Distribution trends of Indonesia's health care resources in the decentralization era

Abstract

Indonesia has been decentralized since 2001, and we evaluated the distribution trends of physicians, puskesmas (community health centers), hospitals, and hospital beds in 34 provinces in Indonesia for 2000 to 2014. Inequality index of Gini showed improvement of the distribution of physicians and decreased from 0.38 to 0.29. The indices in distributions of hospitals and hospital beds also decreased from 0.26 to 0.17 and from 0.25 to 0.18, respectively. However, the index in the distribution of puskesmas increased from 0.19 to 0.28. We also investigated the legislative transitions of the laws concerning health resources and found the strong affects of compulsory work laws for physicians and the increment of health budget. In the decentralization era, the local governments have some political autonomy for the development of health resources; however, the national government should monitor the nationwide distribution of health resources and advice necessary recommendations to the local governments.

An unintended consequence of provider payment reform: The case of capitation grants in the National Health Insurance reform of Indonesia

“…This urban‐rural inequity in terms of the distribution of additional human resources for health indicates that rural residents may not be receiving adequate health care services as compared with the urban residents. It is not uncommon for health resources such as health workers and the quality of health services to be distributed unevenly in Indonesia, as previous studies found that rural areas in Indonesia had the tendency to be consistently disadvantaged, despite the overall rise in the number of health workers and private sector growth nationally . This unevenness should raise an alarm to the government and policy makers who are concerned about improving health equity within the nation.…”

“…The tight fiscal budget could be the major concern of the national government as the tax revenue as a share of GDP in Indonesia has declined from about 11.2% in 2011 to 9.9% in 2017. 37 As a result of having low endowment of permanent health workers whose allocation is dictated by the national government, district governments and health centre managers may then have to tap into their given autonomy-a decision-making power privilege endowed under the decentralisation law 26,27 -to utilise capitation grants to beef up the manpower in community health centres. Though it is difficult to identify the actual reason for the substantial reduction in full-time permanent health workers from the dataset we have, the results nevertheless point to the occurrence of an unintended consequence of provider payment reform that affects the compositions and dynamics of human resources for health.…”

“…The IFLS is an ongoing longitudinal socio‐economic and health survey representing 83% of the Indonesian population living in 13 out of 26 provinces as of 2014. Besides collecting a wealth of information from individuals and households, the IFLS also collected information from communities and various schools and health facilities within the communities . The first wave of the IFLS was conducted in 1993, followed by wave two in 1997, wave three in 2000, wave four in 2007, and the most recent wave in 2014 and 2015.…”

“…Capitation is a prospective payment grant paid monthly by BPJS‐Health to all public and private primary health providers in a contract with them, based on the number of registered enrolees in each health facility. As a highly decentralised country with more than 500 districts, local district governments in Indonesia are endowed with decision‐making and implementation autonomy in a variety of public service delivery domains, including heath service delivery . As community health centres started receiving substantial capitation grants from BPJS‐Health, district‐level regulations were enacted to give the providers more autonomy to decide on the utilisation of capitation grants.…”

“…As a highly decentralised country with more than 500 districts, local district governments in Indonesia are endowed with decision-making and implementation autonomy in a variety of public service delivery domains, including heath service delivery. 26,27 As community health centres started receiving substantial capitation grants from BPJS-Health, district-level regulations were enacted to give the providers more autonomy to decide on the utilisation of capitation grants. These autonomy-enhancing regulations include giving the managers of the community health centres discretion to make decisions on the performance incentive for the existing staff in a more flexible manner and to hire more contract health workers to meet the rising health services demand resulting from the National Health Insurance expansion.…”