Poor quality for the poor? A study of inequalities in service readiness and provider knowledge in Indonesian primary health care facilities

Abstract

Background For many low and middle-income countries poor quality health care is now responsible for a greater number of deaths than insufficient access to care. This has in turn raised concerns around the distribution of quality of care in LMICs: do the poor have access to lower quality health care compared to the rich? The aim of this study is to investigate the extent of inequalities in the availability of quality health services across the Indonesian health system with a particular focus on differences between care delivered in the public and private sectors. Methods Using the Indonesian Family Life Survey (wave 5, 2015), 15,877 households in 312 communities were linked with a representative sample of both public and private health facilities available in the same communities. Quality of health facilities was assessed using both a facility service readiness score and a knowledge score constructed using clinical vignettes. Ordinary least squares regression models were used to investigate the determinants of quality in public and private health facilities. Results In both sectors, inequalities in both quality scores existed between major islands. In public facilities, inequalities in readiness scores persisted between rural and urban areas, and to a lesser extent between rich and poor communities. Conclusion In order to reach the ambitious stated goal of reaching Universal Health Coverage in Indonesia, priority should be given to redressing current inequalities in the quality of care.

Out‐of‐Pocket expenditure and patient experience of care under‐Indonesia's national health insurance: A cross‐sectional facility‐based study in six provinces

“…As such, it provides more granular and direct insights and allows deriving conclusions for short‐term improvements, as well as future reform planning and execution. The Indonesian JKN reform gained a lot of praise and attention among researchers and health policy makers, but, naturally for a transformation process of such a scale, not without rightfully highlighting the remaining challenges on the ground 22,23,32–34,54,55 . This paper complements existing evidence, by adding new knowledge on coverage effectiveness along two UHC dimensions, financial protection and quality of services during the initial implementation of JKN.…”

“…The Indonesian JKN reform gained a lot of praise and attention among researchers and health policy makers, but, naturally for a transformation process of such a scale, not without rightfully highlighting the remaining challenges on the ground. 22,23,[32][33][34]54,55 This paper complements existing evidence, by adding new knowledge on coverage effectiveness along two UHC dimensions, financial protection and quality of services during the initial implementation of JKN. To our knowledge, this is the first study examining OOPE and patient experience among JKN members, by building on data collected directly from beneficiaries at time of their encounter with the health system.…”

“…This goes in line with findings on gender inequality in Indonesia reflected in pay gaps at work, higher levels of unpaid housework performed by women, and lower SES overall. [63][64][65] Other studies have examined equity of access and health utilization changes under JKN, 30,34,[66][67][68] with mixed results. 28 find that JKN insured patients incurred higher OOPE (9% more on inpatient services and 15% more on outpatient services) than the uninsured, a pattern which was also found in Indonesia prior to JKN implementation.…”

“…Indonesia's health indicators demonstrate the divide, for example, maternal mortality ratio is above 200 in eastern provinces, while West Java, Jakarta and Bali range below 100 32 . Effects of income related health inequalities further persist and have been described extensively, 23,24,32–34,41 for example, stunting rates are 43% of children in East Nusa Tenggara compared to 9% of children in Jakarta province. The poorest and therefore worse performing regions are generally located in the eastern part, but also provinces on the islands of Kalimantan, Sulawesi and Nusa Tenggara 41 .…”

“…32 The studies concluded calling for further research on details of OOPE under JKN, and particularly its underlying components, drivers and potential countermeasures. Further, health care quality is a big concern in Indonesia, 22,23,[32][33][34] but research on quality, patient experience or satisfaction and patient-centredness is spotty 33 and if available, has representation limitations such as small patient samples, being single facility bound, service-specific and combinations thereof. [35][36][37][38][39] A recent literature review from 2021 and in the Indonesian language 36 the paper we follow the two main outcomes, OOPE and patient experience, which taken together are reflective of coverage effectiveness under JKN.…”