Overview
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The lack of oversight over private health services is of concern, however, and needs urgent attention. Little information has been gathered on actual hours spent in public service. A large part of almost all health workers’ income comes from providing private services. Where private services are plentiful, it may well be that health care workers are spending less time in public service. This may lead to inefficiencies in the use of public budgets for health, a large part of which is for salaries.
Quality of Health Facilities and Health Practitioners The government of Indonesia has given attention to improving the quality of health providers through additional training, especially in the area of maternal health. For example, in 1997 the government began an inservice, competency-based training program in skills ranging from normal birth to emergency obstetric care. New requirements for midwifery training were also introduced that changed basic midwifery training from one year after vocational nursing school, to a three-year, post–high school, diploma program. The Indonesian Medical Association (IDI) also piloted a training program in emergency obstetric care for general practitioners in early 2000. That program was discontinued in 2005, when a ministerial decree allowed family practice doctors with additional training to provide emergency obstetric care in remote areas. These and other initiatives and policy changes would be expected to have improved the quality of health providers. Overall quality of services provided by public and private facilities and freestanding practitioners has improved over time in all provinces for prenatal care, child curative care, and adult care. However, the improvements in quality—measured as ability to diagnose and treat—were marginal, and overall quality remains low, with health workers only responding correctly to about half of the standard questions and procedures in the diagnostic vignettes presented in the most recent Indonesia Family Life Survey (IFLS).1 Although quality is not perfectly measured by vignettes, the information on health provider knowledge available from this source is the latest and most reliable evidence available. Moreover, these data are representative across regions for different types of health providers and the three types of care. Changes in provider quality over time can be analyzed, as the 1997 IFLS used the same vignette module. Increasing the number of private sector physicians per 100,000 population is associated with improvement in the average diagnostic ability of all facilities. The changes in prenatal care, child curative care, and adult curative care scores from diagnostic and treatment vignettes are all