urban-rural disparities, socioeconomic inequality in health, and the need to cover the poor and informal workers align with reducing health inequalities and promoting inclusion in health systems (Refs 17, 118, 119, 121, 227, 228).

Target under SDG 17: Partnerships for the Goals

• Target 17.17: Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships. This is relevant to references that discuss strengthening health systems through partnerships, the role of the private sector, and multi-stakeholder collaborations for decision-making in health (Refs 21, 22, 265).

Indicators for Measuring Progress

While the article does not present raw data, the research topics cited imply the use of specific indicators to measure progress towards the identified targets.

• Indicator 3.8.1 (Coverage of essential health services): This is implicitly measured in studies that analyze the “impact of national health insurance on access to public health services” (Ref 23), “hospital utilization” (Ref 17), and the development of “essential packages of care” (Ref 240). The UHC Service Coverage Index is a key tool for this.
• Indicator 3.8.2 (Proportion of population with large household expenditures on health): This is directly implied in references that analyze “catastrophic health expenditure” and “financial protection” under health insurance schemes (Refs 234, 247). These studies measure the financial burden of healthcare on households.
• Indicator 3.4.1 (Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease): Progress towards this is measured using metrics like “Disability-Adjusted Life Years (DALYs),” “burden of disease,” and mortality estimates for NCDs, which are central themes in many of the cited global and national health studies (Refs 7, 39, 40, 42, 44, 47, 53, 54, 60, 61).
• Indicator 3.c.1 (Health worker density and distribution): This is the underlying metric for studies on “strengthening Indonesia’s health workforce” (Ref 21), bridging gaps in “healthcare deserts” (Ref 165), and analyzing human resources as a critical component for UHC (Refs 230, 241, 256).

Source: equityhealthj.biomedcentral.com