of Health Services in Indonesia:

Transcription

1 New Insights into the Supply and Quality of Health Services in Indonesia: A Health Workforce Study 1 (C. ROKX, J. GILES, E. SATRIAWAN, P. HARIMURTI, P. MARZOEKI & E. YAVUZ) PRESENTED BY: ELAN SATRIAWAN DEPT OF ECONOMICS UNIVERSITAS GADJAH M ADA

2 Main Research Questions 2 How has the supply of health facilities and providers, including private, changed over time? How has the quality of health providers changed over time? How has the utilization of health care changed over time?

3 Data Sources Individual and health provider data from 2 of the 4 IFLS surveys, 1997 and 2007; Facilities: health provider diagnostic and treatment ability Individual: id utilization i of health h services Village-level data from PODES 1996 and 2006 Health facility and provider data to examine supply at the community level 3

4 Changes and Distribution: ib i Supply and Quality of Health Workers 4

5 Distribution of Physicians in Indonesia, Table 3 1: Distribution of Physicians in Indonesia, Per 100K Residents % change National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other Provinces Urban Rural Source: PODES 1996 and

6 Distribution of Midwives in Indonesia, Table 3 3: Distribution of Midwifes in Indonesia, 1996 & 2006 Per 100K Residents % change National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other Provinces Urban Rural Source: PODES 1996 &

7 Facility Staffing of Puskesmas and Pustu, Table 3 4: Facility Staffing of Puskesmas and Pustu, National Urban Rural Puskesmas Number of MDs No MD (%) Number of Midwives Number of Nurses Pustu Number of Midwives Number of Nurses

8 Distribution of Physicians Providing Private Health Services Per 100 k of population % change National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other provinces Urban Rural

9 Distribution of Midwives providing private health services, per 100 k of population % change National Urban Rural Java & Bali Urban Rural Sumatera Urban Rural Other provinces Ub Urban Rural

10 Measuring Quality: Diagnostic and Treatment Vignettes Majority of previous studies focus on structural quality An important element of quality is skill and knowledge of health workers Use vignette information from IFLS to measure knowledge of health workers Focus on three clinical case: prenatal, child curative and adult curative care Evaluation of HW knowledge based on responses to a presented case Caveat: Vignettes may underestimate skill because 10

11 Clinical case scenario Prenatal care Care for an adult with respiratory infection Care of a child with diarrhea and vomiting Evaluate hypertensive disorders History History 1 Ask history of high blood pressure 1 Ask about duration of illness 1 Ask about duration of illness 2 Take blood pressure 2 Ask about previous respiratory illnesses 2 Ask about frequency of illness 3 Test urine protein 3 Ask about blood in cough 3 Ask about appearance of stools/vomit 4 Ask about smoking habit 4 Ask about color of sputum 4 Ask about blood in stools Take history and physical 5 Ask about chest pain 5 Ask about fever 5 Ask about history of heart disease Physical and sputum Physical 6 Ask about history of diabetes 6 Take temperature 6 Take temperature 7 Ask about family history of illnesses 7 Listen to respiration 7 Check for sunken fontanelles 8 Take height measurements 8 Examine ears 8 Check skin turgor 9 Weigh patient 9 Assess chest indrawing 9 Take pulse 10 Measure uterine height 10 Assess for cyanosis 10 Check alertness 11 Assess whether high-risk pregnancy 11 Test sputum Care and advice Perform diagnostics and prevention 11 Administer oral rehydration fluids 12 Determine tetanus immunization status 12 Recommend when to return if worse 13 Test for sexually transmitted infections 14 Test hemoglobin levels 15 Advise on nutrition 16 Give iron-folate Establish case management system 17 Date the pregnancy 18 Plan for delivery 19 Plan for follow-up visits 11

12 Quality of health care and its change across type of facilities, 1997 & 2007 (% raw score) 1. Pre natal care Public Private Difference * * Difference 358~ ~ Child curative care * Difference 7.94~ 6.55~ Adult curative care ~ " Difference 12.33~ 12.31~ 0.02 Notes: (~) sign at 1%, ( ) sign at 5%, (*) sign at 10%. 12

13 Quality distribution of public and private health providers (% raw score) Public Prenatal care Child cur care Adult cur care Prenatal care Child cur care Adult cur care Least competent, 1 st quintile nd quintile rd quintile th quintile Most competent, 5th quintile Private Least competent, 1st quintile nd quintile rd quintile th quintile Most competent, 5th quintile Sources: IFLS 1997 &

14 Diagnostic Quality by Region: Prenatal Care Public Private Public Private Public Private Java/Bali Sumatra Other Provinces

15 Diagnostic Quality by Region: Child Curative Public Private Public Private Public Private Java/Bali Sumatra Other Provinces

16 Diagnostic Quality by Region: Adult Curative Public Private Public Private Public Private Java/Bali Sumatra Other Provinces

17 Diagnostic Quality by Community Type: Prenatal Care Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces

18 Diagnostic Quality by Community Type: Child Care Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces

19 Diagnostic Quality by Community Type: Adult Care Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces

20 Utilization in Indonesia,

21 Changes in Utilization of Health Services vs Self medication with Over Counter Medicine (%) Outpatient Inpatient All utilization OTC medicine Source: IFLS 1997 & 2007

22 Choice of Provider When Ill for Out Patient Services (%) Source: IFLS 1997 & 2007

23 Utilization by Region (IFLS Provinces) Sumatera Java/Bali Other Sumatera Java/Bali Other Outpatient Inpatient

24 Utilization by Urban-Rural (IFLS provinces) Urban Rural Urban Rural Outpatient Inpatient

25 Impacts of Private Sector Growth 25 EFFECTS ON THE QUALITY AND UTILIZATION OF CARE

26 How Might the Private Sector Affect Quality of Care? Quality Change from 1997 to 2007 is Influenced by: Legacy (level of quality in the past) Changes in Socioeconomic Characteristics of the Community Change in Utilization Rate Change in Private Practices per 100K (PODES) We are Interested in Two Questions: How do Private Practices Affect Average Quality within the Community? Positive: Attract Providers with Better Knowledge and Skill Negative/no effect: attract only crowd, not necessarily high quality ones. What about Average Quality of Care in the Puskesmas? Positive: Competition & Providers Interested in Dual Practice Negative: Decline in Public Quality 26

27 Growth in Private Physician Practices is Associated with Improvements in Diagnostic Ability Effect of Increasing Private Sector Provision on Diagnostic Ability of Health Care Providers Sample Effects of Private by Diagnostic Vignette All Facilities Public Facilities Pre Natal Vignette Score Change in Private Physicians Practices Per 100 Thousands ** (0.025) (0.026) Change in Private Midwife Practices Per Thousands (0.001) (0.014) Child Curative Care Vignette Score Change in Private Physicians Practices Per ** Thousands (0.031) (0.037) Change in Private Midwife Practices Per 100 Thousands (0.027) (0.025)

28 Uili Utilization i of Health lh Services and the Private Sector 28

29 Utilization and the Private Sector 29 Utilization is influenced by Availability, cost, preferences, perceptions of quality A Larger Private Sector May Lead to Or Increased utilization of individuals using private providers Increased supply of health providers Lower costs including wait times. Decreased Utilization Due to Exit of Public Providers Decreased Utilization Due to an Increase in Fees

30 Growth of the Private Sector is Associated with Increased Usage by Poorer Households in Communities 30 Effect of Increasing Number of Private Sector Providers Per Hundred Thousand on the Probability of Visiting a Health Facility When Ill Poorest 20 Percent of Richest 20 Percent of Sample Community Community All Observations 0.031*** Urban Male Female Rural Male 0.053** Female 0.059** 0.002

31 The Choice Between Private and Public Sector Providers What factors influence choice between private and public sectors? 31 Patient: Cost of service, perceptions of quality Dual Practice Provider: Sorting of affluent patients to private practice With the expansion of the private sector poorer members of community may Use private practices more if the cost and quality do not differ much between public and private Use public practices more if cost is lower (e.g., effects of Askeskin program), if providers engage in sorting and if congestion is reduced as some patients seek care in private sector

32 Expansion in Utilization is Realized by Increased Use of the Puskesmas by Poorer Members of the Community 32 Effect of Increasing Number of Private Sector Providers Per Hundred Thousand on the Probability of Visiting the Puskesmas When Ill Poorest 20 Percent of Richest 20 Percent of Sample Community Community All Observations 0.081** Urban Male Female Rural Male 0.215** Female

33 APPENDICES 33

34 PTT Scheme Helps to Increase Recruitment to Rural Areas 34 PTT Doctors Recruited and location classification Ordinary Remote Very Remote Total ,549 7,042 3,270 29,861 Average per year 1, , ,826 2,517 1,885 8,228 Average per year , ,489 1,700 4,184 Average per year ,092 Source: Ruswendi, D., 2007

35 Policy Implications 35

36 Policy Suggestions: Supply 36 Rethink the 6-month mandatory service period in remote and very remote areas, especially regarding preventive and promotive health care Develop and experiment with other incentives schemes Ensure meaningful engagement g with the private health providers and conduct more in-depth analysis of effects on dual practice Adapt planning methods to needs-based d and link to civil service reform, taking into account existing providers, including gprivately yprovided services

37 Policy Suggestions: Supply (Continued) Revisit allocation of public funds to those areas where there is a clear need for publicly provided services; in poor and remote areas Revisit the one size fits all strategy to service delivery Take the demographic and epidemiological i i l transitions and the implications for the need for health workers skills mix and quantity into the planning and budgeting exercises 37

38 Policy Suggestions: Quality Regulatory framework: Establish standards Rationalize accreditation 38 Associate professional organizations with continuing education and licensing Formalize and limit public recruitment and all licensing to formally certified providers from accredited d schools

39 Policy Suggestions with regards to Quality Con t Urgent need to better control establishment of new schools Certification of health workers should be based on skills, not knowledge only Consider privileging for remote areas at the same time as improving i quality 39

40 Policy Suggestions: Quality (Continued) Provider Payment methods currently underdeveloped but initiatives starting Very important with upcoming health financing reform Evaluate ongoing and develop more pilots Experiment with non-monetary incentives in underserved areas 40