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
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?
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
Changes and Distribution: ib i Supply and Quality of Health Workers 4
Distribution of Physicians in Indonesia, 1996-2006 Table 3 1: Distribution of Physicians in Indonesia, 1996 2006 Per 100K Residents 1996 2006 % change National 15.65 18.36 17.4 Urban 40.24 36.18 10.1 Rural 5.39 5.96 10.6 Java & Bali 16.18 18.53 14.5 Urban 38.97 34.06 12.6 Rural 437 4.37 449 4.49 28 2.8 Sumatera 14.62 18.72 28.1 Urban 41.98 41.16 1.9 Rural 585 5.85 763 7.63 30.4 Other Provinces 15.09 17.44 15.6 Urban 44.76 40.63 9.2 Rural 759 7.59 766 7.66 09 0.9 Source: PODES 1996 and 2006. 5
Distribution of Midwives in Indonesia, 1996-2006 Table 3 3: Distribution of Midwifes in Indonesia, 1996 & 2006 Per 100K Residents 1996 2006 % change National 35.22 36.86 4.64 Urban 30.26 31.36 3.63 Rural 37.29 40.69 912 9.12 Java & Bali 27.55 26.12 5.19 Urban 23.84 25.08 5.21 Rural 29.47 27.06 8.19 819 Sumatera 53.73 54.09 0.67 Urban 46.45 48.05 3.45 Rural 56.06 57.07 180 1.80 Other Provinces 39.07 51.45 31.67 Urban 43.25 42.23 2.36 Rural 38.02 55.34 45.5555 Source: PODES 1996 & 2006 6
Facility Staffing of Puskesmas and Pustu, 1997-2007 7 Table 3 4: Facility Staffing of Puskesmas and Pustu, 1997 2007 National Urban Rural 1997 2007 1997 2007 1997 2007 Puskesmas Number of MDs 1.51 1.90 1.63 2.04 1.29 1.58 No MD (%) 3.4 7.0 2.44 6.18 5.08 8.65 Number of Midwives 5.85 3.69 4.99 3.78 7.30 3.51 Number of Nurses 5.05 6.14 4.88 6.02 5.34 6.42 Pustu Number of Midwives 0.98 0.81 1.14 1.06 0.84 0.50 Number of Nurses 1.08 1.06 1.21 1.19 0.99 0.86
Distribution of Physicians Providing Private Health Services Per 100 k of population 1996 2006 % change National 9.90 13.71 38.45 Urban 26.50 27.65 4.33 Rural 2.98 4.01 34.65 Java & Bali 10.98 15.44 40.54 Urban 25.98 28.06 7.98 Rural 3.21 4.03 25.43 Sumatera 9.15 11.91 30.08 Urban 28.53 26.59 6.79 Rural 2.95 4.65 57.80 Other provinces 7.27 10.31 41.69 Urban 26.57 26.90 126 1.26 Rural 2.40 3.30 37.78 8
Distribution of Midwives providing private health services, 1996-2006 per 100 k of population 1996 2006 % change National 8.57 20.64 140.84 Urban 1.66 21.07 1169.28 Rural 11.45 20.34 77.64 Java & Bali 6.97 20.95 200.57 Urban 1.77 20.58 1062.71 Rural 9.66 21.28 120.29 Sumatera 14.24 27.55 93.47 Urban 181 1.81 29.15 1510.5050 Rural 18.22 26.76 46.87 Other provinces 7.33 12.07 64.67 Ub Urban 086 0.86 13.56 1476.7474 Rural 8.96 11.43 27.57 9
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
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
Quality of health care and its change across type of facilities, 1997 & 2007 (% raw score) 1. Pre natal care Public Private Difference 2007 45.64 44.14 1.5* 1997 42.06 40.41 1.65* Difference 358~ 3.58 373~ 3.73 0.15 015 2. Child curative care 2007 63.67 61.92 1.75* 1997 55.72 55.37 0.35 Difference 7.94~ 6.55~ 1.39 3. Adult curative care 2007 59.41 56.80 2.61~ 1997 47.10 44.49 2.59" Difference 12.33~ 12.31~ 0.02 Notes: (~) sign at 1%, ( ) sign at 5%, (*) sign at 10%. 12
Quality distribution of public and private health providers (% raw score) Public 1997 2007 Prenatal care Child cur care Adult cur care Prenatal care Child cur care Adult cur care Least competent, 1 st quintile 18.6 31.1 20.9 27.6 43.8 30.7 2nd quintile 34.8 46.7 41.3 40.1 58.3 50.0 3rd quintile 44.6 58.3 54.5 47.4 66.7 63.6 4th quintile 55.5 69.6 68.2 53.9 79.0 72.7 Most competent, 5th quintile 70.1 85.6 81.88 67.8 93.8 81.88 Private 1997 2007 Least competent, 1st quintile 17.0 26.6 22.5 24.9 29.9 29.5 2nd quintile 31.4 47.0 36.4 36.8 49.4 45.5 3rd quintile 44.4 58.3 50.8 45.0 63.6 54.5 4th quintile 55.5 69.8 63.6 55.1 77.0 68.0 Most competent, 5th quintile 69.5 86.6 74.2 65.7 94.1 83.5 Sources: IFLS 1997 & 2007 13
Diagnostic Quality by Region: Prenatal Care 14 50 45 40 35 30 25 20 1997 2007 15 10 5 0 Public Private Public Private Public Private Java/Bali Sumatra Other Provinces
Diagnostic Quality by Region: Child Curative 15 70 60 50 40 30 2007 1997 20 10 0 Public Private Public Private Public Private Java/Bali Sumatra Other Provinces
Diagnostic Quality by Region: Adult Curative 16 70 60 50 40 1997 30 2007 20 10 0 Public Private Public Private Public Private Java/Bali Sumatra Other Provinces
Diagnostic Quality by Community Type: Prenatal Care 17 50 45 40 35 30 25 20 1997 2007 15 10 5 0 Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces
Diagnostic Quality by Community Type: Child Care 18 70 60 50 40 30 2007 1997 20 10 0 Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces
Diagnostic Quality by Community Type: Adult Care 19 60 50 40 30 1997 2007 20 10 0 Urban Rural Urban Rural Urban Rural Java/Bali Sumatra Other Provinces
Utilization in Indonesia, 1997-2007 7 20
Changes in Utilization of Health Services vs Self medication with Over Counter Medicine (%) 21 60 50 40 30 1997 2007 20 10 0 Outpatient Inpatient All utilization OTC medicine Source: IFLS 1997 & 2007
Choice of Provider When Ill for Out Patient Services (%) 40 22 35 30 25 20 15 10 5 0 1997 2007 Source: IFLS 1997 & 2007
Utilization by Region (IFLS Provinces) 23 25 20 15 10 1997 2007 5 0 Sumatera Java/Bali Other Sumatera Java/Bali Other Outpatient Inpatient
Utilization by Urban-Rural (IFLS provinces) 24 25 20 15 10 1997 2007 5 0 Urban Rural Urban Rural Outpatient Inpatient
Impacts of Private Sector Growth 25 EFFECTS ON THE QUALITY AND UTILIZATION OF CARE
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
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 27 0.057** (0.025) 0.021 (0.026) Change in Private Midwife Practices Per 100 0.001 0.001 Thousands (0.001) (0.014) Child Curative Care Vignette Score Change in Private Physicians Practices Per 100 0.069** 0.023 Thousands (0.031) (0.037) Change in Private Midwife Practices Per 100 Thousands 0.018 (0.027) 0.002 (0.025)
Uili Utilization i of Health lh Services and the Private Sector 28
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
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*** 0.022 Urban Male 0.030 0.002 Female 0.025 0.009 Rural Male 0.053** 0.019 Female 0.059** 0.002
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
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** 0.049 Urban Male 0.037 0.005 Female 0.025 0.021 Rural Male 0.215** 0.087 Female 0.041 0.112
APPENDICES 33
PTT Scheme Helps to Increase Recruitment to Rural Areas 34 PTT Doctors Recruited and location classification Ordinary Remote Very Remote Total 1992 2002 19,549 7,042 3,270 29,861 Average per year 1,955 704 327 2,986 2003 2006 3,826 2,517 1,885 8,228 Average per year 957 629 471 2,057 2006 2007 995 1,489 1,700 4,184 Average per year 498 745 850 2,092 Source: Ruswendi, D., 2007
Policy Implications 35
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
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
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
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
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