New insights into the provision of health services in Indonesia : a health workforce study

D I R E C T I O N S I N D E V E LO P M E N T Human Development 73069 New Insights into the Provision of Health Services in Indonesia A Health Workforce Study Claudia Rokx John Giles Elan Satriawan Puti Marzoeki Pandu Harimurti Elif Yavuz 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: feedback@worldbank.org 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. 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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 Overview 1 Context and Background 1 The Importance of the Indonesian Health Workforce 2 Summary of Findings 3 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 x Contents 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 Status and the Choice between Public and Private Sector Outpatient Care? (Full Sample) 116 A4.7 What Is the Relationship between Socioeconomic Status and the Choice between Public and Private Sector Outpatient Care? (Urban Male Sample) 117 A4.8 What Is the Relationship between Socioeconomic Status and the Choice between Public and Private Sector Outpatient Care? (Urban Female Sample) 117 A4.9 What Is the Relationship between Socioeconomic Status and the Choice between Public and Private Sector Outpatient Care? (Rural Male Sample) 118 A4.10 What Is the Relationship between Socioeconomic Status and the Choice between Public and Private Sector Outpatient Care? (Rural Female Sample) 118 A4.11 Utilization and Quality (All Samples) 119 A4.12 Utilization and Quality (Urban Sample) 120 A4.13 Utilization and Quality (Rural Sample) 121 A5.1 Growth of the Private Sector and Change in District Average Prenatal Care Vignette Scores, 1997–2007 124 A5.2 Growth of the Private Sector and Change in District Average Child Curative Care Vignette Scores, 1997–2007 125 A5.3 What Is the Association between Training and the Prenatal Care Vignette Score? 126 A5.4 What Is the Association between Training and the Child Curative Care Vignette Score? 127 A5.5 What Is the Association between Training and the Adult Curative Care Vignette Score? 128 Foreword Indonesia has made improving the access to health workers, especially in rural areas, and improving the quality of health providers key priority areas of its next five-year development plan. Significant steps and policy changes were taken to improve the distribution of the health workforce, in particular the contracted doctors program and later the contracted midwives program, but few studies have been undertaken to measure the actual impact of these policies and programs. This study makes an effort to start reviewing the impacts of past poli- cies and policy changes. It links the changes in supply and quality of health workers to past policies in the area of health workforce but also to changes in financing and civil service reforms. In addition, very important aspects of health professional education and changes in demand for services are reviewed. The study findings show Indonesia’s progress in increasing the number of health workers and providing better access to health services, especially in remote areas. Although midwifery services are well distributed between urban and rural areas, general practitioners are not deployed equally. The study also presents interesting results regarding changes over time in health providers’ ability to diagnose and treat in the areas of prenatal, child curative, and adult curative care, using the Indonesia Family Life Survey. xi xii Foreword Based on the findings of the study and consultations with the government and with stakeholders in the area, suggestions for policy changes, further research topics, and areas for experimentation are laid out. The study described here provides valuable inputs to the government of Indonesia’s next five-year national development plan and the ongoing reforms of the health workforce that are part of the overall health sector reform, with the objective of strengthening Indonesia’s health system to improve health outcomes. The information and results in this study pro- vide important inputs to future work on health provider skills mix and composition to adapt to the changes in demand and need created by the demographic, epidemiological, and nutritional transitions that are taking place in Indonesia. Nina Sardjunani Deputy Minister for Human Resources and Cultural Affairs State Ministry for National Development Planning (Bappenas) Emmanuel Y. Jimenez Sector Director East Asia Human Development Sector World Bank Acknowledgments This report was prepared by a team led by Claudia Rokx (Lead Health Specialist, East Asia Human Development Sector Department, EASHD). The main authors are Claudia Rokx, John Giles (Senior Labor Economist, DECRG), Elan Satriawan (Assistant Professor, School of Economics, Gadjah Mada University), Puti Marzoeki (Senior Health Specialist, EASHD), Pandu Harimurti (Health Specialist, EASHD), and Elif Yavuz (doctoral student, Harvard University School of Public Health). The final report benefited from the comments of Magnus Lindelow (Senior Economist, EASHD), Jishnu Das (Senior Economist, DECRG), and Marko Vujicic (Health Economist, HDNHE). Other World Bank staff members and professionals who provided comments and assistance during the writing of the study include Eko Pambudi (Research Analyst, EASHD), George Schieber (Senior Health Policy Adviser, consultant), Ajay Tandon (Senior Economist, HDNHE), William Wallace (Lead Economist, EASPR), Jed Friedman (Senior Economist, DECRG), Christoph Kurowski (Sector Leader, LCSHD), Kenneth Chomitz (Senior Adviser, IEGWB), Pablo Gottret (Lead Economist, SASHD), Mariam Claeson (Program Coordinator, SASHD), Anna Revenga (Sector Director, PREMPR), Sandy Lieberman (Lead Health Economist, consultant), and Agnes Soucat (Adviser, AFTHE). Editorial assistance was provided by Chris Stewart and Mary Fisk. xiii xiv Acknowledgments On the government side, the team coordinated closely with, and bene- fited from, the valuable inputs, reviews, and consultations of, Nina Sardjunani (Deputy for Human Resources and Culture, Bappenas), Prof. Fasli Jalal (Director General of Higher Education, Ministry of National Education), Bambang Giatno (Chair of Board for Development and Empowerment of HHR), Arum Atmawikarta (Director for Health and Community Nutrition, Bappenas), Abdurrahman (Head of Center for HRH Planning and Empowerment, Ministry of Health [MoH]), Sri Wahyuni (Center for Health Development, MoH), Susilawaty (Head, Division of Program and Human Resources, Center for Medical Education Personnel, MoH), Hikmandari (Public Communication Department, MoH), Tati Suryati and Martuti Budiharto (Center for Research and Health Development, MoH), and Arsita Pudji Rahardjo (Special Assistant to the Director General, Higher Education, Ministry of National Education), and from professional associations—Prof. Hardyanto Soebono (Chairman of Doctor Council), Prof. Achir Yani S. Hamid (Chairman, PP–PPNI), and Harni Koesno (Chairman, PP–IBI). The team also acknowledges the assis- tance of a number of academics, including Prof. Laksono Trisnantoro of Gadjah Mada University, and Mardiati Nadjib of the University of Indonesia, and of Firman Witoelar of SurveyMeter. The team also benefited from inputs and assistance from the donor partners in health in Indonesia, in particular, Rosalia Sciortino (Health Adviser, AusAID), Ainsley Hemming (Program Development Specialist, AusAID), Khyn Win Win Sue (Child Survival and Development Cluster, UNICEF), and Franz von Roenne (Principal Health Adviser, Gesellschaft fur Technische Zusammenarbeit [GTZ]). The study was conducted under the general guidance of Joachim von Amsberg (Country Director, Indonesia), Emmanuel Jimenez (Sector Director, East Asia Human Development Sector Department), Juan Pablo Uribe (Health Nutrition and Population Sector Manager), and William Wallace (Lead Economist, Poverty Reduction and Economic Management). This study could not have been conducted without the generous sup- port from the Australian government’s aid agency, AusAID, and the UK Department for International Development (DFID). Abbreviations Askeskin Asuransi Kesehatan Masyarakat Miskin (Health Insurance for the Poor) Bappenas Badan Perencanaan Pembangunan Nasional (State Ministry for National Development Planning / Indonesian National Development Agency) BDD Bidan di Desa (village midwife) BKN Badan Kepegawaian Negara (National Civil Service Agency) BPPSDMK Badan Pengembangan dan Pemberdayaan Sumber Daya Manusia Kesehatam (National Institute of Health / Human Resources Development and Empowerment) BPS Badan Pusat Statistik (Central Bureau of Statistics) DEPKES Departmen Kesehatan (Ministry of Health) Desa village Desa Siaga alert village DHS Demographic and Health Survey EAP East Asia and Pacific GDP gross domestic product GDS Governance and Decentralization Survey GNI gross national income xv xvi Abbreviations IDI Ikatan Dokter Indonesia (Indonesian Medical Association) IFLS Indonesia Family Life Survey IMMPACT Initiative for Maternal Mortality Programme Assessment IMR infant mortality rate Jamkesmas Jaminan Kesehatan Masyarakat (Community Health Insurance Scheme) KKI Konsil Kedokteran Indonesia (Indonesian Medical Council) MENPAN Ministry of State Apparatus Reform MMR maternal mortality ratio MoH Ministry of Health MoNE Ministry of National Education NCD noncommunicable disease OTC over the counter PCE per capita expenditure PODES Potensi Desa (Survey of Village Potential) Polindes pondok bersalin desa (village midwife) Posyandu pos pelayanan terpadu (integrated health services post) PTT pegawai tidak tetap (contract employee) Puskesmas pusat kesehatan masyarakat (public health center) Pustu puskesmas pembantu (auxiliary health center) Riskesdas riset kesehatan dasar (basic health research) Overview This book is part of the inputs prepared at the request of the govern- ment of Indonesia’s national development agency, Bappenas, to inform the development of the next National Development Plan 2010–14. Other inputs include reports on health financing, fiscal space for health, health public expenditure review, and assessments of maternal health and pharmaceuticals. Context and Background Over the past decade, a number of important reforms and transitions have taken place in Indonesia and in the health sector in particular. They include the decentralization of responsibilities for service delivery to the district level; policy reforms of the incentive structure for health providers, espe- cially regarding compensation for service in remote areas; and policy changes to increase the supply of midwives in rural and remote areas. Demographic and epidemiological transitions have also occurred, causing changes in the pattern of disease prevalence in Indonesia. With chronic dis- ease on the rise, Indonesia now faces a double burden of disease. Resources for the health sector have steadily increased since the financial crisis in 1996 but remain low in comparison to those in other low-middle-income 1 2 New Insights into the Provision of Health Services in Indonesia countries (World Bank 2008). Private health practitioners are now pro- viding a large share of health care, and private institutions such as med- ical and midwifery schools are educating a large share of the incoming health workforce. The Indonesian government is committed to improving both financial and physical access to quality health care. Past and ongoing reforms aim to improve the supply, quality, and utilization of care to produce better health outcomes, particularly in remote areas and among the poor. Financial protection against catastrophic expenditures has improved sub- stantially since the introduction of the health insurance program for the poor, Askeskin/Jamkesmas. Furthermore, a number of legal acts have been used as the basis for improving the quality of Indonesian physicians. The Medical Practice Act (2004) supported the establishment of the Indonesian Medical Council (KKI), which produced standards for physi- cian competencies and medical education in 2006. Given the varying capacities of Indonesian medical schools, however, the standards are not implemented consistently, and, as a consequence, large and growing varia- tion in quality exists among schools and their graduates. The Importance of the Indonesian Health Workforce This study is concerned with the impact of the above-mentioned reforms on the Indonesian health care workforce. It is an area with great potential for improving health outcomes but also one that is complex and challenging. In Indonesia, some key health workforce challenges relate to (a) limited supply of health care providers at the primary as well as the hospital level; (b) payment systems that do not encourage an optimal distribution of health workers, equitable access to care, and effi- cient provision of services; (c) shortcomings in the quality of maternal and child care, as well as adult care; (d ) lack of oversight and effective licensing in an expanding private health sector; and (e) continuing chal- lenges related to planning, recruitment, and retention of health workers, particularly since decentralization. Given the slow progress in improving health outcomes and limited evi- dence linking health performance and the health workforce in Indonesia, a pressing need exists to make more information available about past experiences to inform future policy changes. This study seeks to con- tribute to the government of Indonesia’s broader health system assess- ment by answering key health workforce questions. It examines changes in the supply and quality of health service providers and practitioners and,  Overview 3 where possible, links those changes with past and ongoing reforms. Based on these analyses, the study provides policy suggestions for the areas in need of reform. Summary of Findings Study findings highlight the importance not only of improving the sup- ply of health care, but also of improving quality, so as to improve health outcomes. Over the period studied, important gains in the determinants of health outcomes have occurred in Indonesia. At the same time, how- ever, the study shows that Indonesia, despite the significant gains, contin- ues to suffer from serious challenges in the number and distribution, and in particular the quality, of its health workers. Supply of Health Facilities and Health Practitioners Indonesia’s health policy, “Healthy Indonesia 2010,