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A Health Workforce Study Public Disclosure Authorized DIRECTIONS IN DEVELOPMENT Human Development Public Disclosure Authorized New Insights into the Provision of Health Services in Indonesia A Health Workforce Study Public Disclosure Authorized Claudia Rokx John Giles Elan Satriawan Puti Marzoeki Pandu Harimurti Elif Yavuz Public Disclosure Authorized New Insights into the Provision of Health Services in Indonesia New Insights into the Provision of Health Services in Indonesia A Health Workforce Study Claudia Rokx, John Giles, Elan Satriawan, Puti Marzoeki, Pandu Harimurti, and Elif Yavuz © 2010 The International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org E-mail: [email protected] All rights reserved 1 2 3 4 13 12 11 10 This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this volume do not necessar- ily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, col- ors, denominations, and other information shown on any map in this work do not imply any judgement on the part of The World Bank concerning the legal status of any territory or the endorsement or accept- ance of such boundaries. Rights and Permissions The material in this publication is copyrighted. Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law. The International Bank for Reconstruction and Development / The World Bank encourages dissemination of its work and will normally grant permission to reproduce portions of the work promptly. For permission to photocopy or reprint any part of this work, please send a request with complete infor- mation to the Copyright Clearance Center Inc., 222 Rosewood Drive, Danvers, MA 01923, USA; telephone: 978-750-8400; fax: 978-750-4470; Internet: www.copyright.com. All other queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2422; e-mail: [email protected]. ISBN: 978-0-8213-8298-1 eISBN: 978-0-8213-8299-8 DOI: 10.1596/978-0-8213-8298-1 Library of Congress Cataloging-in-Publication Data New insights into the provision of health services in Indonesia : a health work force study / Claudia Rokx . [et al.]. p. ; cm. — (Directions in development) Includes bibliographical references and index. ISBN 978-0-8213-8298-1 (alk. paper) — ISBN 978-0-8213-8299-8 1. Public health—Indonesia. 2. Public health personnel—Indonesia. 3. Medical personnel—Indonesia. I. Rokx, Claudia, 1964- II. World Bank. III. Series: Directions in development (Washington, D.C.) [DNLM: 1. Health Manpower—Indonesia. 2. Health Policy—Indonesia. 3. Health Services—supply & distribution—Indonesia. 4. Health Services Accessibility—Indonesia. 5. Quality of Health Care— Indonesia. W 76 N5313 2010] RA541.I55N49 2010 362.109598—dc22 2010002472 Cover photo: Antara foto Cover design: Naylor Design, Washington, D.C. Contents Foreword xi Acknowledgments xiii Abbreviations xv Overview1 Context and Background1 The Importance of the Indonesian Health Workforce2 Summary of Findings3 Policy Suggestions 8 Notes 12 References 13 Chapter 1 Introduction 15 Rationale and Objectives of This Report 16 The Focus of the Report 20 Structure and Outline of the Study 22 Notes 23 References 24 v vi Contents Chapter 2 Indonesia’s Health System and Policies Affecting the Health Workforce 25 Health Outcomes and the Health Workforce 25 Policies Affecting the Supply and Quality of the Health Workforce 32 Notes 37 References 38 Chapter 3 The Supply and Distribution of Health Practitioners and Health Facilities 41 Changes in the Supply of Health Practitioners, 1996–2006 42 Changes in Staffing at the Public Health Facilities, Puskesmas and Pustu, 1997–2007 47 Changes in the Supply of Public Health Facilities, 1996–2007 50 Notes 54 References 56 Chapter 4 Effects of Changes in the Supply of Health Workers on the Use of Health Services 57 Patterns in the Use of Services and Changes in Provider Choice, 1997–2007 57 Choice of Providers 60 Changes in the Supply of Private Health Services and Utilization 65 Notes 67 References 68 Chapter 5 The Quality of Public Health Facilities and Practitioners 71 Changes in the Structural Quality of Public Health Facilities: Puskesmas and Pustu 72 Measuring Diagnostic Ability Using Indonesia Family Life Survey Vignettes 76 Changes in Diagnostic and Treatment Ability over Time 77 Quality and In-Service Training 84 Changes in Quality and Growth of the Private Sector 85 Notes 87 References 88 Contents vii Chapter 6 Discussion and Policy Suggestions 91 Key Findings on Quantity and Distribution 92 Policy Suggestions on Quantity and Distribution 93 Key Findings Regarding Quality 96 Policy Suggestions Regarding Quality 97 Further Research Options: Provider Payment Methods 98 Notes 98 Appendix 1 Data Sources 99 Notes 100 Appendix 2 Definitions of Health Facilities and Providers 101 Appendix 3 Convergence in Quality 105 Quality Convergence by Region 107 Rural-Urban Differences in Quality Convergence 109 Differences in Quality Convergence by Socioeconomic Status 109 Appendix 4 Private Health Care Providers and Utilization 111 Growth of the Private Sector and Choice between Private and Public Sector Providers 113 Notes 121 Appendix 5 Health Provider Knowledge and the Private Sector 123 The Correlations between Training and Experience and Health Provider Knowledge 124 Appendix 6 Types of Incentives 129 Bibliography 131 Index 133 Box 5.1 Food for Thought—Unpacking the Health Production Function: Quality and Health Outcomes 73 viii Contents Figures 1.1 Factors that Affect Health Outcomes 22 2.1 Global Comparisons of Physician, Health Worker, and Hospital Bed Supply to Income 27 2.2 Life Expectancy and Infant Mortality versus Income, 2006 28 2.3 Maternal Mortality and Child Nutrition versus Income, 2000–06 29 2.4 Inequalities among Provinces in Infant and Child Mortality in Indonesia, 2007 31 3.1 Number of Puskesmas and Ratio of Puskesmas and Hospitals to Population, by Province, 2007 52 A3.1 Evidence of Convergence in Quality: Change in Community Average Vignette Scores, 1997–2007 106 A3.2 Regional Differences in Quality Convergence: Change in Community Average Vignette Scores, 1997–2007 108 A3.3 Rural-Urban Differences in Quality Convergence: Change in Community Average Vignette Scores, 1997–2007 110 Tables 2.1 Health Outcomes in Indonesia and Selected Countries, 2006 30 3.1 Distribution of Physicians in Indonesia,1996–2006 43 3.2 PTT Physicians Recruitment and Location Classification, 1992–2007 44 3.3 Distribution of Midwives in Indonesia, 1996 and 2006 45 3.4 Average Facility Staffing of Puskesmas and Pustu in Urban and Rural Settings, 1997–2007 47 3.5 Average Facility Staffing of Puskesmas and Pustu by Region, 1997–2007 48 3.6 Proportion of Puskesmas Physicians with Dual Practice, 1997 and 2007 49 3.7 Distribution of Physicians Providing Private Services in Indonesia, 1996–2006 53 3.8 Distribution of Private Midwife Practices in Indonesia, 1996–2006 53 4.1 Changes in Utilization of Health Services versus Self-Medication 58 Contents ix 4.2 Changes in Inpatient and Outpatient Utilization by PCE Quintile 59 4.3 Choice of Provider of Outpatient Services when Ill 61 4.4 Outpatient Services Utilization by Type and PCE Quintile 61 4.5 Choice of Outpatient Services Provider when Ill 64 4.6 Effect of Increasing the Number of Private Physicians on Probability that the Poor Will Visit a Facility when Ill 66 5.1 Structural Indicators and Quality Scores for Prenatal, Child Curative, and Adult Curative Care in 2007, by Clinical Setting 75 5.2 Structural Indicators and Quality Scores for Prenatal, Child Curative, and Adult Curative Care in 1997, by Clinical Setting 75 5.3 Clinical Case Required Standards of Diagnostic and Treatment Practice 78 5.4 Quality of Public Health Services in Indonesia, 1997–2007, by Region 79 5.5 Detailed Quality Scores for Prenatal, Child Curative, and Adult Curative Care by Urban–Rural and Public– Private Setting 79 5.6 Detailed Quality Scores on Prenatal, Child Curative, and Adult Curative Care Vignettes, by Clinical Setting, 2007 81 5.7 Competence Distribution of Public and Private Health Care Providers—Scores on Vignettes Measuring Diagnostic and Treatment Abilities 83 5.8 Types of Training and Experience with a Positive Effect on Provider Quality Shown by Vignette Scores 85 5.9 Effect of an Increase in Private Practices on Diagnostic Ability of Health Care Providers 86 A4.1 How Does Utilization of Outpatient Services Vary with Socioeconomic Status and Access to Private Health Providers? (Full Sample) 113 A4.2 How Does Utilization of Outpatient Services Vary with Socioeconomic Status and Access to Private Health Providers? (Urban Male Sample) 114 A4.3 How Does Utilization of Outpatient Services Vary with Socioeconomic Status and Access to Private Health Providers? (Urban Female Sample) 114 xContents A4.4 How Does Utilization of Outpatient Services Vary with Socioeconomic Status and Access to Private Health Providers? (Rural Male Sample) 115 A4.5 How Does Utilization of Outpatient Services Vary with Socioeconomic Status and Access to Private Health Providers? (Rural Female Sample) 115 A4.6 What Is the Relationship between Socioeconomic
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